Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Arbors Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, intact cognition, and chronic bladder and frequent bowel incontinence required moderate assistance with toileting and two staff for toilet use. During observed incontinent care, a CNA washed hands upon room entry but twice removed soiled gloves and donned clean gloves without performing hand hygiene between glove changes while cleaning the perineal and rectal areas and then applying a clean brief. In interviews, the CNA acknowledged knowing hand hygiene was required and that she had forgotten, while the Administrator and an RN confirmed their expectation that staff perform hand hygiene between glove changes. Facility policy stated that hand hygiene is required after removing gloves or aprons.
Food items in the kitchen freezer were found without labels or dates, including opened chicken thighs, chicken wings, and ground beef. The DM said she removed the items to make space for ice storage and forgot to date them, and the Administrator said kitchen staff and the DM were responsible for daily checks to ensure foods were dated and labeled.
A resident with vascular dementia and severely impaired cognition was ordered haloperidol and lorazepam, but the record contained no medication consent and no HHSC Form 3713 consent before the antipsychotic and anti-anxiety meds were administered or available for review. Staff interviews confirmed that consent should be obtained before giving these medications, and the resident was observed drowsy and unaware of her medication regimen.
Lack of Weekly Monitoring for Psychotropic Medications: Two residents with severe cognitive impairment were receiving antipsychotic, antianxiety, and antidepressant medications, but the facility did not document the required weekly nursing summary assessments for side effects. Care plans identified the need to monitor and report adverse reactions, and staff interviews confirmed that weekly monitoring was expected for these high-risk meds.
Inaccurate MDS Coding for Hospice Services and Antiplatelet Therapy: A resident with vascular dementia and severely impaired cognition had a quarterly MDS that omitted hospice services and miscoded Plavix as an anticoagulant. Records showed the resident had a hospice order and a Plavix order, while the care plan addressed antiplatelet therapy but did not include hospice care. The MDS Coordinator acknowledged the coding errors, and the RN and Administrator stated the MDS and care plan were expected to be accurate and complete.
Baseline Care Plan Not Completed Within 48 Hours: A resident with vascular dementia, severely impaired cognition, behaviors, and ADL assistance needs did not have a baseline care plan completed within 48 hours of admission. Record review showed the care plan was not initiated until 15 days after admission. Staff interviews indicated the admitting nurse was responsible for completing the initial care plan and that it should be reviewed within the required timeframe.
A resident with vascular dementia and severely impaired cognition was receiving hospice care, but the comprehensive care plan was not reviewed and revised after the significant change MDS to include hospice services. The MDS Coordinator said she was responsible for care plan revisions with each assessment and was unsure how hospice was missed, while the RN and Administrator confirmed the care plan should be updated with significant changes and current care needs.
Improper perineal care during incontinent care was observed for a resident with bowel and bladder incontinence, moderate cognitive impairment, and a care plan for pericare after each incontinent episode. A CNA wiped the resident’s buttocks and rectal area back to front instead of front to back, and later acknowledged the error; the ADON, acting DON, and Administrator stated female incontinent care should be performed front to back, consistent with facility policy.
A resident with a g-tube and continuous enteral feeding was observed receiving incontinent care while the HOB was lowered and the feeding remained running. The care plan and MD order required the HOB to stay elevated during tube feeding, and staff interviews confirmed the nurse should have been notified to pause or disconnect the feeding before care was provided.
Missing Annual CNA Competency Evaluation: The facility failed to complete a yearly competency review for a CNA. Record review showed the CNA had a skills check-off at hire, but no evidence of an annual evaluation within the past 12 months. Interviews with the CNA, ADON, acting DON, and Administrator confirmed they were not aware the annual evaluation had not been completed, and the requested policy was not provided before exit.
A resident with multiple pressure ulcers was on EBP, but an LVN performed wound care without wearing a gown. She washed her hands, used gloves while preparing supplies, and then completed heel wound care without the required gown. The LVN, ADON, interim DON, and administrator all stated gowns and gloves were expected during wound care for residents on EBP, and the facility policy identified targeted gown and glove use for residents with wounds.
