Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Manor At Seagoville during CMS and state inspections, most recent first.
Mechanical/Hoyer lifts on two resident halls were observed unlocked and unsecured, parked in room doorways while residents maneuvered their wheelchairs around them. An RN, an LVN, and a CNA each stated that mechanical lifts should be locked when not in use and stored away from high-traffic resident areas, noting that failure to lock them could result in injuries such as broken limbs or serious harm requiring hospitalization. The facility’s Mechanical Lift Protocol states that all lifts are to be returned to their assigned lift station when not in use, but this was not followed.
A resident with moderate cognitive impairment and multiple medical diagnoses was receiving ordered G-tube feedings of FEEDING 2 CAL HN at a specified rate and duration, but surveyors observed that the feeding bag and tubing in use were not labeled with date, time of initiation, or resident information. The LVN caring for the resident acknowledged that facility policy requires labeling of enteral feedings to ensure timely replacement and prevent contamination and admitted the setup should have been labeled. An RN confirmed that feedings must be labeled before administration and that all feedings are to be discarded after 24 hours, and the DON stated her expectation that the administering nurse label and date the feeding and that each assigned nurse verify proper labeling, consistent with facility policy requiring documentation of date, time, amount, method, and related details for tube feedings.
A resident receiving IV Cefepime via a midline catheter did not have the IV antibiotic bag labeled with the start date/time or nurse initials, and the IV tubing was not dated, contrary to facility IV therapy policy requiring all IV tubing to be labeled with date, time, and initials and changed at specified intervals. The resident’s active care plan lacked focus areas or interventions related to IV therapy. The LVN who administered the medication acknowledged forgetting to date and initial the IV medication and tubing despite prior in-servicing, and the DON confirmed that nurses were expected to label IV medications and tubing during every antibiotic administration, noting the risk of infection and medication error.
A resident with heart failure and moderate cognitive impairment, receiving O2 at 2 L/min via nasal cannula, was found using oxygen tubing dated several weeks earlier and an empty humidifier, despite an active order for weekly tubing and humidifier changes. Nursing staff gave conflicting information about whether changes were to occur on Wednesday or Saturday nights, while the DON stated policy required weekly changes and checks as part of routine assessment. Although staff reported being in-serviced on infection control and oxygen tubing care, the ordered schedule for changing the resident’s oxygen equipment was not followed.
A resident with complex medical needs experienced a misappropriation of property when approximately 23 tablets of Hydrocodone and the associated narcotic log went missing from the medication cart. Despite staff shift counts and negative drug tests for all involved, the medication and log were never recovered, and the facility could not determine how the diversion occurred. The resident did not miss any doses, but the event represented a failure to protect the resident from drug diversion.
A facility failed to maintain accurate records and perform proper shift-to-shift counts for controlled substances, resulting in the loss of approximately 23 tablets of Hydrocodone and the corresponding narcotic log for a resident with complex medical needs. Staff were unable to account for the missing medication, and required documentation was not completed or was missing, despite policies mandating these procedures.
A resident with complex medical needs did not have required medications and treatments documented by an RN during a double shift, resulting in missing entries in the MARs and TARs. The lack of documentation included essential care such as tracheostomy care, wound care, and medication administration, with staff interviews revealing unawareness of the issue and attributing it to possible EMR system problems.
A resident with severe cognitive impairment and a recent catheterization experienced bleeding and was sent to the hospital. Afterward, the resident's family reported an allegation of sexual abuse by a staff member to facility staff. The administrator was notified but did not immediately report the allegation to law enforcement as required, instead initiating an internal investigation and delaying police notification for two days.
A resident with severe cognitive impairment and multiple diagnoses was transferred to the hospital due to a significant change in condition, but the responsible party was not notified at the time of transfer as required by facility policy. The omission was discovered after a grievance was filed by the family member, and the LVN involved reported forgetting to notify due to being busy.
