Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Mission At Blue Skies Of Texas East during CMS and state inspections, most recent first.
A resident's care plan was found to be incomplete, missing measurable timetables and specific actions to address all identified needs. Documentation did not reflect comprehensive planning or interventions for the resident.
A nurse inaccurately documented a resident's vital signs and assessment times, recording them as occurring when the resident was not present in the facility. The nurse admitted to entering incorrect times and not labeling the entry as a late entry, which was confirmed by interviews with the DON and Administrator. This failure resulted in incomplete and inaccurate medical records, contrary to facility policy.
A resident with diabetes and chronic kidney disease experienced critically high blood glucose readings and missed a scheduled insulin dose due to medication unavailability. Despite physician orders and facility policy requiring immediate notification for blood sugar levels above 350 mg/dL, the physician was not informed of the elevated readings, as confirmed by staff interviews and record review.
A resident with a feeding tube received undiluted medications administered directly into the tube, and the containers for feeding formula and water were not labeled or discarded after use. Nursing staff acknowledged these lapses, and facility policy required both dilution of medications and proper labeling and disposal of feeding containers to ensure safe care.
A resident with diabetes and other chronic conditions did not receive scheduled doses of fast-acting insulin due to the facility's failure to maintain an emergency supply and delays in pharmacy delivery. Nursing staff documented the medication was unavailable, and the resident's blood sugar was elevated at the time the dose was missed, indicating a lapse in pharmaceutical services and medication administration procedures.
A resident was not protected from a significant medication error, reflecting a lapse in the medication administration process.
A CNA in the memory unit was observed plating meals while wearing a facial hair restraint that did not cover his moustache, despite being aware of the requirement to cover all facial hair during food service. The Dietary Manager confirmed the expectation for proper use of hair restraints, and the Food Code requires food employees to wear restraints that prevent hair from contacting exposed food.
A resident with severe cognitive impairment and diabetes experienced multiple instances of low blood glucose levels, but the facility staff failed to notify the physician as required by the physician's orders. The nursing staff, including agency nurses, were unaware of the specific notification parameters and did not follow the orders due to a lack of training and clear protocols. The facility lacked guidelines for blood glucose monitoring, contributing to the oversight.
A facility failed to maintain complete and accurate clinical records for a resident, missing documentation of blood glucose readings and hospital stay records. Nurses reported obtaining the readings but did not document them due to the absence of a designated place for entries. Additionally, the resident's hospital records were not uploaded into the electronic medical record in a timely manner, as expected by the facility's policy.
A facility failed to create a comprehensive care plan for a resident with diabetes, omitting necessary details such as blood glucose monitoring frequency and physician notification parameters. The MDS Coordinator relied on physician orders for specifics, while the DON stressed the need for accurate care plan documentation. The resident had severe cognitive impairment and required significant assistance with ADLs.
A resident with diabetes was admitted to a facility without appropriate diabetic care orders, leading to months without blood sugar monitoring. This resulted in elevated blood sugar levels, as staff failed to reconcile hospital discharge orders with previous diabetic management. The oversight was identified through interviews and record reviews, highlighting a breakdown in communication and order reconciliation.
A CNA placed a pillow over a resident's face, calling it 'pillow therapy,' which was witnessed by another CNA. The resident, with COPD and anxiety, was not cognitively impaired. The incident was reported to the DON and state agency, and the CNA admitted to the action as a joke. The facility's investigation confirmed the incident, highlighting a failure to protect the resident from abuse.
The facility failed to develop comprehensive care plans for three residents with severe cognitive impairments, neglecting to address their need for placement on a secured memory care unit. Interviews revealed a lack of consensus among staff on the necessity of including this information in care plans.
A facility failed to ensure proper treatment for a resident with an enteral feeding tube, as an LVN did not check for residual volume, used incorrect flush volumes, and administered medications with a syringe plunger instead of gravity flow, contrary to physician's orders and facility policy.
The facility failed to maintain accurate clinical records for four residents admitted to the locked memory care unit without physician orders, despite severe cognitive impairments and dementia diagnoses. Interviews revealed a misunderstanding of the requirements for such admissions, contrary to the facility's policy.
A facility failed to ensure a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was properly completed, missing the physician's license number and date of signature, rendering the document invalid. The resident, with severe cognitive impairment and multiple medical conditions, was thus considered full code status against their wishes.