A resident with cognitive impairment and physical limitations experienced multiple episodes of bowel incontinence and did not receive appropriate assistance from staff with ADLs or cleaning, despite documented care needs. Staff failed to provide direct help, leaving the resident soiled and her environment uncleaned for extended periods, resulting in feelings of humiliation and self-isolation.
A resident with multiple chronic conditions did not receive a physician-ordered estradiol vaginal cream for over a month because the order was not entered into the pharmacy system or administered. Nursing staff and the DON were unaware of the order, and facility policy requiring prompt entry of new medication orders was not followed.
Two CNAs provided catheter care to a resident with an indwelling Foley catheter and on enhanced barrier precautions without donning required gowns and without changing gloves or performing hand hygiene after removing the resident's brief. The resident, who had multiple chronic conditions and required extensive assistance, had a care plan specifying the use of gloves and gowns for catheter care. Despite documented staff training and clear signage, infection control procedures were not followed during the observed care.
A resident with severe cognitive impairment and high ADL assistance needs was provided a shower with water that was not adequately warm, despite staff initially believing it was comfortable. The resident later expressed discomfort, and it was confirmed that the water was cool. Maintenance had been aware of ongoing hot water issues in the area, but the problem was not fully resolved at the time of the incident.
The facility failed to ensure proper securement of indwelling catheters for two residents, leading to potential risks of discomfort and injury. One resident with moderately impaired cognition and multiple health issues was observed without a catheter strap, contrary to physician orders. Another resident with severe cognitive impairment and urinary retention also lacked a securement device, with observations showing the catheter tubing draped across his shoulder. Interviews confirmed that nursing staff were responsible for catheter securement, but facility protocols lacked guidelines for applying securement straps.
Two residents with moderately impaired cognition and incontinence issues were at risk due to inaccessible emergency call lights in their shared bathroom. The facility failed to ensure the call lights were within reach, as required by their care plans, potentially preventing residents from notifying staff of their needs.
A resident with a suprapubic urinary catheter received improper catheter care from a CNA, who failed to wash hands between glove changes and reused a washcloth without changing to a clean portion. The CNA also incorrectly applied barrier cream around the catheter site. These actions, observed during a survey, were contrary to the facility's infection control policy and put the resident at risk of infection.
The facility did not follow its smoking policy, as observed in the smoking area where an ashtray contained an empty cigarette package and paper towels, posing a fire hazard. The previous housekeeping supervisor, responsible for emptying the ashtray and trash can, had not worked for weeks, and the key to the locked trash can was missing. The Maintenance Director and Administrator acknowledged the issue and planned to reassign the task to housekeeping.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during incontinent care. An [AGE]-year-old female resident with dementia, intact cognition (BIMS score 15), and documented bladder and frequent bowel incontinence required moderate assistance with toileting hygiene and two staff for toilet use per her care plan. During an observation of incontinent care, two CNAs entered the resident’s room and washed their hands upon entry. CNA A performed the perineal care while CNA B assisted with positioning. CNA A appropriately cleaned the front perineal area, then the resident was rolled onto her left side so CNA A could clean the buttocks and rectal area. During this care, CNA A removed soiled gloves and donned clean gloves twice without performing hand hygiene in between glove changes. She first removed gloves after cleaning the front perineal area and put on new gloves without washing or sanitizing her hands, then cleaned the rectal area. After cleaning the rectal area, she again changed gloves without performing hand hygiene and then applied a clean brief. In an interview, CNA A acknowledged she knew she was supposed to wash or sanitize her hands when changing gloves and stated she had forgotten, and she recognized this as an infection risk. The Administrator and an RN both stated they expected staff to perform hand hygiene between glove changes and acknowledged that failure to do so could increase infection risk. The facility’s infection control policy stated that hand hygiene is required after removing gloves or aprons.