A resident with severe cognitive impairment and mobility needs did not have a care plan that included specific interventions for bed positioning to prevent falls, despite a recent fall and changes in her condition. Staff did not consistently follow or update the care plan, and the interdisciplinary team did not revise it to reflect the resident's current needs, resulting in a deficiency in care planning.
A treatment cart containing prescribed topical ointments and sterile supplies was found unlocked and unattended while an LVN was in a resident's room. The LVN admitted forgetting to lock the cart, and the Administrator confirmed that facility policy requires carts to be locked when not in direct view of staff.
The facility failed to provide necessary nail care for three residents, resulting in long, unclean fingernails. Despite requiring assistance, the residents did not receive proper grooming, leading to increased risks of infection and loss of dignity. Staff interviews revealed a lack of awareness and responsibility for nail care duties, contrary to the facility's policy.
The facility's kitchen failed to meet food service safety standards, with observations of uncovered, unlabeled, and expired food items in the walk-in freezer and refrigerator. Interviews with staff confirmed the responsibility of all kitchen personnel to ensure proper food labeling and storage, which was not adhered to, posing a risk of food-borne illness.
A facility failed to update a resident's care plan to include management of a dialysis AV fistula in the left forearm. The resident, who was cognitively intact and had conditions such as hypertension and end-stage renal disease, had physician orders for regular checks of the dialysis site. However, these were not included in the care plan, potentially affecting the resident's care. Interviews with staff confirmed the oversight.
A resident with a history of stroke, diabetes, and heart failure was observed using oxygen without a physician's order, contrary to facility policy. The resident's care plan and medical records lacked documentation for oxygen therapy, and the DON confirmed that orders are necessary unless in emergencies. This oversight led to a deficiency in providing appropriate respiratory care.
A facility failed to label and date medications properly, as observed with open bottles of valproic acid and levetiracetam on a medication cart without open dates. An LVN administered these medications without checking expiration dates, despite acknowledging the importance of dating for effectiveness. Interviews with the ADON and DON confirmed the policy of dating medications upon opening and removing them after 28 days.
A CNA failed to follow enhanced barrier precautions during incontinence care for a resident with multiple health issues, including blindness and end-stage renal disease. The CNA did not wear a gown while providing care, despite the resident being on enhanced barrier precautions due to her medical condition. Interviews with facility staff confirmed the expectation for PPE use during high-contact care activities, as outlined in the facility's infection control policy.
A resident in a long-term care facility experienced discomfort after a caregiver applied Icy Hot to their bottom instead of the prescribed barrier cream during incontinence care. Despite the resident's complaint of burning, the caregiver did not remove the cream. The resident, who was cognitively intact and had a history of hypertension and end-stage renal disease, was later assessed and cleaned by another nurse. The Director of Nursing confirmed that the caregiver was not qualified to apply Icy Hot, as there was no order for its use at the time.
A caregiver in an LTC facility applied Icy Hot to a resident without a physician's order and without being qualified, leading to a burning sensation for the resident. The resident, who was cognitively intact and had a history of hypertension and end-stage renal disease, kept the Icy Hot for personal use, but it was mistakenly used during incontinence care. The facility's policy required only licensed individuals to administer medications, which was not followed.
A resident in an LTC facility experienced a burning sensation after a caregiver mistakenly applied Icy Hot cream instead of a barrier cream during incontinence care. The resident, who was cognitively intact and had the cream stored in his drawer for shoulder pain, did not have an order for the cream. The facility failed to store the cream properly, as required by State and Federal laws, and the caregiver did not verify the cream before application, contrary to the facility's medication administration policy.
