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 Traymore Nursing Center during CMS and state inspections, most recent first.
A resident with chronic respiratory failure and COPD, care planned for altered respiratory status and ordered to receive continuous O2 at 2 L/min via nasal cannula with routine O2 saturation checks, was observed in a wheelchair with a portable O2 tank while the nasal cannula tubing was dragging on the floor and not in use, meaning the resident was not receiving ordered continuous oxygen. Staff, including a CNA, an LVN, the Infection Preventionist, and the DON, acknowledged that oxygen tubing should not be on the floor, should be stored in a plastic bag when not in use, and should be changed weekly per facility policy, and that residents with continuous O2 orders should always have access to oxygen, but these expectations and policies were not followed in this instance.
A newly admitted male resident with a history of brain tumor removal, cerebral edema, left-sided hemiplegia/hemiparesis, and high fall risk was documented by hospital discharge and PT/OT evaluations as requiring max/total assistance by two persons for transfers and toileting. Despite this, an LVN transferred the resident alone from bed to wheelchair and to the toilet, then left him in the bathroom with the door closed or nearly closed, without a call light safety discussion. The resident lost his balance while attempting to wipe himself and fell to the bathroom floor, sustaining a small head laceration. A CNA and the resident’s roommate reported that the LVN was not present at the time of the fall, while the LVN gave conflicting accounts of being outside the bathroom and characterizing the event as a witnessed fall. The resident’s admission assessments were incomplete, therapy evaluations were not yet entered into the chart, and the fall was not recorded on the facility’s Accident/Incident Log, contributing to the failure to follow the documented two-person assist requirement and provide adequate supervision to prevent the accident.
A resident with severe cognitive impairment, dementia, stroke history, weakness, and mobility needs was observed in bed with the call light clipped to a curtain and out of reach on multiple occasions. An LVN and the assigned RN confirmed the placement issue, and the DON stated call lights were expected to remain within reach unless otherwise care planned; the facility policy also required the call light to be within the resident's reach before staff left the room.
A resident with schizoaffective disorder was admitted with a prior PASRR Level I screening marked negative for MI, ID, or DD, but the facility did not identify the discrepancy or refer her for a PASRR Level II review. Her MDS documented schizophrenia and antipsychotic use, and the record showed no evidence of any Level II screening or evaluation despite the diagnosis and care plan focus on schizoaffective disorder.
A resident with multiple serious health conditions and a documented Full Code status was found unresponsive and without vital signs after significant blood loss from a dislodged dialysis port. Despite being CPR certified and aware of the resident's code status, nursing staff did not initiate CPR or any life-saving measures prior to the arrival of emergency medical personnel, in direct violation of the resident's care plan and physician orders.
A resident at an LTC facility experienced medication errors due to transcription and communication issues. Upon admission, the resident's medications were not correctly ordered, leading to missed doses of Carbidopa-Levodopa and double doses of Memantine HCL ER. The errors were attributed to a pharmacy technician's oversight and the ADON's failure to correct the dosage frequency. Staff interviews indicated minimal risk to the resident, who showed no significant changes in condition.
The facility failed to complete quarterly MDS assessments for two residents within the required timeframe. One resident's assessments were marked 'In-Progress' and not transmitted, with the last completed assessment being an annual MDS. This resident had multiple diagnoses, including dementia and multiple sclerosis. Another resident's quarterly assessment was also 'In-Progress' and not transmitted, with the last completed assessment being a previous quarterly MDS. This resident had diagnoses including anemia and Alzheimer's. Delays were due to capturing rehabilitation minutes and awaiting signatures, potentially affecting care plans and reimbursement.
A CNA in a LTC facility failed to change gloves and perform hand hygiene while providing incontinent care to a resident, leading to a deficiency in infection control practices. The resident, who had cognitive impairment and incontinence, was at risk due to the CNA's lack of adherence to established protocols, despite having been trained in infection control.