Food items in freezer were not labeled or dated
Penalty
Summary
The facility failed to store food in accordance with professional standards in its only kitchen reviewed for food service safety. During an observation on 1/12/2026 at 9:17 AM, the DM was present in the kitchen and the walk-in freezer contained an opened box of chicken thighs with two bags of chicken thighs that were not dated or labeled on the box or bags, two bags of chicken wings on a shelf in the freezer that were not dated or labeled, and a large roll of ground beef on a shelf in the freezer that was not dated or labeled. During an interview on 1/12/2026 at 9:19 AM, the DM said she was responsible for making sure foods were dated and labeled when removed from their original containers or boxes in the kitchen. She said she removed the chicken and ground beef when she made space for storing bags of ice and forgot to date them. During an interview on 1/14/2026 at 10:36 AM, the Administrator said the kitchen staff and DM were responsible for checking food in the kitchen daily to ensure they are dated and labeled. Record review of the facility policy titled Food Storage and Supplies indicated that open packages of food are to be stored in closed containers or sealed bags and dated to when opened.
Missing consent for psychotropic medications
Penalty
Summary
The facility failed to ensure a resident was informed in advance and had documented consent for ordered psychotropic medications. Resident #5, a female admitted with vascular dementia, had a quarterly MDS showing a BIMS of 05 and documentation in the care plan that she required antipsychotic and anti-anxiety medications related to behavior management. Her order summary showed haloperidol 2 mg by mouth daily and lorazepam 0.5 mg by mouth every 4 hours as needed for anxiety were ordered on 12/18/2025, but the record contained no medication consent and no HHSC Form 3713 consent for either medication before administration. The medication administration record showed Resident #5 received haloperidol daily as ordered, while lorazepam was not administered. During observation, she was sitting on the side of her bed and appeared drowsy, and she stated she was waking up but might lie back down and sleep longer and was unaware of her medication regimen. Staff interviews indicated that consent for medications in the antipsychotic and antianxiety classifications should be obtained before administration, and the acting DON and Administrator stated that the nurse obtaining the order should discuss the medication with the resident or responsible party and obtain consent prior to administration.
Lack of Weekly Monitoring for Psychotropic Medications
Penalty
Summary
The facility failed to ensure appropriate monitoring for psychotropic medications for two residents who were receiving antipsychotic, antianxiety, and antidepressant drugs. Resident #5, a female with vascular dementia and severely impaired cognition with a BIMS of 05, had orders for haloperidol 2 mg daily and lorazepam 0.5 mg every 4 hours as needed for anxiety. Her care plan identified the need for antipsychotic and anti-anxiety medications and for monitoring, recording, and reporting side effects and adverse reactions, but the nurse weekly summary log showed no weekly assessment to monitor psychotropic side effects between the documented assessments. Resident #48, a female with Alzheimer’s disease and severely impaired cognition with a BIMS of 00, had orders for quetiapine 100 mg twice daily, quetiapine 50 mg daily, venlafaxine 100 mg daily, Zoloft 50 mg every other day, and clonazepam 1 mg twice daily. Her care plan also identified the need for antidepressant, antianxiety, and antipsychotic medications and for monitoring and reporting side effects to the physician. The medication administration record showed the medications were given, but there was no documented monitoring for medication side effects, and the nurse weekly summary log did not show weekly assessments during the period reviewed. During interviews, an LVN stated that when residents receive antipsychotic, antidepressant, or antianxiety medications, nurses document weekly monitoring for side effects on the weekly summary and that the nurse in charge must initiate the assessment. The Regional Compliance Nurse stated that these high-risk medications should be monitored weekly and that the DON and ADON should review the summaries at least monthly to ensure completion. The Administrator stated that these medications should be monitored no less than weekly to ensure they were not acting as a chemical restraint and to identify side effects or adverse reactions.