Unlocked Mechanical Lifts Left in Resident Hallways
Penalty
Summary
Surveyors identified a deficiency in maintaining an environment free from accident hazards on the 200 and 300 halls, where mechanical/Hoyer lifts were left unlocked and unsecured when not in use. On the 300 hall, an unlocked and unsecured mechanical lift was observed parked in the doorway of a resident room, with residents maneuvering their wheelchairs around the lift. A similar observation was made on the 200 hall, where another unlocked and unsecured mechanical lift was parked in the doorway of a resident room, again with residents maneuvering their wheelchairs around it. These lifts were not stored at their assigned lift stations as outlined in the facility’s Mechanical Lift Protocol, which states that all lifts will be returned to their assigned lift station to charge when not in use. During interviews, RN A stated that Hoyer/mechanical lifts should be stored away from high-traffic areas where residents could access them and get hurt, and confirmed he had been in-serviced on mechanical lifts, including storage. LVN C stated that mechanical lifts should always be locked in common areas such as hallways when not in use and that Hoyer lifts are stored at the end of the hall away from residents; she stated that failure to lock the lifts could cause accidents, including broken arms or legs. CNA D stated that mechanical lifts must always be locked and the red button activated to ensure there are no moving parts, and that a resident might attempt to support themselves and sustain serious injuries requiring hospitalization. The DON stated that her expectation was that all mechanical lifts were to be locked when not in use and that all staff had been educated and trained in proper usage and safety of mechanical lifts.
Unlabeled Enteral Feeding Setup for G-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an enteral feeding setup was properly labeled and dated in accordance with professional standards and facility policy for one resident receiving G-tube feedings. The resident was an adult female with moderate cognitive impairment (BIMS score 12) and diagnoses including hypertension, aphasia, and respiratory care needs. Her MDS and care plan documented that she required tube feeding with FEEDING 2 CAL HN at 40 ml/hour via feeding tube, to run from 9:00 a.m. to 7:00 a.m. for a total volume of 880 ml over 22 hours, with the head of bed elevated and residuals checked per protocol. Active physician orders matched these parameters. During an observation at 10:22 a.m., surveyors noted that the resident’s enteral feeding bag and tubing connected to the G-tube were unlabeled, with no indication of the date, time of initiation, or resident information. In interviews, the LVN assigned to the resident confirmed she was responsible for the resident and stated that facility policy required labeling of enteral feedings to ensure timely replacement and prevent contamination, acknowledging that the feeding setup should have been labeled and attributing initiation of the feeding to the night shift. An RN stated that enteral feedings should be labeled before administration and explained that unlabeled feedings could result in administration of expired feeding, noting that all feedings should be discarded after 24 hours and that he had been in-serviced on G-tube feeding administration. The DON stated her expectation that the nurse administering the feeding would label and date the feeding before administration and that each nurse assigned to the resident should check during their assessment to ensure the feeding was properly labeled, noting the risk of administering the wrong feeding and not knowing how long the feeding had been infused. Facility policy on administration of formula via feeding tube required documentation of date and time of feeding, amount, method and route of delivery, patient reactions and tolerance, and recording of formulas, water amounts, and medications, further underscoring that the observed unlabeled feeding setup did not comply with established procedures.
Failure to Label IV Antibiotic and Tubing per Facility Policy
Penalty
Summary
Surveyors identified a deficiency in the administration and labeling of IV antibiotic therapy for Resident #1. The resident was a female with moderate cognitive impairment (BIMS score 12), admitted with diagnoses including hypertension and respiratory care, and her MDS reflected IV medications and IV access. Physician orders dated 03/20/2026 directed Cefepime HCl 2 gm/100 ml to be given intravenously every 8 hours for 14 days. On 04/01/2026 at 10:20 a.m., observation showed the resident receiving Cefepime via a midline catheter, but the IV antibiotic bag was not labeled with the date and time it was initiated or the initials of the nurse who administered it. The IV tubing in use was also not dated, despite facility policy requiring all IV tubing to be labeled with date, time, and initials and changed every 96 hours or sooner if contamination or system compromise was suspected. Record review on 04/01/2026 at 10:10 a.m. showed that the resident’s active care plan did not include any focus areas or interventions related to IV therapy or the identified failure. During an interview at 10:24 a.m., LVN C, who was the resident’s nurse and had administered the IV antibiotic, acknowledged she had forgotten to date and initial the medication and to date the IV tubing, and stated she had previously been in-serviced on IV medication administration requirements, including dating and initialing at the time of administration. In a separate interview at 4:26 p.m., the DON confirmed that nurses were expected to initial and date IV medications and IV tubing during every antibiotic administration and stated that the risk to the resident included infection and not knowing when the medication was started, which could lead to a medication error. The facility’s written Intravenous Therapy policy, implemented 12/1/2025, required all IV tubing to be labeled with date, time, and initials, which was not followed in this instance.
