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 Plaza At Lubbock during CMS and state inspections, most recent first.
Unsafe and Poorly Maintained Bathroom and Shower Areas: A public bathroom near the nurse's station had a loose toilet seat that moved several inches, and shower rooms on Hall 200 and Hall 400 had loose and missing tiles, a broken shower door, water-damaged vanity, and corrosion and calcium buildup under a sink faucet. CNA E and the MS stated the issues were known, with maintenance requests reportedly entered, but the repairs had not been completed.
A resident meal service deficiency occurred when lunch trays for regular, mechanical soft, and pureed diets were found to be bland, poorly flavored, and inconsistent in taste and texture. Surveyors sampled the trays and noted processed/plastic taste in the ham, bad taste in pureed items, and a strong acidic taste in the tomato soup substitution. Staff acknowledged that food was not always tasted before service, that a recipe change may have altered the pureed spinach bake, and that residents had complained about food taste and seasoning.
Kitchen Food Storage and Sanitation Deficiencies: The facility failed to store, prepare, distribute, and serve food according to professional standards. Observations found bowls and plates stored right side up, a dirty deep fryer with food crumbs and dark oil, a grease-covered oven door, unlabeled and undated food items in the refrigerator, and improperly sealed items in dry storage. Staff interviews confirmed kitchen staff were responsible for cleaning, labeling, and dating food items, and the DM stated bowls and plates should have been stored upside down.
The facility failed to maintain infection control during EBP and personal care. An LVN administered g-tube meds to a resident on EBP without a gown, another resident on EBP had no door sign or PPE box in the room, and CNAs failed to remove a dirty bed pad, change gloves, or perform hand hygiene during incontinence and foley care. The residents involved had significant medical conditions including wounds, trach/PEG, bladder incontinence, and cognitive impairment.
PASRR Level I assessments for two residents did not accurately reflect their mental health status. One resident had syringomyelia and syringobulbia with a history of bipolar II, and the other had lack of coordination with a history of bipolar II and dementia; both had MDS records showing psychiatric/mood disorders and medication orders consistent with bipolar treatment, yet their PASRR forms marked mental illness as no. Staff interviews confirmed both residents had bipolar II and that the PASRRs were not accurate.
Puree Foods Not Prepared to Proper Texture: A surveyor observation found that a puree meal tray included ham with small chunks that required chewing and spinach bake with a thick consistency that also required chewing. An LPN-level kitchen staff member stated puree should be pudding-like and smooth, while the DM and ADM said puree foods should not require chewing and that staff had been trained on proper food forms.
A resident with a full code status was found unresponsive with no pulse or respirations, but the RN on duty did not initiate CPR, believing the resident showed signs of death. The resident's medical history included malignant neoplasm and other conditions. EMS later noted the absence of rigor mortis, and the RN's documentation was incomplete. Interviews revealed inconsistencies in understanding and executing the facility's CPR policy, leading to a risk for residents with full code status.
A resident was mistakenly given lorazepam, a medication not prescribed to her, due to a mix-up with medication cards. The error was identified by a Med Aid, but the responsible RN did not immediately notify the physician, family, or DON, nor did he initiate increased monitoring. The facility's policies on medication error reporting and change of condition notification were not followed, leading to a delay in communication and monitoring.
A resident received lorazepam without a physician's order due to a misidentification by an RN, who administered the medication to the wrong resident. The error was not immediately reported to the physician or family, delaying necessary monitoring and assessment. The facility's policy for reporting medication errors was not followed, contributing to the deficiency.
A facility failed to protect residents from abuse and neglect, with incidents involving inappropriate sexual comments by an RN towards a resident, verbal abuse and neglect by a CNA towards another resident, and rough handling by the same CNA towards a third resident. These actions led to emotional and physical distress for the residents involved.
A CNA in an LTC facility was observed taking a bag of chips from a resident's room without consent, violating the facility's policy on misappropriation of property. The resident, who had multiple medical conditions and a BIMS score of 00, was unable to communicate effectively. The CNA claimed the resident indicated the chips were a gift, but the facility's policy prohibits accepting gifts or taking residents' belongings without consent.
The facility failed to inform 7 out of 18 residents about their rights to file grievances, including the process, access to forms, and the ability to file anonymously. The grievance procedure was not posted, and residents were unaware of how to submit grievances or receive written decisions.
The facility failed to provide scheduled activities for residents, impacting their physical, mental, and psychosocial well-being. Observations revealed that activities like Washer Toss, Outdoor Lemonade Social, and Bible Study were not conducted as planned, leaving residents waiting without communication from the AD. Interviews indicated a lack of adherence to the activity schedule and insufficient alternative arrangements when activities were canceled or delayed.
The facility failed to properly label and store drugs and biologicals, as observed during a treatment cart inspection. A tube of Medihoney gel and zinc oxide ointment were not dated when opened, and a single-use collagen powder packet was found open without a date. An expired hydrofera blue wound dressing was also found. Staff interviews confirmed these items should have been dated or discarded, highlighting a lapse in adherence to facility policy.
The facility failed to properly label and date food items in the kitchen, as observed during multiple inspections. Unlabeled and undated items included mayonnaise, mustard, sandwiches, milk, egg salad, salsa, juice, and tartar sauce. Interviews with the KMGR and ADM confirmed that the facility's policy required labeling and dating of all food items to prevent foodborne illnesses. The oversight in adhering to these standards could risk food contamination.
