Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around August 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 Tuskegee Airmen Texas State Veterans Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities, fully dependent on staff for toileting, was found heavily soiled in two urine-saturated briefs with perineal redness, indicating incontinence care was not provided as needed. The care plan required assistance by two staff for toileting, yet during a skin assessment a CNA failed to perform hand hygiene before donning gloves and unfastening the brief, revealing the double briefing. The assigned CNA later admitted applying two briefs to act as a pad, despite knowing this was against training and could cause skin breakdown, and could not explain why the resident had not been changed since her last reported rounds. Other CNAs, an RN, the ADON, and the DON all acknowledged that double briefing was prohibited, that staff were expected to round and provide incontinence care every two hours and as needed, and that failure to do so and doubling briefs could lead to skin issues and infections, as reinforced by prior in-service training and the facility’s incontinent/perineal care policy.
Two residents with severe cognitive impairment and significant medical conditions received incontinence care and a skin assessment during which CNAs and an RN failed to follow the facility’s hand hygiene and glove-change protocols. Staff donned gloves before washing hands, cleansed urine-soaked perineal and buttock areas, and then applied clean briefs without changing gloves or performing hand hygiene between dirty and clean tasks, and left rooms with trash after glove removal without washing hands. In interviews, the CNAs and RN admitted they knew they were required to perform hand hygiene before resident contact, between care tasks, when gloves were soiled or changed, and after care, and acknowledged that failure to do so could cause contamination and cross-contamination, consistent with the facility’s hand hygiene policy and the DON’s stated expectations.
A resident with severe cognitive impairment, prior falls, and a known elopement history, wearing a Wander Guard bracelet, exited through a side service-hallway door that could be opened without a code and did not produce an audible alarm on the unit. Housekeeping staff noticed the resident with a walker in an adjacent clinic parking lot and notified nursing, and an LVN retrieved the resident, who was confused but uninjured. Surveyors found that the door alarms were quiet, the door and another similar door did not alarm when opened, and the Wander Guard alert on the nurse call system sounded the same as call lights, leading staff not to recognize or respond to door alerts, with some staff dismissing or canceling alerts and not checking doors or residents with Wander Guard bracelets.
A resident with Parkinsonism, chronic heart and respiratory disease, and intact cognition required substantial assistance with personal hygiene per the MDS and care plan, but ADL records for two months consistently showed no showers/bed baths and no refusals, and the shower binder contained only one refusal sheet. The resident appeared clean on observation, though a family member recently observed poor hygiene and overgrown fingernails and voiced concerns about infrequent showers. Staff interviews revealed conflicting information about the resident’s scheduled shower days and shifts, mis-entry of shower times in the EHR, absence of shower sheets, and a CNA who reported giving bed baths but not documenting them or using shower sheets. LVNs, the ADON, and the Administrator confirmed that showers/bed baths were expected to be documented in the EHR and on shower sheets, but acknowledged that for this resident there was no documentation to verify that bathing care had been provided, constituting a failure to maintain a complete and accurate medical record.
A resident with severe cognitive impairment, Alzheimer’s disease, visual deficits, and a history of falls developed an unwitnessed bruise that progressed to a black eye, with discoloration around the right eyelid and under the eye. Multiple CNAs and nurses observed the evolving bruise and documented that the resident could not explain how it occurred, and no fall or altercation was witnessed. The DON later concluded the resident likely hit a nightstand while rolling in bed with a CPAP mask, but this was not observed and remained an injury of unknown origin. Although the facility’s abuse policy defined such unwitnessed, unexplained, and suspicious injuries as reportable and required immediate reporting to state authorities, the Administrator decided not to report the incident to HHSC, resulting in a deficiency for failure to timely report suspected abuse or neglect and the associated investigation.
A resident with severe Alzheimer’s disease, obstructive sleep apnea, depression, and vertigo had ongoing nightly CPAP treatment ordered and provided, including specific mask and humidifier care, but the quarterly MDS did not code CPAP use under Section O for special treatments. Staff, including the FM, RN, LVN, and DON, confirmed nightly CPAP use since admission, while the MDS coordinator stated Section O was not coded if CPAP was not documented during the 7-day look-back and acknowledged that failing to code treatments could place the resident at risk. The Administrator expected accurate coding but was unaware of the risk if treatments were not coded, and despite repeated surveyor requests, no MDS assessment policy was provided before exit.
A resident with Alzheimer’s disease, obstructive sleep apnea, depression, and vertigo had MD orders for nightly CPAP use and daily CPAP equipment care, but the comprehensive care plan did not address this treatment. The MDS showed severe cognitive impairment and functional limitations, and staff interviews confirmed the resident received CPAP at night while several nurses and the MDSC were unaware that CPAP was omitted from the care plan. The DON and Administrator stated they expected all current treatments, including CPAP, to be reflected in care plans, and facility policy required interdisciplinary, resident-centered care plans with measurable goals and approaches, but this resident’s CPAP therapy was not incorporated.