Failure to Follow Oxygen Tubing and Humidifier Change Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards and physician orders for a resident receiving oxygen therapy. A female resident with heart failure, moderate cognitive impairment (BIMS score of 12), and an active care plan for oxygen therapy was observed on 2 L/min oxygen via nasal cannula. Record review showed an active physician order for oxygen tubing and humidifier changes every Wednesday night shift. However, on observation, the oxygen tubing in use was dated several weeks earlier and the humidifier bottle attached to the oxygen setup was empty. The resident’s care plan included monitoring for signs and symptoms of respiratory distress and obtaining SpO2 as needed for shortness of breath, and there was a facility policy for safe oxygen administration and documentation, but the ordered schedule for changing equipment was not followed. Staff interviews revealed inconsistent understanding of when oxygen tubing and humidifiers were to be changed. One RN stated the resident was on continuous oxygen and that nurses were responsible for checking and changing oxygen tubing, indicating tubing and humidifiers were changed every Wednesday night. An LVN, however, stated that oxygen tubing and humidifiers were supposed to be changed on the Saturday night shift and that she usually checked tubing to ensure it was dated. The DON stated her expectation was that the assigned nurse should check oxygen tubing and nebulizer masks as part of the overall assessment and that facility policy was to change oxygen tubing and humidifiers weekly and when dirty or contaminated. Staff, including the RN, LVN, and DON, all reported that nurses had been in-serviced on infection control and oxygen tubing care, yet the resident’s tubing and humidifier were not changed per the active order.
Failure to Prevent Drug Diversion of Controlled Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident's right to be free from misappropriation of property, specifically involving the diversion of approximately 23 tablets of Hydrocodone, a controlled narcotic medication. The resident, who had diagnoses including end stage renal disease requiring dialysis, dyspnea, hyperkalemia, fluid overload, and pain, was prescribed Hydrocodone-Acetaminophen for pain management. The medication was documented as missing from the medication cart, along with the corresponding narcotic log, during a routine medication administration. Multiple staff statements indicated that the medication and log were present during previous shift counts, but were later discovered missing, and no staff could account for their disappearance. The facility's investigation included reviewing staff statements, drug testing all staff who had access to the medication cart, and auditing medication carts and logs. Staff involved in the medication management process denied diverting the medication and all tested negative for controlled substances. The missing medication and narcotic log were never recovered, and the facility was unable to determine how the medication was diverted or who was responsible. The pharmacy confirmed delivery of the medication, and the resident did not miss any doses, as another blister pack was available and used for administration. The resident was out of the facility on leave when the diversion was discovered and reported that he had not missed any doses of his pain medication. Staff interviews and record reviews confirmed that the resident's pain management was not interrupted, and he expressed feeling safe and having no concerns about medication administration. The facility's policies required strict accounting and shift-to-shift counting of controlled substances, but the failure to prevent the diversion of the resident's medication and the associated narcotic log constituted a failure to protect the resident from misappropriation of property.