The facility failed to maintain an effective infection prevention and control program, with multiple instances of improper hand hygiene and wound care techniques observed among staff. Several CNAs and an LVN did not adhere to proper handwashing protocols before and after providing care to residents, including those with conditions like Parkinsonism and pressure ulcers. Additionally, a CNA failed to sanitize hands between serving meals, risking cross-contamination. Despite receiving training, staff cited nervousness and lack of adherence to protocols as reasons for these deficiencies.
A resident's privacy was compromised during wound care when a CNA and LVN failed to pull the privacy curtain, despite closing the door. The resident, with multiple medical conditions, was exposed during the procedure. Staff interviews revealed a lack of awareness about the necessity of using the privacy curtain, despite training. The facility lacked a specific policy on this matter.
Two residents in an LTC facility received inadequate wound care due to improper techniques used by an LVN. The LVN failed to use a new gauze pad for each cleaning, increasing the risk of infection. Despite training, the LVN admitted to not following correct procedures. The facility's policy lacked specific guidance on cleaning techniques.
A resident in a LTC facility reported feeling violated after a straight catheter procedure was performed without informed consent while she was asleep. The resident, who was cognitively intact and continent, was not informed of the need for a repeat urine sample due to contamination of the previous sample. Facility staff failed to document a physician order for the procedure, and there was a lack of proper communication and consent, leading to the resident's distress and a police report.
A facility failed to protect two residents from abuse, resulting in a deficiency. One resident underwent an invasive catheter procedure without consent, causing her distress, while another resident faced verbal abuse from a CNA. The catheter procedure lacked a physician's order and was performed at an inappropriate time, contributing to the resident's trauma. The verbal abuse occurred at the nurse's station, showing a lack of respect for the resident's dignity.
A resident with a history of acute kidney failure and muscle weakness reported UTI symptoms, but the facility failed to notify the physician immediately. Despite the resident's complaints, there was no documentation of communication with the physician, contrary to the facility's policy. Interviews revealed discrepancies in the notification process, with the RN believing he had informed the FNP, who stated she received no such communication.
A resident with a history of acute kidney failure underwent a straight catheter procedure without a physician's order after a urine sample was deemed contaminated. The procedure was performed while the resident was asleep, without her consent, and contrary to facility policies on urine specimen collection and physician orders. The resident reported feeling violated and traumatized by the experience.
A resident with a history of acute kidney failure and muscle issues did not receive required lab tests upon admission, as per physician orders. The tests were delayed, despite the resident showing symptoms, due to unclear responsibilities and communication among staff. The facility's policy for obtaining and transcribing orders was not followed.
A resident reported symptoms of a UTI, but the facility failed to document communication between staff and the FNP or obtain proper orders for a UA. A straight catheterization was performed without prior consent, leading to the resident feeling violated. Interviews revealed a lack of communication and documentation, contrary to the facility's policy.
The facility failed to provide accurate pharmaceutical services, resulting in undocumented medication administration and medication errors for multiple residents. Medications were not administered within the prescribed 2-hour window, and narcotic sheets were not reconciled properly, with one MA documenting administration while not clocked in. These failures could lead to serious medication errors and adverse effects for the residents.
The facility failed to document medication administration for 41 out of 46 residents reviewed, risking incorrect medication dosages. Multiple residents had scheduled medications that were not recorded in the MAR, and there was no documentation of physician notification for these errors.
The facility failed to immediately inform residents, consult with physicians, and notify representatives of medication errors for two residents. Despite identifying the errors on the same day, notifications were delayed until over a week later. This delay could have resulted in unawareness of changes in the residents' conditions, although no negative outcomes were reported.
Unsafe and Poorly Maintained Bathroom and Shower Areas
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in multiple areas of the building. During observation, the public bathroom near the nurse's station had a toilet seat that was broken and moved from side to side about 3 to 4 inches. The report also identified concerns in shower rooms on Hall 200 and Hall 400, including loose and missing tiles, a broken shower room door on Hall 200, water damage to a vanity, and corrosion and calcium buildup under a hand sink faucet. During observation and interview, the shower room on Hall 200 was seen with two large areas of red tape, each about 12 by 12 inches, covering missing tiles in the shower. CNA E stated the tape had been on the wall for about one year and that the MS was aware of the missing tiles and had requested a work order. The same shower room door was observed broken at the top half, with the wood separating down the side for about 12 inches, and CNA E stated the MS was aware of that issue as well. The MS stated he was aware of the tape covering missing tiles, loose tiles, water damage to the vanity, the broken door in the Hall 200 shower room, the broken toilet seat in the public bathroom, and the corrosion and buildup under the faucet in the Hall 400 shower room. He stated he was responsible for maintenance requests, checked the request book daily, and prioritized work based on resident safety and need. The ADM stated she was not aware of the repairs needed in the shower rooms or the broken toilet seat, and said the MS was responsible for maintenance requests and daily walk-throughs. The facility policy stated maintenance service shall be provided to all areas of the building, grounds, and equipment and that the building must be maintained in safe and operable condition at all times.