Failure to Maintain Continuous Oxygen Therapy and Proper Oxygen Tubing Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care, including oxygen therapy, in accordance with professional standards and physician orders for one resident. The resident was an older female with chronic respiratory failure with hypercapnia, COPD, and a care plan for altered respiratory status/difficulty breathing, including an intervention to receive oxygen per physician orders. Active physician orders required continuous oxygen at 2 L/min via nasal cannula and oxygen saturation checks each shift with a goal of maintaining O2 saturation at or above 92%. During observation, the resident was in a wheelchair with a portable oxygen tank on the back, but the nasal cannula tubing was dragging on the floor and she was not receiving oxygen as ordered. Staff interviews confirmed that the resident had an order for continuous oxygen and that, at the time of observation, the nasal cannula was on the floor rather than in place. CNA and LVN staff acknowledged that the nasal cannula should not be on the floor due to infection concerns and that residents with continuous oxygen orders should always have access to oxygen. The Infection Preventionist stated that nursing staff were expected to check oxygen tubing as part of their assessment to ensure it was not on the floor, that tubing should be stored in a plastic bag when not in use, and that tubing should be changed weekly and as needed. The DON confirmed that residents with continuous oxygen orders were expected to always have access to oxygen and that tubing dragging on the floor posed an infection risk. Facility policies on oxygen administration and infection prevention and control referenced appropriate cleaning, storage, and weekly changing of oxygen cannula, tubing, and humidifier bottles, but the observed condition of the resident’s oxygen tubing and lack of continuous oxygen use did not align with these policies or the physician’s orders.
Resident Left Unsupervised on Toilet Despite Two-Person Assist Requirement, Resulting in Fall and Head Laceration
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistance to prevent accidents for a newly admitted male resident with significant neurological and mobility impairments. The resident had a history of a brain tumor removal with a large head incision and staples, cerebral edema, hemiplegia and hemiparesis affecting the left non-dominant side, and supraventricular tachycardia. Hospital discharge paperwork dated 03/26/26 and a PT evaluation dated 03/27/26 indicated that he required maximal assistance from two persons for ADLs, including toileting and functional transfers, and an OT evaluation indicated total assistance by two persons for toileting. Despite these documented needs and the family member’s report that both he and the hospital informed the facility that the resident was a two-person assist and a high fall risk, the resident’s admission and entry MDS assessments were incomplete, and the therapy evaluations were not entered into the medical record during his short stay. On 03/30/26, the resident used his call light to request assistance to the bathroom. According to the resident, the roommate, and CNA B, LVN A transferred the resident from bed to wheelchair, wheeled him to the bathroom, placed him on the toilet, then left the bathroom and the room, closing or nearly closing the bathroom door. The resident stated he did not request privacy and that no call light safety conversation occurred. While attempting to wipe himself, he lost his balance and fell to the bathroom floor, causing the bathroom door to open. The roommate reported hearing a loud thump, then the resident yelling for help, and observed the resident on the bathroom floor with a cut on his head. The roommate went into the hall to get help and found CNA B, who entered the room, saw the resident on the bathroom floor, then left to get LVN A. CNA B and LVN A then lifted the resident from the floor to his wheelchair and then to his bed. CNA B observed a small head laceration with some bleeding. During interviews, LVN A initially stated he had not read any information regarding the level of care the resident needed and acknowledged that the resident was newly admitted. He also stated that he first reported being outside the resident’s room when the fall occurred, then later changed his account, saying he was standing outside the bathroom with the door ajar and observed the fall, characterizing it as a witnessed fall. The resident, his roommate, and the family member all reported that LVN A was not present in the bathroom or immediately outside the door at the time of the fall. LVN A acknowledged that a resident requiring two-person assistance for ADLs who is assisted by only one person and left alone on the toilet could become unstable, off balance, and fall, and that such a resident could sustain broken bones, cuts, and fractures. The family member reported being notified about four hours after the fall and stated that LVN A misrepresented the circumstances by claiming to have been present and to have witnessed the fall. The administrator later stated she believed the fall to be witnessed based on LVN A’s account and was unaware that the fall was not documented on the facility’s Accident/Incident Log for that date. The resident’s care plan, printed on 04/03/26, included a focus on assistance with ADLs related to left-sided paralysis and a focus on fall risk, including a fall with a head laceration on 03/30/26. Interventions listed included encouraging independence within limitations, providing support for dressing, toileting, personal hygiene, and bathing each shift, ensuring the call light was within reach, and educating the resident and family about safety and what to do if a fall occurs. However, at the time of the fall, the resident reported that he was not instructed on call light safety in the bathroom and was left alone on the toilet despite his need for two-person assistance. The DOR confirmed that PT and OT evaluations documented the need for two-person assistance for transfers and toileting, but this information had not yet been entered into the resident’s medical chart during his three-day stay. The facility’s policies on Quality of Care and Fall Investigation and Intervention required care and services based on comprehensive assessment and root cause analysis