Failure to Maintain Accurate Controlled Substance Records Resulting in Missing Medication
Penalty
Summary
The facility failed to maintain an established system of records for the receipt and disposition of all controlled drugs, resulting in the inability to accurately reconcile controlled substances for one hall and one resident who had orders for controlled medications. Specifically, the facility did not ensure that employees with access to controlled medications properly counted the inventory, and approximately 23 tablets of Hydrocodone, along with the corresponding medication card and narcotic log, were missing from the medication cart. Staff statements indicated that the medication card was present at the end of one shift but was missing at the start of another, and no staff member could account for its disappearance. The required narcotic count sheets and logs were not completed or were missing, and the facility was unable to determine how the medication and log went missing. The resident involved was a male with end stage renal disease requiring dialysis, as well as other significant medical conditions including dyspnea, hyperkalemia, fluid overload, and pain related to a recent surgical procedure. He was prescribed Hydrocodone-Acetaminophen for pain management, with orders for administration every four hours as needed. Documentation showed that the resident had not missed any doses of his pain medication, as another card of the same medication was available and used during the period in question. However, the facility's failure to maintain accurate records and perform proper shift-to-shift narcotic counts led to the loss of both the medication and the narcotic log, and staff were unable to provide an explanation for the discrepancy. Interviews and record reviews revealed that staff who had access to the medication cart denied diverting the medication and tested negative for controlled substances. The facility's policies required verification and documentation of controlled medication receipt, shift-to-shift counts, and immediate reporting of discrepancies, but these procedures were not followed in this instance. The missing medication and log were never located, and the facility was unable to identify the individual responsible for the loss or diversion of the controlled substance.
Failure to Document Medication and Treatment Administration in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, a registered nurse (RN) did not document the administration of physician-ordered medications and treatments for a resident during her assigned double shift. Review of the resident's Medication Administration Records (MARs) and Treatment Administration Records (TARs) for the specified date showed missing initials and lack of documentation for multiple required treatments, including tracheostomy care, wound care, nebulizer treatments, aspiration precautions, and vital sign monitoring. There was also no progress note or other nursing documentation indicating that the care and medications were provided on that day. The resident involved was a male with severe cognitive impairment and total dependence for activities of daily living. His medical history included hypertension, neurogenic bladder, diabetes, Parkinson's disease, respiratory failure, anoxic brain damage, and a history of tracheostomy and G-tube feeding. He required frequent and complex care interventions, such as suctioning, oxygen therapy, skin care, and regular monitoring for signs of aspiration and infection. Despite these needs, the required documentation to confirm that these interventions were performed was absent for the identified shift. Interviews with facility staff revealed that the RN believed she had provided the care but attributed the lack of documentation to possible technical issues with the new electronic medical record (EMR) system. Other staff, including the Director of Nursing (DON) and the Weekend Supervisor, were unaware of the missing documentation until after the fact. The facility's own policies required that all care, medications, and treatments be documented in the resident's medical record, including the date, time, and details of the care provided. The absence of this documentation meant there was no verifiable record that the resident received the necessary care and treatments as ordered.
Failure to Timely Report Alleged Sexual Abuse to Law Enforcement
Penalty
Summary
The facility failed to ensure that an allegation of sexual abuse involving a resident was reported immediately to local law enforcement, as required by state law. The incident involved a male resident with severe cognitive impairment and a diagnosis of vascular dementia, depression, and insomnia. The resident was admitted for short-term care and had a physician's order for a Foley catheter. On the day of the incident, the resident experienced bleeding from the urethra during catheter removal, which was documented by nursing staff and resulted in the resident being sent to the hospital. After the resident was hospitalized, a family member reported to facility staff that the resident had alleged sexual abuse by a staff member. The administrator was notified of the allegation after midnight, and the information was relayed to the Director of Nursing and the corporate office. However, the administrator did not immediately notify local law enforcement, as required. Instead, the administrator initiated an internal investigation and reported the incident to the state, but delayed contacting the police until two days after the initial allegation was made. Interviews with facility staff and family members confirmed the timeline of events and the delay in reporting to law enforcement. The administrator stated that she did not contact the police initially because the resident was not present at the facility and she did not find evidence to substantiate the allegation. The facility's own abuse protocol required immediate reporting to authorities within two hours for incidents involving reasonable suspicion of serious bodily injury or abuse, which was not followed in this case.