A resident with Alzheimer's disease and obstructive sleep apnea was routinely using a CPAP machine at night, but the facility failed to obtain and maintain a physician order for the actual CPAP treatment and settings, and the use of CPAP was not reflected on the MDS or in the care plan. Existing MD orders only addressed cleaning and maintenance of the CPAP equipment, while nursing staff reported that they were administering CPAP therapy nightly. The ADON stated that nursing staff were responsible for entering MD orders into the EMR and was unaware that no treatment order for CPAP use had been obtained.
A resident with Alzheimer’s disease and severe cognitive impairment, who was care planned for risk of adverse medication side effects, had physician orders and MAR directions for a daily Rivastigmine (Exelon) transdermal patch with removal of the old patch before applying a new one. Record review showed documentation of patch removal from one scapula and application to the other, but no documentation of any patch on the arm. During medication administration, an LVN found two Rivastigmine patches on the resident at the same time—one on the upper arm with an illegible date and one on the scapula dated the prior day—removed both, and applied a new patch. The LVN and the medication aide acknowledged that only one patch should be in place at a time and that the aide may have missed an existing patch, while facility leadership stated their expectation that staff follow physician orders, manufacturer specifications, and the six rights of medication administration.
A resident with a history of behavioral symptoms and aggression was not under one-on-one supervision, despite care plans identifying significant risks. During a meal, this resident physically assaulted another resident, causing a fall, facial laceration, and hip fracture that required hospitalization. Staff were present but did not prevent the incident, and the lack of adequate supervision and preventive interventions led to a serious injury and an Immediate Jeopardy finding.
A resident with a history of dementia and aggressive behaviors was not adequately supervised and physically assaulted another resident, resulting in a fall, facial laceration, and hip fracture. Staff were aware of the resident's behavioral triggers but did not provide the necessary level of supervision to prevent the incident, leading to significant injury.
Failure to Provide Adequate Incontinence and ADL Care, Including Improper Double Briefing
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary ADL assistance, including incontinence care, to a resident who was dependent on staff for toileting hygiene. The resident was an elderly male with diagnoses including Parkinsonism, chronic ischemic heart disease, respiratory failure, anxiety disorder, and PTSD, and had severely impaired cognition with a BIMS score of 7. His care plan documented an ADL self-care performance deficit related to Parkinsonism and impaired balance, with an intervention requiring assistance by two staff for toileting. Despite this, the resident was found wet during a skin assessment, and he could not recall when his brief was last changed. During an observation, staff entered the resident’s room to perform a skin assessment and provide incontinence care. CNA B and RN C donned PPE and gathered supplies, but CNA B failed to perform hand hygiene before putting on gloves and unfastening the resident’s brief. Upon opening the brief, they found the resident wearing two briefs that were heavily soaked in urine, with some redness noted in the perineal area. The presence of two briefs and the resident being heavily soiled indicated that incontinence care had not been provided as needed. In interviews, CNA D, who was assigned to the resident, stated she had changed him after breakfast and admitted to applying two briefs, using one as a pad because he wet his briefs a lot and to prevent soiling his clothes. She acknowledged knowing that residents were not supposed to have double briefs and that this could cause skin breakdown, and stated she had been trained on not putting two briefs on residents and on rounding every two hours. She reported last rounding at 9:00 AM and had no explanation for why she had not changed the resident. Other staff, including CNA B and RN C, confirmed awareness that double briefing was not allowed and that it posed a risk of skin breakdown. The ADON and DON stated their expectations that staff perform rounds every two hours and as needed, that nurses monitor CNAs, and that staff not double briefs, noting that failure to round and doubling briefs could lead to skin issues and infections. Training records showed prior in-service education on toileting, checking and changing residents every two hours and as needed, and handwashing techniques, and the facility’s Incontinent/Perineal Care policy emphasized promoting cleanliness and preventing infection and skin irritation.