The facility failed to protect a resident's confidentiality by not ensuring an LVN locked the Medication Cart Computer screen, leaving the resident's information exposed. The LVN admitted to the HIPAA violation, and the DON confirmed the expectation to secure resident information.
The facility failed to ensure accurate MDS assessment documentation for a resident, incorrectly recording the discharge status as to a short-term hospital instead of home. This discrepancy was confirmed through interviews and record reviews.
The facility failed to ensure a safe environment for two residents with severe cognitive impairment by leaving disposable razors on their bathroom counters. Both residents were observed with razors in their rooms, and staff expressed uncertainty about the facility's policy on razor storage. The DON confirmed the lack of a specific policy, acknowledging that razors should not be in residents' rooms on the secure unit.
The facility failed to lock the Household Treatment Cart when unattended and did not update a medication label after a change in orders for a resident with hypertension. The unlocked cart contained potentially harmful items, and the incorrect medication label could lead to adverse effects.
The facility failed to maintain an effective infection control program, as evidenced by an LVN not sanitizing hands between glove changes and an RN using gloves from her pocket, leading to potential contamination.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records, which did not contain comprehensive or measurable interventions to address the resident's identified needs.
Inaccurate Medical Record Documentation by Nursing Staff
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, as required by accepted professional standards. Specifically, a nurse entered progress notes indicating that vital signs were taken at a time when the resident was not present in the facility. The nurse documented that vitals were taken at 10:31 AM, but the resident had left the facility earlier that morning and did not return until after the time recorded for the vitals. Additionally, the nurse admitted to documenting the assessment at an incorrect time and not labeling the entry as a late entry, which is contrary to facility policy. The nurse also acknowledged making errors in documenting the resident's continence status and the timing of the vital signs due to being in a hurry. Interviews with the nurse, DON, and Administrator confirmed that the documentation did not accurately reflect the resident's condition or the timing of care provided. The facility's documentation policy requires all entries to be factual, accurate, complete, and current, but this standard was not met in this instance. The inaccurate documentation could lead to confusion among the interdisciplinary team regarding the resident's care and condition.
Failure to Notify Physician of Critically High Blood Glucose Levels
Penalty
Summary
The facility failed to immediately notify a resident's physician when blood glucose readings exceeded the physician-ordered parameters. Specifically, a male resident with diagnoses including heart failure, type 2 diabetes, and chronic kidney disease had blood sugar readings of 386 mg/dL and 400 mg/dL on the same morning, both above the threshold of 350 mg/dL that required physician notification according to the resident's orders. The resident did not receive his scheduled morning dose of insulin Lispro before breakfast because the medication was not available until later in the morning. Despite these elevated readings and the missed insulin dose, there was no documentation that the physician was notified as required. Interviews with facility staff, including the LVN who documented the readings, the Staff Development Coordinator, the ADON, and the DON, confirmed that the physician should have been notified immediately upon obtaining blood sugar results outside the ordered parameters. The facility's own protocol also required immediate intervention and physician notification for blood glucose levels greater than 350 mg/dL. The lack of timely notification was acknowledged by staff and was not in accordance with physician orders or facility policy.
Failure to Dilute Medications and Label/Discard Enteral Feeding Containers
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube did not receive appropriate care during medication administration and enteral feeding. The resident, who had diagnoses including pneumonia, gastro-esophageal reflux, heart failure, and was dependent on a feeding tube, was observed receiving medications that were not diluted before being administered through the feeding tube. The nurse administered undiluted liquid and crushed medications directly into the tube, flushing with only small amounts of water between each medication, contrary to facility policy and physician orders. Additionally, the containers used for the resident's feeding formula and water were not labeled with the required identifiers such as the resident's name, date, time, or nurse's initials. These containers were observed hanging at the bedside after the feeding was completed, rather than being discarded as required. Interviews with nursing staff confirmed that labeling and timely disposal of feeding containers were not consistently performed, and staff acknowledged the importance of these practices for resident safety and compliance with facility protocols. Facility policy required that medications be diluted with water before administration via feeding tube and that feeding formula containers be labeled and discarded after use. The Director of Nursing confirmed that these steps were necessary to prevent tube blockage and ensure the resident received the full benefit of medications and safe nutrition. The failure to follow these procedures was directly observed and confirmed through staff interviews and record review.