Food Served Was Bland and Inconsistent Across Meal Textures
Penalty
Summary
The facility failed to ensure that food served for lunch was palatable, attractive, and at a safe and appetizing temperature for regular, mechanical soft, and pureed food forms. During confidential interviews, 3 of 15 residents reported concerns about food palatability, stating that the food was not good, lacked flavor, was very bland, and tasted like nothing. On observation, test trays arrived in the family dining room and were sampled by surveyors. The regular baked ham was described as bland, the mechanical soft baked ham had a processed/plastic taste and lacked flavor, and the pureed baked ham had a processed/plastic taste, lacked flavor, was very chunky, and required chewing. The pureed spinach bake did not taste like the regular spinach bake and had a bad taste and very thick consistency, and the pureed bread had a bad taste. The regular tomato soup substitution had a strong acidic taste and bad taste. During interviews, the ADM stated the pureed spinach bake and regular spinach did not have the same taste. The dietary staff member stated he sometimes tasted food before serving it, but not all the time, and said breadcrumbs had been added to the pureed spinach bake the day before, which may have changed the taste. He also stated the mechanical soft ham was delivered already chopped, the pureed ham was made from the mechanical soft ham, and the ham had a different texture than the regular ham, though he did not know why because it was delivered that way. He stated he had tasted the pureed ham from the lunch meal and it had a gritty taste, and that residents had complained about the tomato soup not tasting good. The DM and ADM both acknowledged concerns about food taste and stated that residents could eat less and lose weight if the food did not taste good. Record review showed four food-related complaints in the grievance log and resident council concerns that food on the halls could be cold, flavorless, and inconsistently seasoned. The facility policy stated recipes were to be used and followed when preparing menu items.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation, stacks of bowls and plates were stored right side up on metal shelves, leaving the inside surfaces exposed. The deep fryer contained small brown food crumbs in the baskets and along the inside, the oil was dark brown, and there were food crumbs and grease splatter inside the fryer. The oven door had seven lines of brown grease dripping from the top to the bottom of the door. The refrigerator contained five sandwiches, one block of yellow cheese, and three pitchers of juice that were all unlabeled and undated. The dry storage area had a large container of salt, a box of potato pearls, and a box of baking soda that were not fully sealed, with the potato pearls dated 01/04/26 and the other items undated. The walk-in freezer contained a large container of hard-boiled eggs with a best use by date of 01/01/26. Staff interviews confirmed the kitchen staff were responsible for cleaning, labeling, and dating food items, and the DM stated the deep fryer was expected to be deep cleaned every Friday and that bowls and plates should have been stored upside down.
Infection Control Failures During EBP and Incontinence Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for residents observed during survey. During medication administration, an LVN provided g-tube medications to a resident with a tracheostomy, gastrostomy tube, dysphagia, and an order for Enhanced Barrier Precautions (EBP) without wearing a PPE gown. The LVN stated she did not notice the blue EBP tag behind the resident’s name and said the PPE box had been placed in the bathroom instead of inside the room. A second resident with cerebral palsy, severe cognitive impairment, a stage 4 sacral ulcer, and an order for EBP related to wounds did not have an EBP sign on the door or a PPE box available in the room during observation. The care plan and physician orders identified EBP for the resident, and the facility’s records noted that EBP was to be used for wounds and that signs and PPE were to be placed in the resident’s room. During incontinence and foley care observations, CNA B removed a dirty brief from a resident with Parkinson’s disease, diabetes, and bladder incontinence, then laid the resident on a dirty bed pad and placed a clean brief without removing the pad. During foley care for another resident with COPD, diabetes, liver cirrhosis, and moderate cognitive impairment, CNA C did not change gloves or perform hand hygiene when moving from dirty to clean tasks, and CNA D did not perform hand hygiene between glove changes. The facility’s policies stated that hand hygiene is required after glove removal and that perineal care requires disposal of gloves, hand hygiene, and application of new gloves before placing a new brief.
PASRR Level I Assessments Did Not Reflect Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that PASRR Level I assessments accurately reflected the mental health status of 2 of 24 residents reviewed for PASRR screening. Resident #5 was admitted with a primary diagnosis of syringomyelia and syringobulbia and had a medical history that included bipolar II, multiple sclerosis, and type 2 diabetes. His admission MDS showed a BIMS score of 12 and identified bipolar disorder as an active psychiatric/mood disorder, and his physician orders included aripiprazole. However, his PASRR Level I form dated 9/24/2025 marked mental illness as "NO." Resident #16 was admitted with a primary diagnosis of lack of coordination and had a medical history that included bipolar II, type 2 diabetes, muscle weakness, and dementia. His quarterly MDS showed a BIMS score of 0 and identified bipolar disorder and depression as active psychiatric/mood disorders. His care plan referenced anticonvulsant medication monitoring, and his physician orders included divalproex sodium, which was ordered twice daily. Despite these findings, his PASRR Level I form dated 4/08/2024 marked mental illness as "NO" and identified dementia as the primary diagnosis. During interviews, the MDS Nurse stated she reviewed PASRRs for accuracy by checking diagnoses and social security information, and she stated both residents had bipolar II, which she identified as a mental illness. She stated Resident #5 would need reevaluation by the local authority to correct the PASRR, while Resident #16 could have dementia as his primary diagnosis. The ADM stated the MDS Nurse was responsible for requesting changes or updates to PASRRs and stated she did not believe the PASRRs for either resident were accurate because both residents had bipolar II.