Failure to Follow Hand Hygiene and Glove Protocol During Incontinence Care and Skin Assessment
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program, specifically related to hand hygiene and glove use during incontinence care and skin assessments. For one male resident with Parkinsonism, chronic ischemic heart disease, respiratory failure, anxiety disorder, and PTSD, who had severely impaired cognition and was dependent on staff for toilet hygiene, staff did not follow proper hand hygiene procedures. During incontinence care, a CNA and an RN donned personal protective equipment before washing their hands, then cleansed the resident’s heavily urine-soaked perineal area, abdominal folds, and penis, and turned him to cleanse his bottom area. Without performing hand hygiene or changing gloves, the CNA applied a clean brief. The CNA then left the room after removing gloves and gown and walked down the hall with trash without washing her hands, while the RN remained in the room, removed her gloves, and washed her hands only at the end. A second male resident with hemiplegia following cerebral infarct affecting the left nondominant side, severely impaired cognition, and dependence on staff for toilet hygiene also received incontinence care that did not comply with hand hygiene standards. A CNA put on gloves before washing her hands, then explained the procedure, positioned the resident, unfastened a urine-soaked brief, and cleansed the resident’s abdominal folds and penis, followed by cleansing his bottom area after turning him onto his side. Without performing hand hygiene or changing gloves between dirty and clean tasks, the CNA applied a clean brief. She then left the resident’s room after removing her gloves and walked down the hall with trash without washing her hands. In interviews, the CNAs and RN acknowledged they did not perform hand hygiene as required before, during, and after resident contact and between different care tasks. They each stated they knew they were expected to wash hands before contact with residents, between care, when gloves were soiled or changed, and after care, and that failure to do so could lead to contamination, cross contamination, and spread of infection. The DON confirmed her expectation that staff perform hand hygiene before resident contact, between care, when gloves were soiled, and when changing gloves, and stated that failure to do so could lead to cross contamination and spread of infection. The facility’s hand hygiene policy stated that staff will perform hand hygiene to aid in the prevention of the transmission of infections.
Elopement Due to Ineffective Door Alarms and Inadequate Staff Response
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and effective use of assistance devices to prevent an elopement by a cognitively impaired resident. The resident was an older male with mild cognitive impairment of uncertain cause, heart failure, hypertension, and a pacemaker, who had severe cognitive impairment on assessment with a BIMS score of 4. He was able to ambulate independently, had a history of two or more falls without injury, and had previously eloped through the front door by following visitors, after which a Wander Guard bracelet was applied and he was care planned as an elopement risk. A subsequent elopement evaluation again identified him as an elopement risk and indicated that the safest option would be relocation to a secured unit. On the date of the incident, the resident exited the facility through an ancillary side door on a service hallway and was later observed in the adjacent clinic parking lot. Video footage showed he left the facility at 3:22 PM and was found in the parking lot at 3:26 PM. A housekeeper looking out a breakroom window saw a resident with a walker in the back parking lot, recognized him as one of their residents, and, along with another housekeeper, left the breakroom, turned off the door alarm, and notified nursing staff that the resident was outside. An LVN then located the resident in the clinic parking lot, noted he was alert but confused with impaired safety awareness and expressing a desire to go to town, and escorted him safely back to the facility, where assessment revealed no injuries and stable vital signs. Surveyor observations and staff interviews identified multiple system failures related to door alarms and staff response that contributed to the elopement. The door used by the resident was labeled “No Exit,” had a Wander Guard system and keypad, but could be opened without a code and without triggering an audible alarm; a similar door at the opposite end of the hallway also did not alarm when opened. When the Director of Maintenance activated the Wander Guard alarm on the implicated door, the alarm was not audible on the resident care unit (Alpha pod), and staff did not appear aware of it; only a “ding dong” sound identical to call light alerts was heard at the nurse call system. Staff on multiple pods did not respond to door alerts displayed on the call light monitor, did not check doors, and did not check residents with Wander Guard bracelets, with one nurse stating an alert was “not one of our doors” and another instructing to “cancel it.” Housekeeping staff reported not hearing the door alarm while in the breakroom and only hearing it once in the hallway, and the Maintenance Worker acknowledged the alarm volume was not very loud. These observations, combined with the resident’s known elopement risk and prior elopement history, led surveyors to determine that the facility failed to provide adequate supervision and effective alarm systems to prevent the resident’s elopement.