of falls, but the incomplete assessments and lack of integration of therapy findings contributed to staff not following the documented two-person assist requirement for this resident. NP C at the hospital confirmed that the resident was admitted from the facility after the fall with a small head laceration and that the hospital discharge paperwork specified a two-person assist. The resident described wearing non-slip socks at the facility and expressed that he knew he needed assistance with ADLs due to his worsened health status after surgery. He became emotional when describing the fall and stated he did not want to return to the facility because he believed the fall could have been prevented. Interviews with staff and the family member confirmed that LVN A had previously received education on falls, incidents, and family notification, and that both LVN A and CNA B had attended a facility-wide in-service on falls protocol on 03/25/26. Despite this, LVN A did not remain with the resident in the bathroom, did not ensure two-person assistance for transfers and toileting as indicated by hospital and therapy documentation, and delayed notifying the family member for several hours after the fall while he completed paperwork and other assignments.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure Resident #14 had reasonable accommodation of needs and preferences by not keeping the call light within reach. Resident #14 was an [AGE] year-old male admitted on [DATE] with severely impaired cognitive function and diagnoses including cerebral infarction, major depressive disorder, metabolic encephalopathy, dementia, hypertension, hyperlipidemia, cataract, muscle weakness, dysphagia, and ataxic gait. He used a walker and required staff supervision or hands-on help for toileting hygiene, bathing, dressing, grooming, turning in bed, sitting up, standing, and toilet transfers, with occasional urinary and bowel incontinence. His care plan included anticipating and meeting resident needs and ensuring the call light was within reach. During observation, Resident #14 was found in bed with the call light clipped to the privacy curtain at the foot of the bed and out of his reach. This was observed on two separate occasions, and the resident was unable to provide reliable information because of cognitive impairment. An LVN confirmed the placement and stated she was unsure why it was clipped to the curtain, while an RN assigned to the resident stated she had rounded earlier that morning and found the call light clipped to the curtain before repositioning it within reach. The DON stated call lights were to always be within reach unless care planned otherwise and confirmed staff were expected to round hourly and ensure the call light was within reach. The facility policy stated the call light must always be within the resident's reach before staff leave the room.
Failure to Refer Resident With Schizoaffective Disorder for PASRR Level II Review
Penalty
Summary
The facility failed to refer one resident for a Level II PASRR resident review after not identifying a discrepancy between a negative PASRR Level I screening and the resident’s mental disorder diagnosis at admission. Resident #9 was admitted with diagnoses including respiratory failure with hypercapnia, hypertension, type 2 diabetes mellitus, chronic kidney disease stage 4, schizoaffective disorder, and muscle weakness, and she did not have a dementia diagnosis. Her MDS assessment documented schizophrenia and use of an antipsychotic medication, while her PASRR Level I screening from the prior year was marked negative for mental illness, intellectual disability, or developmental disability. The resident’s electronic record showed no evidence that any additional PASRR Level II screening or evaluation had been completed after the initial Level I screening. Her care plan included a schizoaffective disorder focus related to communication problems. During interview, the MDS coordinator stated the Level I PASRR had been incorrectly marked negative based on the schizoaffective disorder diagnosis and that the resident should have had a Level II PASRR evaluation; she also stated that identifying the discrepancy was the MDS coordinator’s responsibility. The facility policy stated that if a resident receives a new diagnosis that could be considered a positive PASRR for MI, ID, or DD, the facility will complete a form 1012 and follow through to determine whether a physical or mental evaluation is needed.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to provide basic life support, including CPR, to a resident who was found unresponsive and without vital signs. The resident, an elderly male with diagnoses including encephalopathy, heart failure, acute respiratory failure with hypoxia, stage 4 chronic kidney disease, and end-stage renal disease, had a documented Full Code status in his care plan and physician orders. On the evening in question, the resident had returned from a vascular procedure and dialysis, and was last seen alert and without distress. Later, a nurse discovered the resident unresponsive in his wheelchair, with significant blood loss and the dialysis port cap in his hand, indicating the port had been pulled out. Upon finding the resident unresponsive, the nurse checked for vital signs and found none, then called for assistance and 911. Despite being CPR certified and instructed by the 911 dispatcher to begin CPR, the nurse did not initiate any life-saving measures. Other licensed nurses and certified nursing assistants arrived but also did not perform CPR, even after confirming the resident's Full Code status. The crash cart was not brought to the room until after emergency personnel arrived, and no staff attempted to move the resident to a hard surface or begin chest compressions as required by the resident's care plan and facility policy. Interviews with staff confirmed that no CPR or other life-saving interventions were performed prior to the arrival of emergency medical services. The staff involved acknowledged awareness of the resident's Full Code status and their own CPR certification, but did not provide an explanation for their inaction. The facility's management confirmed that the failure to initiate CPR was not in accordance with the resident's advance directives, physician orders, or the facility's procedures for responding to unresponsive residents.