Inaccurate MDS Coding for Hospice Services and Antiplatelet Therapy
Penalty
Summary
The facility failed to ensure an accurate MDS was completed for Resident #5 on the quarterly assessment dated 1/05/2026. Resident #5 was an [AGE] year-old female admitted to the facility with a diagnosis of vascular dementia, and her BIMS score of 05 indicated severely impaired cognition. The quarterly MDS did not include her hospice services, and her antiplatelet medication was miscoded as an anticoagulant. Record review showed that Resident #5 had an order dated 12/18/2025 to admit to hospice services and an order for Plavix 75 mg by mouth daily, which is an antiplatelet medication. Her comprehensive care plan dated 9/23/2025 included the need for antiplatelet medication but did not include hospice care. During interviews, the MDS Coordinator stated she was responsible for entering the MDS assessments and reviewing and revising the care plan with each assessment, and acknowledged that hospice care should have been reflected and Plavix should have been coded correctly. The Regional Compliance Nurse and Administrator both stated that the MDS and care plan were expected to be completed accurately and completely.
Baseline Care Plan Not Completed Within 48 Hours
Penalty
Summary
The facility failed to develop the baseline care plan within 48 hours of admission for Resident #5. Resident #5 was an [AGE] year-old female admitted on [DATE] with vascular dementia, and the admission MDS dated [DATE] showed a BIMS of 07, indicating severely impaired cognition, along with behaviors and a need for assistance with ADLs. Record review showed no baseline care plan was completed within 48 hours of admission, and the care plan was not initiated until 15 days after admission on [DATE]. During interviews, the LVN stated the admitting charge nurse was responsible for completing assessments, orders, and activating the initial care plan, and said the care plan should be initiated within 24 hours so nurses and nurse aides would know the resident’s care needs. The Regional Compliance Nurse stated the admitting nurse should complete the baseline care plan within 48 hours and that the DON or ADON should review admissions in the morning meeting for accuracy and completion. The Administrator stated the baseline care plan should be started by the admitting nurse and reviewed and completed by the IDT within the 48-hour timeframe. The facility policy titled Baseline Care Plans stated the baseline care plan would be developed within 48 hours of a resident’s admission.
Care Plan Not Updated for Hospice Services
Penalty
Summary
The facility failed to ensure Resident #5’s comprehensive care plan was reviewed and revised by the interdisciplinary team after assessment changes, including the significant change assessment. Resident #5 was a female resident with vascular dementia and severely impaired cognition, as shown by a BIMS score of 04 on the significant change MDS assessment. The record also showed that she was receiving hospice care, with an order to admit to hospice services dated 12/18/2025. Record review showed Resident #5’s comprehensive care plan was last reviewed on 11/26/2025 and was not reviewed and revised with the significant change MDS assessment on 12/22/2025 to include hospice services. During interview, the MDS Coordinator stated she was responsible for entering MDS assessments and reviewing and revising the care plan with each assessment and IDT collaboration, and said she was not sure how hospice services were missed from the comprehensive care plan. The Regional Compliance Nurse stated the MDS Coordinator was responsible for revising the care plan at the time of assessment, and the Administrator stated comprehensive care plans should be reviewed and revised with significant changes, quarterly, annually, and as needed with resident care changes.
Improper Perineal Care During Incontinent Care
Penalty
Summary
The facility failed to ensure appropriate incontinent care for a resident who was incontinent of bladder and bowel. Resident #62 was admitted and readmitted to the facility with diagnoses including epilepsy, gastrostomy status, Type 1 diabetes, and major depressive disorder. Her Significant Change MDS assessment indicated moderate impairment in thinking with a BIMS score of 10, substantial to maximal assistance needed for toileting hygiene, and frequent urine and bowel incontinence. Her care plan directed staff to provide pericare after each incontinent episode. During an observation, CNA B and CNA C provided incontinent care to the resident. CNA B wiped the lower abdomen and both thighs, then wiped the vaginal area from front to back. After the resident was turned onto her left side, CNA B wiped the buttocks and rectal area from the rectum toward the urethra, back to front, before placing a brief and applying barrier cream. During interview, CNA B stated he should have wiped front to back and acknowledged improper wiping could lead to a UTI. CNA C, the ADON, the acting DON, and the Administrator all stated female incontinent care should be provided front to back, and the facility policy for female perineal care directed staff to clean the rectal and buttocks area away from the labia, working from the anus outward.