Failure to Notify Responsible Party of Resident Hospital Transfer
Penalty
Summary
The facility failed to immediately notify a resident's responsible party when there was a significant change in the resident's condition that resulted in a hospital transfer. Specifically, a resident with severe cognitive impairment, a history of cerebral infarction, depression, and anxiety disorder, was assessed by an LVN who found the resident with thick secretions, low oxygen saturation, labored breathing, and unresponsiveness. The resident was subsequently sent to the emergency room. Despite facility policy requiring notification of the resident's representative in such situations, the responsible party was not informed of the transfer at the time it occurred. The omission was discovered when the resident's family member filed a grievance after learning about the hospital transfer. The responsible party was listed in the resident's records as having all responsibilities, and the facility's policy clearly stated that notification was required for significant changes in condition or hospital transfers. The LVN involved later stated that the failure to notify was due to being busy and forgetting to make the call.
Failure to Update and Implement Comprehensive Care Plan for Resident at Fall Risk
Penalty
Summary
The facility failed to ensure that a comprehensive, person-centered care plan was developed and implemented to meet all of a resident's needs, specifically for a female resident with severe cognitive impairment, dysphagia, and high blood pressure. The care plan did not include clear interventions regarding the lowering of the bed to prevent falls, despite the resident's recent fall and her need for assistance with transfers and bed mobility. Observations showed that the resident's bed was not in the lowest position as required, and staff interviews revealed inconsistencies in following and updating the care plan based on the resident's current abilities and risks. Record reviews indicated that the care plan was not revised after a significant change in the resident's condition, and the interdisciplinary team had not updated the plan to reflect the resident's individual needs for bed positioning, especially at night. Staff were relying on the care plan for guidance, but it did not accurately reflect the resident's current care requirements. The facility's policy required ongoing assessment and timely updates to care plans, but this was not followed, resulting in a deficiency related to the development and implementation of a complete care plan.
Unlocked Treatment Cart Left Unattended
Penalty
Summary
A deficiency was identified when treatment cart #1 was observed to be unlocked and unattended while a licensed vocational nurse (LVN) was inside a resident's room. The cart contained prescribed topical ointments and sterile supplies, and its drawers could be easily opened. This observation was made during a survey, and the LVN confirmed in an interview that she was aware the cart should have been locked but stated she forgot to do so. She acknowledged that leaving the cart unlocked could allow residents access to ointments, which could potentially be ingested. Further interview with the Administrator confirmed that treatment carts are required to be locked when not in the direct sight of staff, in accordance with facility policy. The Administrator also recognized the risk of residents accessing treatment creams and supplies if the cart is left unlocked. Review of the facility's medication administration policy, revised in April 2019, supported the requirement that medication carts must remain closed and locked when out of sight of the medication nurse or aide.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. This deficiency was observed in three residents who had long, unclean fingernails, which were not trimmed or cleaned by the staff. Resident #34, with severe cognitive impairment and requiring moderate assistance with personal hygiene, had nails approximately 1.0 centimeter in length with black areas underneath. Despite her request for assistance, the staff did not offer nail care during her stay. Resident #11, with moderately impaired cognition and requiring moderate assistance for personal hygiene, also had long nails with a dark red and brown substance underneath. She expressed a desire for her nails to be trimmed but could not recall when they were last attended to. Similarly, Resident #64, with a history of stroke and right-sided weakness, had nails that were not properly trimmed, with pointed, jagged edges and a dark substance underneath. She was unable to remember when her nails were last trimmed. Interviews with staff revealed a lack of awareness and responsibility regarding nail care. CNAs were identified as responsible for cleaning and trimming nails, but there was a disconnect in communication and execution of these duties. The facility's policy on nail care, which aims to prevent infection and maintain hygiene, was not adhered to, leading to increased risks of infection and loss of dignity for the residents.