Puree Foods Not Prepared to Proper Texture
Penalty
Summary
The facility failed to ensure that puree-texture foods were prepared in a smooth, uniform form designed to meet individual needs for 1 of 1 noon meals observed. During an observation on 01/07/26 at 12:40 PM, [NAME] A prepared puree ham, bread, spinach bake, and potatoes and provided a sample tray to the surveyors. The surveyors tasted the puree ham and found small chunks of meat that required chewing, and the spinach bake had a very thick consistency and also required a small amount of chewing. During interviews on 01/08/26, [NAME] A stated puree should be a pudding-like texture and smooth when touched to the top of the mouth, and he said the puree ham tasted gritty. The DM stated [NAME] A had been trained on puree texture but she did not know why the puree ham and spinach were not the proper texture for puree form. The ADM stated she expected puree foods to be smooth and not require chewing, and that kitchen staff had been trained in proper food forms, though she did not remember the last time before 01/07/26 that training occurred. Record review of the facility policy titled, Use of Recipes, stated recipes are to be used when preparing menu items and nutrition services employees are expected to use and follow the recipes provided.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to provide basic life support, including CPR, for a resident who was found unresponsive with no pulse or respirations. The resident was documented as having a full code status, meaning all resuscitation procedures should have been provided during a medical emergency. However, the RN on duty did not initiate CPR upon discovering the resident in this state. The RN believed the resident was deceased based on her assessment, which she claimed showed signs of death, although these signs were not fully documented. The resident, a male with a history of malignant neoplasm and other medical conditions, was found unresponsive in his room by a CMA. The CMA reported the situation to the RN, who then assessed the resident and found no pulse or respirations. Despite the resident's full code status, the RN did not perform CPR, citing the presence of signs of death, which included cold skin and cyanosis. However, EMS staff later noted that the resident did not exhibit rigor mortis, and the RN's documentation was incomplete regarding the assessment of death signs. Interviews with facility staff revealed inconsistencies in the understanding and execution of the facility's policy on code status and CPR initiation. The RN believed the resident was a DNR based on computer records, which was incorrect. The facility's policy required CPR to be initiated unless all signs of death were present, which was not adequately assessed or documented by the RN. This failure to initiate CPR placed residents with a full code status at risk, as the facility did not ensure that staff followed proper procedures for resuscitation.
Removal Plan
- DON or designated nurse will in service all licensed nurses on policy and procedure for identifying code status on residents. No nurses will be allowed to work until training has been completed. Any nurses who did not receive training will receive training prior to the start of their next shift.
- DON or designee will educate all staff on emergency policy and procedures when residents are found to be unresponsive. No nurses will be allowed to work until training has been completed. Any nurses who did not receive training will receive training prior to the start of their next shift.
- DON or designee will monitor 10 staff members per week on competency of 7 signs of death/active signs of death, competency of nurses printing code statuses from EMR and on person, and CNA competency on code status on POC.
- Proof of the education will be submitted to QA committee.
- An Ad Hoc QAPI meeting will be held with the Medical Director, facility administrator, director of nursing, and social services director to review plan of removal.
- Administrator will forward results of audits monthly to the QAPI Committee for review and/or action.
- The Director of Nursing/designee will be responsible for implementation of New Process. The New Process/system will be started and no employee be able to return to work until they complete the Inservice.
Failure to Notify Physician and Family After Medication Error
Penalty
Summary
The facility failed to notify a resident's physician and family regarding a change in the resident's condition after a medication error occurred. RN C administered lorazepam, a medication not prescribed to Resident #1, due to a mix-up with medication cards. This error was discovered shortly after administration, but RN C did not immediately notify the physician, the family, or the Director of Nursing (DON) as required by facility policy. Resident #1, a cognitively intact female with a history of urinary tract infection, obstructive sleep apnea, and muscle weakness, was mistakenly given lorazepam, which was intended for another resident with a similar last name. The error was identified by Med Aid D, who informed RN C of the mistake. Despite this, RN C did not take immediate action to notify the necessary parties or initiate increased monitoring of Resident #1, who was later found to be difficult to arouse the following morning. Interviews with facility staff revealed that RN C assumed Med Aid D would handle the notification process, which led to a delay in informing the physician and family. The DON was not made aware of the incident until the following day, and the physician was only notified after Resident #1's family expressed concerns. The facility's policies on medication error reporting and change of condition notification were not followed, resulting in a lack of timely communication and monitoring for potential adverse effects.
Medication Error Due to Misidentification
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a dose of lorazepam was administered without a physician's order. The error occurred when RN C misread the medication card and administered lorazepam to the wrong resident, who did not have an order for this medication. The resident who received the medication was cognitively intact and had a medical history of urinary tract infection, obstructive sleep apnea, and muscle weakness. The error was discovered shortly after administration, but the physician and family were not notified until the following day. The incident was compounded by a lack of immediate communication and documentation. RN C, who was responsible for the error, did not notify the physician, family, or the Director of Nursing (DON) immediately after the error was discovered. Instead, the error was reported to the DON the following day by Med Aid D, who had been informed of the mistake by RN C. The delay in notification meant that the resident did not receive increased monitoring or assessment immediately following the error. Interviews with staff revealed that RN C was aware of the error shortly after it occurred but did not follow the facility's policy for reporting medication errors. The facility's policy requires immediate evaluation of the patient, notification of the physician and nurse manager, and completion of a Medication Error Report. The DON was not informed of the error until the next day, and the physician was only notified after the DON intervened. This lack of adherence to protocol contributed to the deficiency in ensuring residents were free from significant medication errors.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by inappropriate behavior from staff members towards three residents. Resident #1, a female with multiple medical conditions including spinal stenosis and acute kidney failure, experienced inappropriate sexual comments from RN A. These comments made Resident #1 feel ashamed and embarrassed, leading her to avoid RN A for wound care. The situation was reported by LVN D after Resident #1 confided in her about the discomfort caused by RN A's behavior. Resident #2, a male with conditions such as Parkinsonism and chronic heart failure, faced verbal abuse and neglect from CNA B. Resident #2 reported that CNA B yelled at him for mistakenly addressing her as 'sir' and failed to change his saturated brief, leaving him in discomfort. Despite Resident #2's attempts to communicate his needs, CNA B's response was dismissive, and she did not return to assist him, indicating neglect in care. Resident #3, a male with heart failure and muscle weakness, reported rough handling by a CNA during transfers from his wheelchair to the commode. The description provided by Resident #3 matched CNA B, who was known to be rough and loud with residents. Despite reports of such behavior, the facility's administration was not fully aware of the extent of abuse or neglect by CNA B. The facility's policy on abuse and neglect was reviewed, but the incidents highlight a failure to adhere to these guidelines, resulting in emotional and physical distress for the residents involved.