Tube Feeding Care Not Maintained During Incontinent Care
Penalty
Summary
The facility failed to ensure Resident #62, who had a gastrostomy tube and was receiving continuous enteral feeding, received appropriate care while tube feeding was in progress. The resident’s record showed a diagnosis of gastrostomy status, a Significant Change MDS indicating moderate impairment in thinking with a BIMS score of 10, and a care plan directing staff to keep the head of bed elevated during tube feeding and for 30 minutes afterward. Physician orders also directed that the head of bed be kept up at least 30 degrees during administration of enteral formula or water. During observation, Resident #62 was receiving Diabetisource AC at 53 ml/hr with the head of bed lowered while CNA B and CNA C provided incontinent care. The CNAs performed perineal care, repositioned the resident, and completed the care before CNA B lowered the bed and then elevated the head of bed. In interviews, CNA B said the nurse should have been asked to disconnect the tubing because it could be pulled while attached, and CNA C said the feeding should have been paused because the resident could potentially aspirate. The ADON, acting DON, and Administrator each stated staff should notify the nurse to stop the feeding before care when the head of bed would be lowered.
Missing Annual CNA Competency Evaluation
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months for CNA B. Record review showed CNA B was hired on 11/4/2024, and the only documented competency evaluation in the file was a CNA proficiency audit dated 11/4/2024 indicating satisfactory skills at hire. There was no evidence of a competency evaluation completed within the past 12 months, and the surveyor requested a policy for competency evaluations but none was provided prior to exit. During interviews, CNA B said he had a skills check-off when he was hired but could not remember having one since then. The ADON said she was responsible for ensuring yearly competency evaluations were completed and was not aware CNA B did not have one. The acting DON said the ADON and DON were responsible for ensuring the evaluations were completed on hire and annually thereafter, and the Administrator said the DON was responsible for making sure skill check-offs were done on hire, annually, and PRN. Each stated they were not aware CNA B did not have an annual evaluation.
Failure to Use Required PPE During Wound Care Under EBP
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one resident reviewed for infection control. The deficiency involved a resident admitted with pressure ulcers to the left hip and left heel, who had an MDS assessment showing no impairment in thinking, substantial assistance with activities of daily living, and one Stage 2 pressure ulcer, one Stage 3 pressure ulcer, and one unstageable pressure ulcer. The resident’s care plan, revised before the event, indicated the resident was on enhanced barrier precautions and had pressure ulcers to the left heel and left hip. During an observation, a sign outside the resident’s room indicated enhanced barrier precautions and PPE was available at the doorway. An LVN prepared to perform wound care by washing her hands, applying gloves, cleaning the over-bed table and tray, placing supplies on a protective barrier, cleaning scissors, removing gloves, sanitizing her hands, and putting on clean gloves. She did not put on a protective gown before beginning wound care. She removed the existing dressing from the left heel, cleaned the wound with normal saline and gauze, patted it dry, applied Santyl external ointment and calcium alginate, and covered it with a dressing. In interviews, the LVN stated she should have worn a gown before providing wound care to a resident on enhanced barrier precautions and that gowns and gloves are used to prevent transmission of bacteria from the resident’s room to other residents. The ADON, the Regional Compliance Nurse, and the administrator each stated staff caring for residents on enhanced barrier precautions were expected to follow facility policy and wear the appropriate PPE, including gowns and gloves during wound care. The facility policy on enhanced barrier precautions stated that targeted gown and glove use is part of the intervention and that residents with wounds are indicated for EBP even if not known to be infected or colonized with MDROs.