Deficiencies in Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specifically, food items in the walk-in freezer were not covered, labeled, or dated with expiration dates. An unopened bag of cauliflower florets and a bag of diced yellow squash lacked expiration dates, while a bag of diced chicken was left uncovered. Additionally, the walk-in refrigerator contained tomato sauce in a covered container that was past its shelf life of seven days and should have been discarded. Interviews with the Dietary Manager and another staff member confirmed that all kitchen staff, including dietary aides and cooks, were responsible for ensuring food items were dated, labeled, and covered according to facility guidelines. The Dietary Manager acknowledged that the failure to properly manage food storage could lead to food-borne illnesses. The facility's policy on food storage was reviewed and found to lack specific guidance on the type of date required on food products. The Food and Drug Administration Food Code was also referenced, highlighting the need for proper food labeling and storage to prevent contamination.
Failure to Update Care Plan for Dialysis Access
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #32, which included measurable objectives and time frames to address the resident's mental and psychosocial needs. Specifically, the care plan did not include the management of the resident's dialysis access in the left forearm fistula. This oversight was identified during a review of the resident's comprehensive care plan, which was last updated on 09/19/22, and did not list the dialysis AV fistula as a care area or problem. Resident #32, a cognitively intact male with a BIMS score of 14, was admitted with diagnoses including hypertension, renal insufficiency, end-stage renal disease, and hyperkalemia. The physician's orders required regular checks of the dialysis site for thrill, bleeding, and signs of infection, with any abnormalities to be reported to the MD. However, these requirements were not reflected in the resident's care plan. Interviews with the MDS coordinator and the DON confirmed the care plan should have been updated to include the dialysis AV fistula, and the failure to do so could affect the resident's care.
Failure to Obtain Physician's Order for Oxygen Use
Penalty
Summary
The facility failed to ensure that a resident requiring respiratory care received appropriate care consistent with professional standards. Specifically, the facility did not have a physician's order for the use of oxygen for a resident who was observed using oxygen via a nasal cannula. The resident, who was cognitively intact, had a history of cerebral infarction, type 2 diabetes mellitus, and unspecified diastolic heart failure. Despite these conditions, there was no documentation in the resident's care plan or medical records indicating a physician's order for oxygen therapy. Observations and interviews revealed that the resident was administered oxygen without a physician's order, which is against the facility's policy. A nurse placed the oxygen concentrator and nasal cannula in the resident's room without administering it, yet the resident was observed using it. The Director of Nursing confirmed that a physician's order is required for oxygen administration unless in an emergency situation. The facility's policies on physician orders and oxygen administration were not followed, leading to the deficiency.
Failure to Label and Date Medications Properly
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with accepted professional principles, specifically by not including the open date on medication bottles for a resident. During an observation, it was noted that the 300 Hall medication cart contained open bottles of valproic acid and levetiracetam oral solutions without the required open date. This oversight was confirmed by LVN E, who administered these medications to the resident without checking for expiration dates. The LVN acknowledged the importance of dating medications to ensure they are not used beyond their effective period. Interviews with the ADON and DON further highlighted the facility's policy that liquid medications should be dated upon opening and removed after 28 days to maintain their effectiveness. The ADON mentioned conducting random checks of medication carts, while the pharmacist performed monthly checks and provided staff education. The facility's policy on medication labeling and storage emphasized contacting the dispensing pharmacy for instructions on handling outdated or improperly labeled medications.