Misappropriation of Resident's Property by CNA
Penalty
Summary
The facility failed to protect a resident from the misappropriation of property, specifically a bag of chips, by a Certified Nursing Assistant (CNA). The incident involved a resident with multiple medical conditions, including chronic kidney disease, osteoarthritis, vascular dementia, and cognitive communication deficit, who was unable to communicate effectively due to a BIMS score of 00. The CNA was observed via video evidence taking a bag of chips from the resident's room without consent. The CNA claimed that the resident had pointed to the chips and indicated they were a gift, but the CNA did not take them at that time and later retrieved them, leading to the accusation of misappropriation. The facility's employee handbook and policy on abuse, neglect, and misappropriation clearly prohibit accepting gifts or taking residents' belongings without consent. The CNA admitted to not understanding that taking a snack from a resident was considered misappropriation. Interviews with the Director of Nursing (DON) and the Administrator (ADM) highlighted the potential negative outcomes of such actions, emphasizing the importance of protecting residents' personal belongings. The facility's policy defines misappropriation as the wrongful use of a resident's belongings without consent, which was violated in this instance.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to provide information to residents and their representatives regarding their rights related to filing grievances or concerns. This deficiency was identified for 7 out of 18 confidential residents. These residents were not informed about the grievance process, did not know where to obtain or submit a grievance form, and were unaware of their right to file grievances anonymously. Additionally, the grievance procedure was not discussed during confidential interviews, and there were no postings of the grievance procedure in prominent locations within the facility. During interviews, the residents expressed that they were unaware of how to file a grievance, where to acquire a grievance form, or who to submit it to. They also did not know that they had the right to receive a written decision once their grievance was resolved. These residents had been in the facility for over six months, indicating a prolonged period without proper information on their rights to file grievances. The facility's grievance policy, last updated in 2020, states that residents should be provided with written information on how to file a grievance upon admission. However, the facility did not adhere to this policy, as observed during the survey. The Administrator, who also served as the Grievance Officer, acknowledged that the grievance procedure was not posted for residents and that there was no means for residents to submit grievances anonymously. The Administrator also noted that grievances were resolved through face-to-face discussions, but there was no written grievance form accessible to residents.
Failure to Provide Scheduled Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group, individual activities, and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of 7 of 18 residents reviewed for quality of life. Observations and interviews revealed that scheduled activities such as Washer Toss, Outdoor Lemonade Social, Music Works, Name that Tune, and Bible Study were either not started on time or did not occur at all. Residents expressed their dissatisfaction with the activities not starting on time and the lack of communication from the Activity Director (AD) regarding the status of these activities. On multiple occasions, residents were observed waiting for scheduled activities that did not take place. For instance, during the Washer Toss activity, residents were left waiting without any communication from the AD. Similarly, the Outdoor Lemonade Social and Music Works activities were not conducted as planned, leaving residents waiting without any alternative arrangements. The AD was not present during these scheduled times, and residents reported that activities rarely happened as scheduled, leading them to socialize among themselves instead. Interviews with the AD and the Administrator (ADM) revealed discrepancies in the execution of the activity schedule. The ADM expected the AD to follow the activities on the calendar, inform residents of any changes, and ensure activities began on time. However, the AD admitted to not moving activities to alternative locations when the dining room was unavailable and did not perceive any resident dissatisfaction with the activities not occurring as scheduled. The facility's activity policy emphasized the importance of providing a variety of activities to meet residents' interests and well-being, but the observed practices did not align with these expectations.