Failure to Maintain Emergency Insulin Supply Results in Missed Doses
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident with type 2 diabetes, heart failure, and chronic kidney disease. Specifically, the facility did not maintain an emergency supply of Lispro (fast-acting insulin), resulting in the resident missing a scheduled bedtime dose and a scheduled morning dose of insulin. Documentation on the Medication Administration Record indicated that the insulin was unavailable and awaiting pharmacy fill, and the resident's blood sugar was recorded at 386 at the time the morning dose was missed. Nursing staff confirmed that the insulin was not available in the stat safe and had not been delivered by the pharmacy at the time it was needed. Record reviews and staff interviews revealed that the resident was severely cognitively impaired and required insulin injections as ordered by the provider. The facility's procedures required medications to be administered in accordance with orders and within required time frames, but these procedures were not followed in this instance. The absence of the required insulin and the failure to administer it as scheduled constituted a deficiency in pharmaceutical services, as the resident did not receive therapeutic doses of medication as ordered.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Improper Use of Facial Hair Restraints During Food Service
Penalty
Summary
A deficiency was identified in the facility's memory unit satellite kitchen regarding improper use of facial hair restraints by dietary staff during food plating. Observations on two separate occasions showed a CNA plating meals while wearing a facial hair restraint that covered his chin but not his moustache. The CNA only adjusted the restraint to cover his moustache after noticing the presence of a State Surveyor. The CNA acknowledged during an interview that he was aware of the requirement to cover all facial hair while handling food, but stated the restraint often fell off or got caught on his name tag, leading to improper use. The Dietary Manager confirmed that all staff working in the satellite kitchens, including CNAs, were required to have food handler certification and to wear hair restraints that properly cover all facial hair, including moustaches, during food service. The Dietary Manager also stated that improper use of hair restraints could result in hair contaminating food. Review of the applicable Food Code confirmed the requirement for food employees to wear hair restraints designed and worn to effectively keep hair from contacting exposed food.
Failure to Notify Physician of Low Blood Glucose Levels
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a significant change in the resident's condition. Specifically, the facility did not notify the physician when the resident's blood sugar levels were below the physician-ordered parameters on multiple occasions. The resident, who had severe cognitive impairment and required substantial assistance for activities of daily living, had a history of diabetes mellitus with hypoglycemic episodes. Despite the physician's order to notify for blood glucose levels less than 100 mg/dl, the facility staff did not notify the physician when the resident's blood glucose levels were recorded at 96 mg/dl, 87 mg/dl, 93 mg/dl, and 75 mg/dl on different dates. The nursing staff, including agency nurses, failed to follow the physician's orders due to a lack of awareness and understanding of the specific notification parameters. Interviews with the nurses revealed that they were accustomed to notifying the physician only for blood glucose levels below 60 or 70 mg/dl, based on their training and previous practices. The nurses did not fully read or understand the specific parameters set for this resident, and there was no documentation of physician notification for the low blood glucose readings. Additionally, the facility lacked clear guidelines, policies, or protocols for blood glucose monitoring, which contributed to the oversight. The facility's administration acknowledged the absence of a protocol or policy for diabetics or blood glucose monitoring. The Director of Nursing and other staff members confirmed that there was no in-service training provided to the agency staff regarding blood glucose monitoring or changes in condition. The lack of training and clear protocols led to the failure to notify the physician, which could potentially result in inadequate and untimely intervention for residents experiencing changes in their condition.
Incomplete Documentation of Blood Glucose Readings and Hospital Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the documentation of blood glucose readings and hospital stay records. The resident, who had severe cognitive impairment and required insulin injections, had missing blood glucose readings on several dates. Nurses, including agency staff, reported obtaining the readings but did not document them in the medical record due to the absence of a designated place for such entries. The Assistant Director of Nursing (ADON) acknowledged the oversight and mentioned that the facility had a triple-check system for new orders, which failed to catch the missing documentation. Additionally, the facility did not upload the resident's hospital records from a recent stay into the electronic medical record. The Administrative Services Manager, responsible for overseeing medical records, confirmed that the hospital records were not uploaded and explained the usual process for uploading such documents. The Director of Nursing (DON) stated that the expectation was for records to be uploaded within 24-48 hours after receipt, but this did not occur until after surveyor intervention. The lack of documentation for blood glucose readings and the delay in uploading hospital records could lead to incomplete and inaccurate medical records, potentially affecting the resident's care. The facility's policy on maintaining electronic medical records emphasizes the importance of complete and accurate documentation, which was not adhered to in this case.