Failure to Provide Dignified and Respectful Care During Incontinence Episodes
Penalty
Summary
The facility failed to treat a resident with respect and dignity, and did not provide care in a manner that promoted the maintenance or enhancement of her quality of life. On two separate occasions, the resident, who had diagnoses including type 2 diabetes, vascular dementia, and muscle weakness, experienced episodes of bowel incontinence and did not receive appropriate assistance from staff with activities of daily living (ADLs) or with cleaning herself and her environment. The resident required maximum staff assistance for several ADLs, including toileting hygiene, as documented in her care plan and MDS assessment. On one occasion, the resident reported having an episode of bowel incontinence after breakfast, resulting in feces on herself and the bathroom floor. She activated her call light for assistance, but the CNA who responded told her to clean up the mess herself and did not offer help. The resident remained soiled and her bathroom uncleaned for several hours, as confirmed by observations and interviews with the resident, her private sitter, and staff. The resident expressed feelings of humiliation and self-isolation due to the lack of assistance and the way she was treated by staff. On another occasion, the resident contacted her representative for help after staff again refused to assist her following an episode of incontinence. The representative arrived to find the resident still unattended and had to request staff intervention. Even then, staff only handed the resident towels from outside the bathroom rather than providing direct assistance. Facility policies and staff interviews confirmed that nursing staff were responsible for cleaning biological waste and assisting residents with ADLs, but these expectations were not met in the resident's care.
Failure to Administer Physician-Ordered Medication Due to Order Entry Lapse
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the accurate acquiring, receiving, and administering of a physician-ordered medication. A female resident with chronic atrial fibrillation, dementia, neuromuscular bladder dysfunction, and chronic kidney disease had a new order for Estrace (estradiol) vaginal cream, prescribed by her gynecologist to address vaginal prolapse and thinning of pelvic tissues. Despite the order being sent to the facility, there was no record of the medication being entered into the pharmacy system or administered to the resident for 32 days. Interviews with nursing staff and the DON revealed that the order was not entered into the resident's chart, and staff were unaware of the estradiol order. The facility's policy required nurses to document or enter new orders into the system, but this was not followed, resulting in the resident not receiving the prescribed medication. The resident confirmed she had not received the medication and had not discussed it with staff.
Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by staff not following established infection control guidelines and procedures during catheter care for a resident. Specifically, two CNAs performed catheter care for a resident with an indwelling Foley catheter and on enhanced barrier precautions without donning the required protective gowns. Additionally, after removing the resident's brief, the CNAs did not change gloves, wash, or sanitize their hands before proceeding to clean the resident's perineal area and catheter tubing. The resident involved was an elderly female with multiple diagnoses, including chronic atrial fibrillation, dementia, acute cystitis, and chronic kidney disease. She was dependent on staff for most activities of daily living, was always incontinent of bowel, and had an indwelling Foley catheter. Her care plan specified the use of gloves and gowns for catheter care due to her being on enhanced barrier precautions, which are intended to reduce the spread of multidrug-resistant organisms (MDROs). Interviews with the involved CNAs, nursing staff, and facility leadership confirmed that all staff had received training in infection control, catheter care, and PPE use, and that residents on special precautions were clearly identified with signage and PPE supply bins. Despite this, the CNAs did not follow the required procedures during the observed care, which was inconsistent with the facility's infection control policies and the resident's care plan.
Failure to Ensure Access to Warm Water for Resident Showering
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, as evidenced by the lack of access to warm water for showering for one resident. The resident in question was an elderly male with a history of left femur fracture, prostate cancer, generalized muscle weakness, severe cognitive impairment, and significant assistance needs for activities of daily living. On the date of the incident, staff initially believed the shower water was warm, but after the resident expressed discomfort, it was found that the water was cool, though not cold. The resident's care plan required a homelike environment and bathing assistance, but the water temperature was not adequately ensured to be comfortable during the shower. Interviews revealed that the maintenance supervisor was aware of ongoing hot water issues in one hallway and had previously replaced a mixing valve. After the incident, he assessed and adjusted the valve, and weekly checks of water temperature in sampled rooms were documented as appropriate. However, the administrator was not aware of any water temperature problems prior to the incident, relying on the maintenance supervisor's logs. The facility's policy states that residents have the right to live in safe, decent, and clean conditions and to make choices regarding their care, but this right was not upheld in this instance.