Deficiency in Drug and Biological Labeling and Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled according to professional principles, as observed during a treatment cart inspection. Specifically, a tube of Medihoney gel and a tube of zinc oxide ointment were not dated when opened, and a single-use collagen powder packet was found open without a date or resident information. Additionally, a package of hydrofera blue wound dressing was found with an expired date. These observations were confirmed during interviews with LVN A, the DON, and the ADM, who acknowledged that the items should have been dated or discarded as appropriate. The facility's policy requires that medications be labeled with appropriate auxiliary and cautionary instructions, and that non-prescription medications not labeled by the pharmacy be kept in their original containers. The failure to adhere to these policies was attributed to oversight, as staff are responsible for checking treatment carts for expired and undated supplies. The potential negative outcomes of these deficiencies include the use of expired or contaminated supplies, which could affect the effectiveness of treatments and potentially harm residents.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a series of kitchen tours. On the first day, several food items were found unlabeled and undated, including mayonnaise and mustard cups, sandwich halves, milk, egg salad, salsa, juice, and tartar sauce. These items were identified by the kitchen manager (KMGR) after being pointed out. On subsequent days, some items were dated, but new unlabeled and undated items were found, such as juice flutes and pitchers of liquids. Interviews with the KMGR and the administrator (ADM) revealed that the facility's policy required all food items to be labeled and dated when opened or prepared. The KMGR acknowledged the oversight and stated that dates were added based on her recollection of when the items were prepared. Both the KMGR and ADM emphasized the importance of proper labeling and dating to prevent foodborne illnesses. The ADM also noted that items should not be backdated and should be discarded if the preparation date is uncertain. The facility's policies on food storage and hand hygiene were reviewed, highlighting the requirement for proper labeling and dating of food items and the importance of hand hygiene to prevent infection. The FDA Food Code was also referenced, which mandates that ready-to-eat, time/temperature control for safety food must be clearly marked with a date for consumption or disposal if held for more than 24 hours. The failure to comply with these standards could place residents at risk for food contamination and foodborne illness.
Inadequate Infection Control Practices Observed
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and wound care techniques observed among staff members. Specifically, several Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) did not adhere to proper handwashing protocols before and after providing care to residents. For instance, CNA A did not use proper hand hygiene when assisting with incontinent care for a resident, and CNA C failed to wash hands before gathering supplies for incontinent care. Additionally, LVN A did not use proper wound care techniques, and CNA D did not wash hands before or after assisting with wound care for residents. The report highlights specific cases involving residents with various medical conditions, including Parkinsonism, dementia, and pressure ulcers, who were at risk due to these lapses in infection control practices. For example, Resident #7, who was cognitively intact, was assisted by CNA E, who did not use soap after providing incontinent care. Similarly, Resident #15, who had a stage 2 pressure ulcer and was moderately cognitively impaired, was cared for by CNA C, who did not wash hands properly before and after providing care. These actions could potentially lead to the spread of infections among residents. Furthermore, the report details observations of CNA F failing to sanitize hands between serving meals to residents, which could contribute to cross-contamination. Interviews with staff members revealed that although they had received training in infection control practices, nervousness and lack of adherence to protocols were cited as reasons for the observed deficiencies. The facility's policies on infection control and hand hygiene were not consistently followed, as evidenced by the repeated failures in maintaining proper hygiene standards during care and meal service.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during wound care, which was observed by surveyors. A Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN) did not pull the privacy curtain while providing wound care to a resident, despite closing the door. This oversight occurred during a procedure that required the resident's pants to be removed, leaving the resident potentially exposed. The resident, a female with multiple medical conditions including spinal stenosis, acute kidney failure, and diabetes, was admitted to the facility with specific wound care orders. Interviews with the involved staff revealed a lack of awareness regarding the necessity of using the privacy curtain in addition to closing the door. Both the CNA and LVN acknowledged their training in privacy and dignity but failed to apply it in this instance. The Director of Nursing (DON) and the Administrator confirmed that staff are expected to use both the door and curtain to ensure privacy, and they recognized the potential for emotional distress and embarrassment for the resident due to this oversight. The facility did not have a specific policy on pulling privacy curtains during care.
Improper Wound Care Techniques Observed
Penalty
Summary
The facility failed to ensure that residents with pressure ulcers received the necessary treatment and services consistent with professional standards of practice. This deficiency was observed in the care provided to two residents, who were at risk of complications due to improper wound care techniques. LVN A, responsible for the wound care, did not adhere to the correct wound cleaning techniques, which could potentially lead to the spread of bacteria and infection. Resident #87, a male with multiple medical conditions including a fracture, senile degeneration of the brain, and Guillain-Barre syndrome, was observed receiving wound care that did not follow proper procedures. The LVN used the same gauze pad multiple times to clean the wound, which is against the recommended practice of using a new gauze pad each time to prevent contamination. The resident's care plan and physician orders indicated the need for specific wound care, but these were not followed correctly during the observed procedure. Similarly, Resident #257, a female with conditions such as spinal stenosis, acute kidney failure, and diabetes, also received inadequate wound care. The LVN repeated the same improper technique of using the same gauze pad multiple times on different wounds, increasing the risk of infection. Despite being trained by a wound care education center, the LVN admitted to not following the correct procedures due to nervousness. The facility's policy on wound care did not provide specific guidance on the cleaning technique, contributing to the deficiency.