Failure to Implement Comprehensive Care Plan for Diabetic Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with diabetes mellitus, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental needs. The care plan did not include physician-ordered parameters for notification of blood glucose levels or steps to take if the levels were outside of parameters, nor did it specify symptoms to monitor for low blood sugar. The MDS Coordinator stated that specifics related to diabetes care were not included in the care plan because they were listed in the physician orders, and she believed that staff should review the physician orders for specifics. The resident, who had severe cognitive impairment and required substantial dependence for ADL care, was on a regimen that included insulin injections and oral diabetes medications. Despite this, the care plan lacked details on the frequency of blood glucose monitoring and notification of the physician related to blood glucose levels. The Director of Nursing emphasized the importance of accurate documentation in the care plan to ensure proper treatment. The facility's policy required individualized comprehensive care plans with measurable objectives and timetables, which were not met in this case.
Failure to Provide Diabetic Care Post-Hospitalization
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of diabetes mellitus received appropriate treatment and care according to professional standards of practice and the resident's care plan. Upon admission from the hospital, the resident did not have supporting orders for diabetes management, which led to a lack of daily blood sugar assessments for several months. This oversight resulted in significantly elevated blood sugar levels, as evidenced by a hemoglobin A1C level of 9.9% and finger stick blood sugar readings of 300 and 453 mg/dL. The deficiency was identified as a result of interviews and record reviews, which revealed that the resident's diabetic interventions were not continued post-hospitalization. The charge nurse and other staff members were unaware of the resident's diabetic orders and interventions until several months later. The lack of communication and reconciliation of hospital discharge orders with previous diabetic management orders contributed to the oversight. Interviews with facility staff, including the Administrator, Director of Nursing, and the resident's Nurse Practitioner, highlighted a breakdown in the process of reviewing and implementing necessary diabetic interventions. The facility's failure to monitor and manage the resident's diabetes placed the resident at risk for complications associated with high blood sugar levels.
CNA Engages in Inappropriate 'Pillow Therapy' with Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse when a Certified Nursing Assistant (CNA) placed a pillow over the resident's face, referring to it as 'pillow therapy.' This incident occurred while the resident was lying on her bed and was witnessed by another CNA. The resident involved was a female with a history of chronic obstructive pulmonary disease (COPD), anxiety, and hemiplegia, and was assessed with no cognitive impairment. The incident was reported by the witnessing CNA to the Director of Nursing (DON), who then self-reported the event to the state agency. The alleged perpetrator, CNA H, admitted to the action, describing it as a joke between her and the resident. The facility's records indicated that the incident was part of a pattern of behavior by CNA H, who was known to care for residents with memory or communication challenges. The facility's investigation included interviews and record reviews, which confirmed the occurrence of the incident. The facility's policy on abuse, neglect, and exploitation was reviewed, which outlined procedures for prevention, identification, and reporting of such incidents. Despite the facility's efforts to address the situation, the initial failure to prevent the abuse placed the resident at risk of harm.
Failure to Develop Comprehensive Care Plans for Residents in Secured Memory Care Unit
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental needs. Specifically, the care plans for these residents did not address their need or placement on a secured memory care unit, despite their severe cognitive impairments and diagnoses of dementia. This deficiency was identified through observation, interviews, and record reviews of the residents' care plans and assessments. Resident #12 was admitted with diagnoses including unspecified dementia and severe cognitive impairment, as indicated by a BIMS score of 00. Despite being placed on a secured memory care unit, her care plan did not reflect this need. Similarly, Resident #28, also with severe cognitive impairment and unspecified dementia, had no care plan addressing her placement on the secured unit. Resident #44, diagnosed with Parkinson's disease and dementia, also had a care plan that failed to address his need for placement on the secured unit. Interviews with the Resident Assessment Coordinator, ADM, and DON revealed a lack of consensus and understanding regarding the necessity of including the secured memory care unit in the residents' care plans. The Resident Assessment Coordinator and ADM believed that the focus should be on the residents' diagnoses rather than their specific placement, while the DON emphasized the importance of care plans in ensuring staff awareness of special needs. The facility's policy on comprehensive care plans highlighted the need for individualized plans with measurable objectives, which was not adhered to in these cases.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means received appropriate treatment and services to prevent complications. Specifically, LVN C did not check for residual volume prior to medication administration, did not flush the enteral feeding tube per physician's orders, and administered the flush and medications with the syringe plunger instead of via gravity flow for Resident #12. These actions were observed during a medication pass and were confirmed through interviews and record reviews. Resident #12, a severely cognitively impaired female with multiple diagnoses including severe protein-calorie malnutrition and gastrostomy status, had specific physician orders for the administration of enteral feedings and medications. These orders included checking and recording residuals every shift, flushing the feeding tube with 20-30 ml of water before and after medication administration, and administering medications via gravity flow. However, LVN C deviated from these orders by not checking for residuals, using incorrect flush volumes, and administering medications with the syringe plunger. During interviews, LVN C admitted to not following the prescribed procedures, citing the need to be more forceful with Resident #12's feeding tube. The DON confirmed that pushing fluids and medications with the syringe plunger could traumatize the stomach and emphasized that the facility's policy required administering water and medications via gravity flow. The facility's policy and procedure for administering medications through an enteral tube were also reviewed, which aligned with the physician's orders and standard nursing practices.