Infection Control Breach During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to enhanced barrier precautions during incontinence care for a resident. The resident, a severely cognitively impaired female with multiple health issues including end-stage renal disease and blindness, was on enhanced barrier precautions due to her medical condition. During an observation, the CNA was seen providing care without wearing a gown, despite the presence of feces in the room after the resident had removed her ostomy bag. Interviews with the CNA, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that the facility's expectations were for staff to follow enhanced barrier precaution guidelines, which include the use of personal protective equipment (PPE) such as gowns and gloves during high-contact care activities. The CNA acknowledged forgetting to wear a gown and recognized the risk of infection to the resident and others. The facility's policy on enhanced barrier precautions, revised in March 2024, outlines the necessity of PPE during specific care activities to prevent the transmission of multidrug-resistant organisms.
Resident's Rights and Dignity Compromised by Improper Application of Topical Cream
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, which compromised the resident's quality of life. A caregiver applied Icy Hot, a topical pain reliever, to a resident's bottom instead of the prescribed barrier cream during incontinence care. The resident, who was cognitively intact and had a history of hypertension and end-stage renal disease, complained that the Icy Hot burned. Despite the resident's complaint, the caregiver did not remove the cream, leading to discomfort for the resident. The incident was reported to the Director of Nursing (DON), who confirmed that the caregiver was not qualified to apply Icy Hot, as there was no order for its use at the time. The caregiver claimed that the resident asked to be "greased up" and agreed to the application of Icy Hot, which was kept in the resident's drawer for personal use. The DON acknowledged that the caregiver should have verified the substance before application and noted the risk of an adverse reaction. The resident was later assessed and cleaned by another nurse, but the initial failure to address the resident's complaint promptly resulted in a temporary decrease in the resident's quality of life.
Improper Administration of Topical Medication by Unqualified Caregiver
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of Icy Hot, a topical over-the-counter pain reliever. A caregiver applied Icy Hot to a resident without a physician's order and without being qualified to do so. The resident, who was cognitively intact and had a history of hypertension and end-stage renal disease, reported that during incontinence care, Icy Hot was applied to his bottom instead of the prescribed barrier cream, causing a burning sensation. The resident kept the Icy Hot in his drawer for personal use on his shoulder, and it was mistakenly used by the caregiver. The Director of Nursing (DON) confirmed that the resident did not have an order for Icy Hot at the time of the incident, and the caregiver was not qualified to apply it. The caregiver admitted to applying the Icy Hot after the resident requested to be "greased up" and confirmed its use with the resident. The facility's policy stated that only licensed or permitted individuals could administer medications, which was not adhered to in this case. The incident was reported to the DON, and the Icy Hot was subsequently removed from the resident's room.
Improper Storage and Application of Medication
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by State and Federal laws. This deficiency was identified during a review of a resident's room where an over-the-counter topical cream, Icy Hot, was improperly stored. The resident, a cognitively intact male with diagnoses including hypertension and end-stage renal disease, had the Icy Hot cream in his drawer, which was used by his wife for shoulder pain. The resident reported that during incontinence care, a caregiver mistakenly applied the Icy Hot cream to his bottom instead of the prescribed barrier cream, causing a burning sensation. The Director of Nursing (DON) confirmed that the resident did not have an order for Icy Hot at the time of the incident, and the cream should have been stored on the medication cart if there was an order. The caregiver involved stated that she applied the Icy Hot after the resident requested to be "greased up" and did not verify the cream before application. The facility's policy on administering medication requires that medication carts be kept closed and locked when out of sight, and no medications should be kept on top of the cart. The incident highlighted a failure to adhere to these storage and administration protocols, potentially placing residents at risk of medication misuse and diversion.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 877 citations issued within 25 miles in the last 12 months — including the 40 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Seagoville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Balch Springs Nursing Home | 4.3 mi | ★★★★★ | 9 | 2 |
| Mesquite Tree Nursing Center | 6.7 mi | ★★★★★ | 12 | 0 |
| Cheyenne Medical Lodge | 7.8 mi | ★★★★★ | 1 | 0 |
| Mesquite Village Wellness & Rehabilitation | 8 mi | ★★★★★ | 6 | 0 |
| Edgewood Rehabilitation And Care Center | 8.7 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.