Failure to Obtain Informed Consent for Medical Procedure
Penalty
Summary
The facility failed to ensure that a resident was treated with respect, dignity, and care, specifically in obtaining informed consent for a medical procedure. The incident involved a female resident with a history of acute kidney failure, muscle weakness, and muscle wasting, who was cognitively intact and required moderate assistance with toileting hygiene. The resident was always continent and did not have any urinary appliances. On a particular night, staff performed a straight catheter procedure to collect a urine sample without obtaining clear informed consent from the resident, who was asleep at the time. The resident reported feeling violated by the procedure, which was performed at approximately 3:30 AM. She stated that she was not informed about the need for a repeat urine sample due to contamination of the previous sample until after the catheterization was completed. The resident expressed that she would have refused the catheterization if she had been awake and informed, preferring to provide a urine sample herself. The procedure was described as painful, and the resident reported the incident to the facility administration and the police, feeling that the procedure was unnecessary and handled inappropriately. Interviews with facility staff revealed a lack of proper documentation and communication regarding the procedure. The Director of Nursing (DON) and Administrator (ADM) acknowledged that there was no physician order for the straight catheter procedure and that consent was typically obtained verbally. The staff involved in the procedure claimed that the resident was awake and communicated during the process, but the resident's account differed, indicating she was not fully aware or consenting. The incident highlighted deficiencies in the facility's processes for obtaining informed consent and documenting medical procedures.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a deficiency. The first incident involved a resident who was subjected to an invasive straight catheter procedure without her consent while she was asleep. The resident, who was cognitively intact and had no history of using catheters, reported feeling violated and traumatized by the procedure. The facility staff did not have a physician's order for the procedure, and there was no documentation of consent or communication with the resident prior to the procedure. The procedure was performed at an inappropriate time, around 3:30 AM, which contributed to the resident's distress. The second incident involved verbal abuse directed at another resident by a Certified Nursing Assistant (CNA). The CNA repeatedly called the resident names and belittled him, even after being instructed to stop. This behavior occurred at the nurse's station, indicating a lack of respect for the resident's dignity and a failure to maintain a safe and supportive environment. Both incidents highlight significant lapses in the facility's duty to protect residents from abuse and ensure their well-being. The lack of proper documentation, communication, and adherence to procedures contributed to these deficiencies, placing residents at risk of physical harm, mental anguish, and emotional distress.
Failure to Notify Physician of Resident's UTI Symptoms
Penalty
Summary
The facility failed to immediately inform a resident's physician of a significant change in the resident's condition, specifically symptoms of a urinary tract infection (UTI). The resident, a cognitively intact female with a history of acute kidney failure, muscle weakness, and muscle wasting, reported pain and discomfort during urination on a specific date. Despite the resident's complaints, there was no documentation in the nursing notes of communication with the physician regarding this change in condition. The facility's policy requires immediate notification of the physician for acute or sudden changes in a resident's condition, which was not adhered to in this case. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed discrepancies in the notification process. The RN believed he had notified the Family Nurse Practitioner (FNP) and collected a urine sample, but there was no documentation to support this. The FNP stated she did not receive any communication regarding the resident's UTI symptoms. The facility's policy emphasizes the importance of documenting all communication and actions taken in response to changes in a resident's condition, which was not followed, leading to a delay in medical treatment for the resident.
Inappropriate Catheter Procedure Without Physician Order
Penalty
Summary
The facility failed to ensure a resident, who was continent of bowel and bladder, received appropriate treatment for a urinary tract infection. The resident, a cognitively intact female with a history of acute kidney failure, muscle weakness, and muscle wasting, was subjected to a straight catheter procedure without a physician's order. The procedure was performed after a urine sample collected using a urine collection hat was deemed contaminated. The resident was not informed of the need for a new sample or the method of collection prior to the procedure, which was conducted while she was asleep. The facility did not follow its policy on urine specimen collection, as the appropriate measurement method for urine collection was not determined. Additionally, the facility failed to follow its policy on physician orders by not receiving and transcribing physician orders for a urine analysis recollection. The procedure was performed without a specific order for the method of urine collection, leading to the resident experiencing pain and discomfort. The resident reported feeling violated and traumatized by the procedure, which was conducted at an inappropriate time without her consent. Interviews with facility staff revealed a lack of communication and documentation regarding the contaminated urine sample and the subsequent procedure. The Director of Nursing and other staff members acknowledged the absence of proper documentation and orders for the straight catheter procedure. The facility's policies on urine specimen collection and physician orders were not adhered to, resulting in the resident undergoing an unnecessary and invasive procedure without proper consent or notification.
Failure to Conduct Admission Lab Tests
Penalty
Summary
The facility failed to provide or obtain necessary laboratory services for a resident upon admission, as per the physician's standing orders. The resident, a cognitively intact female with a history of acute kidney failure, muscle weakness, and muscle wasting, was admitted to the facility but did not have the required laboratory tests, including BMP, CBC, U/A, and lipid profile, conducted at the time of admission. The lab work was delayed and only completed several days later, despite the resident experiencing symptoms such as burning during urination and discomfort, which were reported to the FNP. Interviews with facility staff, including the DON, ADM, RN, and LVN, revealed a lack of clarity and communication regarding the responsibility for initiating and documenting admission lab orders. The facility's policy required licensed nurses to obtain and transcribe orders according to practice guidelines, but this was not followed. The FNP was unaware that the admission labs had not been completed, indicating a breakdown in communication and adherence to the facility's standard procedures.
Failure to Document and Communicate Resident's UTI Symptoms and Treatment
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for a resident who reported symptoms of a urinary tract infection (UTI). On 8/9/2024, the resident informed RN D of feeling as if she had a UTI, but there was no documentation of this communication or any subsequent actions taken. Additionally, there was no record of communication between RN D and the facility's Family Nurse Practitioner (FNP) regarding the resident's condition or obtaining an order for a urinalysis (UA). Further deficiencies were noted when a contaminated UA sample was reported to the facility, and there was no documentation of communication between staff and the FNP or any orders for a UA recollection. The resident underwent a straight catheterization on 8/11/2024 at approximately 3:30 AM without prior notification or consent, leading to feelings of violation and upset. The procedure was performed without documented orders, and the resident's report of discomfort and emotional distress was not recorded in the clinical notes. Interviews with the Director of Nursing (DON), Administrator (ADM), and RN D revealed a lack of communication and documentation regarding the resident's condition and the procedures performed. The DON acknowledged the absence of proper documentation and orders, while the ADM and RN D provided conflicting accounts of the events and communications. The facility's policy on documentation was not adhered to, resulting in incomplete and inaccurate medical records for the resident.