Failure to Maintain Accurate Clinical Records
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for four residents. Specifically, Residents #12, #28, #33, and #44 were admitted to the locked memory care unit without physician orders. This deficiency was identified through record reviews, observations, and interviews with staff members. The records for these residents showed severe cognitive impairments and diagnoses of dementia, but there were no corresponding physician orders for their placement in the memory care unit. Resident #12 was admitted with diagnoses including unspecified dementia and severe cognitive impairment, as indicated by a BIMS score of 00. Despite being observed in the secure memory care unit, there was no physician order for this placement. Similarly, Resident #28, who also had severe cognitive impairment and a history of wandering, was found in the memory care unit without a physician order. Resident #33, with a history of wandering and severe cognitive impairment, and Resident #44, with dementia and Parkinson's disease, were also placed in the memory care unit without the necessary physician orders. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed a misunderstanding of the requirements for admitting residents to the memory care unit. Both stated that residents needed a diagnosis of Alzheimer's or dementia and consents but did not necessarily require physician orders. However, the facility's policy indicated that physician orders were required for such placements. This discrepancy led to the deficient practice of admitting residents to the memory care unit without proper documentation, potentially placing them at risk for errors in care and treatment.
Incomplete OOH DNR Document
Penalty
Summary
The facility failed to ensure that a resident's Out-of-Hospital Do Not Resuscitate (OOH DNR) order was properly completed, resulting in the document being invalid. Specifically, the OOH DNR for a resident was missing the physician's license number and the date of signature. This oversight was confirmed by the social worker, who acknowledged that the incomplete document rendered the resident's DNR status invalid, effectively making the resident full code status despite their wishes to the contrary. The resident in question was an elderly female with severe cognitive impairment and multiple medical conditions, including dementia and chronic respiratory failure with hypoxia. The social worker was responsible for initiating the OOH DNR process and confirmed that the document was uploaded into the electronic record without the necessary physician information. The facility's failure to ensure the completion of the OOH DNR could result in the resident receiving unwanted resuscitation efforts. A facility policy regarding Advance Directives was requested but not provided by the time of the exit interview.
Failure to Protect Resident Confidentiality
Penalty
Summary
The facility failed to respect the residents' right to confidentiality in their personal and medical records for one resident. Specifically, the facility did not ensure that an LVN locked the Medication Cart Computer screen, leaving Resident #14's information exposed. This incident was observed when the Medication Cart Computer screen was left open, unattended, and facing the hall with Resident #14's health information exposed for approximately nine minutes. The LVN admitted to leaving the screen unattended to answer the phone and acknowledged that this was a HIPAA violation. Resident #14 is a [AGE] year-old female with a medical history that includes rheumatoid arthritis, hypothyroidism, dysphagia, mood disorder, lack of coordination, and chronic pain. The Director of Nursing (DON) confirmed that it was the facility's expectation for staff to clear or push the walkaway button on the computer screen to protect resident information. The facility's policy and procedure on HIPAA Security Agreement emphasized the importance of maintaining the security and confidentiality of protected health information (PHI).