Medication Errors Due to Transcription and Communication Issues
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, leading to medication errors. Upon admission, the resident's medications, Memantine HCL and Carbidopa-Levodopa, were not correctly ordered and transcribed on the Medication Administration Record (MAR). This resulted in the resident missing four doses of Carbidopa-Levodopa and receiving double doses of Memantine HCL ER over a period of several days. The Assistant Director of Nursing (ADON) entered the medication orders based on what the resident was taking at home, but errors occurred when the pharmacy changed the Memantine order and placed the Carbidopa-Levodopa order in pending confirmation status. The ADON failed to correct the Memantine dosage frequency, leading to the resident receiving an incorrect dosage. The pharmacy's new technician also missed the 'on hand' status of the medications, contributing to the missed doses of Carbidopa-Levodopa. Interviews with staff, including the Medical Director and Pharmacy Consultant, revealed that the errors were due to transcription mistakes and communication issues with the pharmacy. The Medical Director and Pharmacy Consultant assessed the risk of the errors as minimal, noting that the resident did not exhibit significant changes in cognition or mobility during the stay. The facility's policy on pharmacy services emphasizes the responsibility of ensuring accurate medication management, which was not upheld in this instance.
Failure to Complete Timely MDS Assessments for Two Residents
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments for two residents within the required 92-day timeframe. Resident #31's quarterly MDS assessments, dated 6/3/24 and 7/1/24, were marked as 'In-Progress' and had not been completed or transmitted to the CMS system. The last completed assessment for this resident was an annual MDS assessment on 2/16/24. Resident #31 had multiple diagnoses, including non-Alzheimer's dementia, multiple sclerosis, anxiety, depression, repeated falls, cognitive communication deficits, and other speech disturbances. Similarly, Resident #84's quarterly MDS assessment was also marked as 'In-Progress' and had not been completed or transmitted. The last completed assessment for this resident was a quarterly MDS assessment on an earlier date. Resident #84 had diagnoses including anemia, hypertension, Alzheimer's disease, fractures, and muscle weakness. Interviews with the MDS LVN, DON, and Administrator revealed that the assessments were delayed due to various reasons, including capturing rehabilitation minutes and awaiting signatures, which could potentially affect the residents' care plans and facility reimbursement.
Infection Control Deficiency During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Certified Nursing Assistant (CNA) during the provision of incontinent care to a resident. The CNA did not change gloves or perform hand hygiene after cleaning the resident, who was soiled with urine, before applying barrier cream and a clean brief. This lapse in infection control practices was observed during a survey and was confirmed through interviews with the CNA and the Director of Nursing (DON). The resident involved was an elderly female with multiple diagnoses, including cognitive impairment and incontinence. The CNA, who had been employed at the facility for about a month, admitted to not being aware of the requirement to change gloves and perform hand hygiene during incontinent care, despite having been in-serviced on infection control. The facility's policy and procedure for incontinent care and hand hygiene were reviewed, indicating that the CNA had completed a skills check-off but failed to adhere to the established protocols during the observed incident.
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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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Forest Park Nursing & Rehabilitation | 1.9 mi | ★★★★★ | 13 | 1 |
| The Plaza At Edgemere | 2.7 mi | ★★★★★ | 16 | 0 |
| Lakewest Rehabilitation And Skilled Care | 4.4 mi | ★★★★★ | 25 | 1 |
| Avir At Dallas | 4.9 mi | ★★★★★ | 1 | 0 |
| Walnut Place | 4.9 mi | — | 0 | 0 |
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