Failure to Secure Indwelling Catheters
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling catheters, specifically in ensuring the use of securement devices to prevent urinary tract infections and catheter-related injuries. Resident #9, a female with moderately impaired cognition and multiple diagnoses including type 2 diabetes and chronic kidney disease, was observed without a catheter strap, despite a physician's order requiring one every shift. She reported discomfort due to the catheter pulling on her bladder, indicating a lack of adherence to her care plan. Similarly, Resident #25, a male with severe cognitive impairment and urinary retention, was also found without a securement device for his indwelling catheter. Observations revealed that the catheter was not secured during multiple instances, and the resident was seen with the catheter tubing draped across his shoulder, which could lead to discomfort or injury. Despite orders for a securement strap to be applied every shift, there was no documentation of monitoring the placement of the catheter strap in the Treatment Administration Record. Interviews with staff, including the Director of Nursing and the Administrator, confirmed that the responsibility for ensuring catheter securement lay with the nursing staff. However, the facility's Nursing Policy and Procedure Manual for Catheter Care did not include guidelines for the application of a urinary securement strap, highlighting a gap in the facility's protocols. This oversight contributed to the deficiency in care for residents with indwelling catheters.
Inaccessible Emergency Call Lights in Shared Bathroom
Penalty
Summary
The facility failed to ensure that the emergency call lights in the shared bathroom of two residents were accessible from the floor, which could prevent residents from notifying staff of their needs. Resident #3, a female with moderately impaired cognition, required assistance with toileting and was frequently incontinent. Her care plan indicated that her call light should be within reach to prevent falls. Similarly, Resident #18, also with moderately impaired cognition, required assistance with toileting and was occasionally incontinent. Her care plan also emphasized the importance of having the call light within reach to prevent falls. During observations, it was noted that the emergency call light in the shared bathroom of these residents lacked a string, making it inaccessible from the floor. Interviews with staff, including a CNA, the Administrator, the DON, and the Maintenance Man, confirmed that the call light strings were missing and acknowledged the risk this posed to residents. The staff recognized that without accessible call lights, residents could be unable to call for help in case of a fall or other emergencies.
Infection Control Deficiency in Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper foley catheter care provided to Resident #15. The resident, who had a history of dementia, acute cystitis with hematuria, and encephalopathy, required substantial assistance with daily activities and had an indwelling suprapubic urinary catheter. During an observation, CNA D was seen performing catheter care without adhering to proper infection control protocols. Specifically, CNA D did not wash or sanitize her hands between glove changes and reused the same portion of a washcloth to clean the catheter tubing, which could lead to contamination. Additionally, CNA D applied barrier cream around the catheter insertion site, which was not part of the recommended procedure. Both CNA D and LVN E acknowledged the errors during interviews, with CNA D admitting to being nervous and forgetting to use hand sanitizer. The facility's policy on catheter care, which outlines the correct procedure, was not followed, putting the resident at risk of infection. The administrator and DON confirmed that nurse managers were responsible for training CNAs in catheter care, and acknowledged the potential risk of infection if care was not performed correctly.
Failure to Follow Smoking Policy
Penalty
Summary
The facility failed to adhere to its established smoking policy in the designated smoking area. During an observation, a metal ashtray with a push button mechanism was found to contain an empty cigarette package and paper towels, along with multiple used cigarette butts. This was contrary to the facility's smoking policy, which mandates that ashtrays should be emptied into a metal container with a self-closing cover. The presence of these items in the ashtray posed a fire hazard, as noted by the Maintenance Director. Interviews revealed that the previous housekeeping supervisor, who was responsible for emptying the ashtray and the red metal trash can, had not been working at the facility for the past 3 to 4 weeks. The Maintenance Director was unable to locate the key to the red metal trash can, which was secured with a padlock. The Administrator confirmed that the housekeeping team would now take over the responsibility of emptying the ashtray and trash can, acknowledging the potential fire risk posed by the improper disposal of smoking materials.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Rusk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cherokee Trails Nursing Home | 2.5 mi | ★★★★★ | 20 | 0 |
| Legacy At Jacksonville | 13.1 mi | ★★★★★ | 8 | 0 |
| Avir At Jacksonville | 13.3 mi | ★★★★★ | 1 | 0 |
| Twin Oaks Health And Rehabilitation Center | 15.1 mi | ★★★★★ | 12 | 0 |
| Wells Ltc Nursing & Rehabilitation | 23.9 mi | ★★★★★ | 17 | 4 |
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