Inaccurate MDS Assessment Documentation
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident's status for one resident whose MDS records were reviewed for accuracy. Specifically, Resident #54's Quarterly MDS assessment incorrectly documented that the resident was discharged to a short-term hospital. However, the discharge progress note indicated that the resident was actually discharged home with a family member. This discrepancy was confirmed through interviews with the MDS Nurse and another LVN who wrote the discharge progress note, both of whom verified that the resident was discharged home and not to another facility. Resident #54 was admitted to the facility with diagnoses including Angina Pectoris, Atherosclerotic Heart Disease, and Type II Diabetes. The incorrect documentation in the MDS assessment could lead to inadequate care due to the inaccurate reflection of the resident's discharge status. The error was identified during a review of the resident's face sheet, discharge MDS assessment, and discharge progress note, and was later acknowledged by the MDS Nurse who stated that she was in the process of correcting it.
Failure to Remove Disposable Razors from Resident Rooms
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards for two residents with severe cognitive impairment. Resident #4 and Resident #28 were found to have disposable razors left on their bathroom counters. Resident #4, diagnosed with unspecified dementia and severe cognitive impairment, was observed with a green disposable razor on her bathroom counter on two separate occasions. The resident was unable to describe or recall using the razor. A CNA later disposed of the razor, acknowledging that residents should not have disposable razors for safety reasons. Similarly, Resident #28, also diagnosed with unspecified dementia and severe cognitive impairment, was observed with two pink disposable razors in a plastic cup on her sink counter on two separate occasions. A CNA and an LVN both expressed uncertainty about the facility's policy regarding disposable razors, with the LVN stating that such items should not be on the secure/memory care unit due to potential hazards. The Director of Nursing (DON) confirmed that the facility did not have an existing policy addressing the storage of disposable razors but acknowledged that razors should probably not be in residents' rooms on the secure unit. The facility's competency guidelines for shaving residents indicated that disposable razors should be stored in the treatment cart and disposed of appropriately. The facility's policy for the secured household emphasized promoting quality of life and protecting the safety and wellbeing of residents, but it did not specifically address the issue of disposable razors. This oversight in policy and practice led to the presence of potentially hazardous items in the rooms of cognitively impaired residents, posing a risk of harm or injury.
Failure to Secure Medication Cart and Update Medication Labels
Penalty
Summary
The facility failed to ensure the Household Treatment Cart was locked and secured when it was left unattended. During an observation, the cart was found unlocked and facing the hallway next to the dining area. RN G admitted to using the cart for a resident's treatment and acknowledged that it should not have been left unlocked, as it contained tubes of topical medication, shaving razors, oxygen supplies, and nail clippers. The DON confirmed that it was expected for medication/treatment carts to be locked and secured when not in use to prevent unauthorized access and potential harm to residents. Additionally, the facility failed to update the medication label for a resident after a change in medication orders. The resident, who had diagnoses including cardiomegaly, hyperlipidemia, and hypertension, was prescribed Carvedilol. However, the label on the medication package did not match the physician's order, indicating an incorrect dosage. LVN E noted the discrepancy during a medication pass and expressed concern that the incorrect dosage could lead to adverse effects. The DON confirmed that medication labels must match physician orders and that discrepancies could result in incorrect dosages being administered.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two staff members. One incident involved an LVN who did not sanitize or wash her hands between glove changes and turned off the water faucet with her bare hands after washing, leading to potential contamination. This occurred while administering medications to a resident with multiple diagnoses, including severe cognitive impairment and gastrostomy status. The LVN acknowledged the importance of hand hygiene and admitted to the oversight during an interview. Another incident involved an RN who used gloves from her pocket to administer a pain patch to a resident. The RN removed the old patch, disposed of the gloves, and then retrieved new gloves from her pocket, which also contained keys and scissors, leading to potential cross-contamination. The RN admitted that placing gloves in her pocket was against protocol and could result in contamination. The Director of Nursing (DON) confirmed that the facility's expectations for hand hygiene were not met in these instances. The DON emphasized the importance of using a disposable towel to turn off faucets and performing hand hygiene between glove changes to prevent contamination. The facility's policy on infection prevention and control, as well as the performance evaluation checklist for handwashing, were not adhered to by the staff involved in these incidents.
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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.
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legend Oaks Healthcare And Rehabilitation - West S | 1.2 mi | ★★★★★ | 11 | 0 |
| Harbor Valley Health And Rehabilitation | 3.2 mi | ★★★★★ | 19 | 1 |
| Lakeside Nursing And Rehabilitation Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Westover Hills Rehabilitation And Healthcare | 4.9 mi | ★★★★★ | 6 | 0 |
| Windemere At Westover Hills | 5.5 mi | ★★★★★ | 6 | 0 |
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