Failure to Provide Accurate Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident, as evidenced by multiple instances of undocumented medication administration and medication errors. Specifically, the facility did not ensure that medications were administered accurately within the 2-hour window per physician orders for 39 out of 46 residents. Additionally, there was a failure to reconcile narcotic sheets, with one medication aide (MA F) documenting the administration of narcotic medications at times when she was not clocked in or working in the building. These failures could place residents at risk of receiving incorrect amounts of medication or having adverse reactions to medications not prescribed to them. For example, Resident #1, an elderly female with diagnoses including gastroesophageal reflux disease, muscle weakness, and insomnia, had multiple medications scheduled for administration at 7 PM that were not documented as given on 4/12/2024. Similarly, Resident #2, an elderly female with atrial fibrillation and moderate cognitive impairment, had several medications scheduled for 7 PM and 8 PM that were not documented as administered. In both cases, there was no documentation of physician notification of the medication errors in the nurse's notes. Another significant issue involved Resident #6, who received another resident's medication during a medication pass. This resident, a cognitively intact elderly male with diagnoses including hyperlipidemia and cerebral infarction, had multiple medications scheduled for 7 PM that were not documented as administered. Additionally, the facility failed to reconcile narcotic sheets, with MA F documenting the administration of narcotic medications at times when she was not clocked in or working in the building. This lack of proper documentation and reconciliation could lead to serious medication errors and adverse effects for the residents involved.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain resident medical records in accordance with accepted professional standards and practices. Specifically, the facility did not ensure that staff documented medications given to residents in the Medication Administration Record (MAR) for 41 out of 46 residents reviewed. This lack of documentation could place residents at risk of receiving incorrect amounts of medication as prescribed by their physicians. The report details multiple instances where medications were not documented as administered, despite being scheduled and ordered by physicians. For example, Resident #1, a female with diagnoses including gastroesophageal reflux disease, muscle weakness, and hyperlipidemia, had several medications scheduled for administration at 7 PM on 4/12/2024, including a nutritional supplement, bethanechol chloride, lubiprostone, melatonin, and omega-3 fish oil. None of these medications were documented as administered in the MAR. Similarly, Resident #2, a female with atrial fibrillation and moderate cognitive impairment, had multiple medications scheduled for 7 PM and 8 PM on the same date, including Eliquis, a house shake, MiraLAX, a multivitamin, and mirtazapine, which were also not documented as administered. The report also highlights similar deficiencies for other residents, such as Resident #3, who had medications like atorvastatin, ferrous sulfate, and metoprolol succinate scheduled for 7 PM and 8 PM, and Resident #4, who had medications including Colace, lorazepam, and mirtazapine scheduled for 7 PM. In each case, the medications were not documented as administered in the MAR. Additionally, there was no documentation in the nurse's notes for physician notification of these medication errors, further compounding the issue of inadequate record-keeping and potential risk to resident safety.
Failure to Notify Physicians and Families of Medication Errors
Penalty
Summary
The facility failed to immediately inform the resident, consult with the resident's physician, and notify the resident's representative(s) when there was a change in the resident's health status for two residents reviewed for notification of changes. This failure was identified during an investigation of medication administration errors that occurred on 04/12/2024. The errors involved medications being given at times other than ordered, and in some cases, residents receiving the wrong medications. Despite the errors being identified on the same day, notifications to physicians and family members were not made until 04/23/2024, over a week later. Resident #6, a cognitively intact male with diagnoses including hyperlipidemia, cerebral infarction, protein-calorie malnutrition, and neuropathic bladder, had several medications scheduled for 7 pm that were not documented as administered on 04/12/2024. A nurse's note indicated that a head-to-toe assessment was performed, and the resident's condition was reported to a nurse practitioner, but there was no documentation of immediate notification to the resident's physician or family. Similarly, Resident #25, a cognitively intact male with atherosclerosis and insomnia, had medications scheduled for 8 pm that were not documented as administered. The resident was unable to confirm if he received his medications, and there was no documentation of physician notification of the medication error. Interviews with facility staff revealed a lack of immediate action to notify physicians and family members about the medication errors. The Administrator and Corporate RN were aware of the errors on 04/12/2024 but did not ensure that all necessary notifications were made. The DON and other nursing staff also failed to follow through with proper notification procedures, leading to a significant delay in informing the relevant parties. This delay in notification could have resulted in unawareness of changes in the residents' conditions by their physicians and representatives, although no negative outcomes were reported.
What surveyors are citing around you — mapped
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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 142 citations issued within 25 miles in the last 12 months — including the 14 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whisperwood Nursing & Rehabilitation Center | 1 mi | ★★★★★ | 7 | 4 |
| Carillon Inc | 1.2 mi | ★★★★★ | 7 | 0 |
| The Mildred & Shirley L. Garrison Geriatric Educat | 1.4 mi | ★★★★★ | 14 | 5 |
| Southern Specialty Rehab & Nursing | 2.2 mi | ★★★★★ | 13 | 2 |
| Mi Casita Nursing And Rehabilitation Center | 2.3 mi | ★★★★★ | 15 | 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.