Failure to Maintain Complete and Accurate Bathing Documentation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete, accurate, readily accessible, and systematically organized medical record for one resident, specifically regarding documentation of showers and bed baths. The resident was an adult male with diagnoses including Parkinsonism, chronic ischemic heart disease, chronic respiratory failure, anxiety disorder, PTSD, and heart disease. His admission MDS showed intact cognition (BIMS 13) and a need for substantial/maximal assistance with personal hygiene, and his care plan required staff assistance with bathing/showering. However, review of his ADL records for February and March showed "No" for showers/bed baths, with no documentation of refusals, and the facility’s shower binder contained only one shower sheet indicating a refusal on a single date. During observations, the resident appeared clean and well-groomed, but a family member reported that on a recent visit the resident had food on his mouth and face, crust on his eyes, and long fingernails with buildup underneath, and expressed concern that he had not received a shower in a long time. The resident himself stated he received showers but could not recall how often or when. Multiple staff interviews revealed inconsistent information about the resident’s scheduled shower days and shifts, with some staff stating his showers were scheduled for Mondays, Wednesdays, and Fridays on the evening shift, while others stated different days or could not recall precisely when showers were last provided. Record review and staff interviews further showed that the resident’s electronic health record had showers scheduled on the wrong shift (morning instead of evening), and there was no documentation in the electronic record or shower sheets confirming that showers or bed baths had been provided. CNAs and LVNs stated that CNAs were responsible for documenting showers/bed baths in the electronic record and on shower sheets, and nurses were to sign the shower sheets, but several staff, including the ADON and Administrator, were unaware that shower sheets were not being completed for this resident. One CNA reported providing bed baths but admitted not documenting them and not knowing where the shower sheets were located. Facility leadership and nursing staff acknowledged that without documentation they could not verify whether the resident had actually received showers or bed baths, and some staff stated that lack of showers could lead to infections or dry skin.
Failure to Report Injury of Unknown Origin Involving Eye Bruising
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an injury of unknown origin involving suspected abuse or neglect to the state agency (HHSC) for one resident. The resident was an elderly male with Alzheimer’s disease, obstructive sleep apnea, depression, vertigo, impaired vision in the right eye due to macular degeneration and glaucoma, and a history of falls. His MDS showed a BIMS score of 2, indicating severe cognitive impairment, and he required partial to moderate assistance with bed mobility, transfers, and supervision/touching for walking, using a walker or wheelchair. His care plan identified him as cognitively impaired, at risk for elopement and falls, with prior falls including one that had resulted in a right eye bruise, and directed staff to monitor, document, and report pain, bruises, and changes in condition. On or about early February, staff observed discoloration and bruising to the resident’s right eye area without a witnessed event or clear explanation from the resident. Nursing progress notes documented that a nurse was called to the dining area and shown a light bruise to the right eye; the resident denied pain but could feel the area when touched, vital signs were stable, and no change in level of consciousness or other injuries were noted. Subsequent notes described the area as a 3.0 cm x 3.5 cm light bruise near the right eye, with the resident unable to describe what happened. A photograph taken by a nurse showed purple bruising on the upper eyelid and above the eyebrow, with red bruising on the eyelid crease and under the eye. Over the next days, documentation reflected that the discoloration progressed to a “black eye” with multiple colors (purple, green, blue, yellow) around the corner and under the right eye, while the resident continued to deny pain and could not explain the cause. Multiple staff statements and interviews confirmed that the injury was unwitnessed and that the resident, due to impaired cognition, could not reliably report how it occurred. CNAs and nurses reported noticing a bruise or discoloration to the right eye during rounds or shift changes, but there was no consistent account of when the injury first appeared or how it happened. The DON stated that, based on her assessment, she believed the resident had fallen and hit the corner of his nightstand while wearing his CPAP mask, but this was not observed by staff and the resident’s explanation was limited to saying he “rolled over and felt it burn.” The Administrator acknowledged being notified of the injury by nursing staff and stated she did not report the incident to HHSC because she believed it did not meet the criteria for an injury of unknown origin requiring reporting. The facility’s own abuse policy defined an injury of unknown origin as one not observed, not explained by the resident, and suspicious due to extent or location, and required immediate reporting of any allegation of abuse to the Administrator and appropriate authorities. Despite the unwitnessed nature of the injury, the resident’s inability to explain it, and the suspicious location and progression of the bruising, the facility did not report the incident to HHSC, leading to the cited deficiency for failure to timely report suspected abuse, neglect, or theft and the results of the investigation to proper authorities.
Failure to Accurately Code CPAP Treatment on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected ordered CPAP treatment. A quarterly MDS for Resident #1 did not code the use of a non-invasive mechanical ventilator/CPAP in Section O (Special Treatments, Procedures and Programs), despite medical record documentation and staff interviews confirming ongoing CPAP use. The resident, an elderly male with diagnoses including Alzheimer’s disease with severe cognitive impairment (BIMS score of 02), obstructive sleep apnea, depression, and vertigo, had physician orders dated 08/07/2025 for daily CPAP-related care, including wiping the mask and nasal pillows, emptying the humidifier chamber, cleaning it with warm soapy water, rinsing, and air drying. The care plan dated 02/03/2026 addressed cognitive impairment, impaired thought processes related to Alzheimer’s, risk for falls, and communication problems, but the MDS did not reflect the CPAP treatment in Section O. During observations, the resident’s CPAP mask was seen on the nightstand while the resident was in the memory care common area attending activities, and the resident could not be interviewed due to severe cognitive impairment. Multiple staff interviews, including with the FM, RN, LVN, and DON, confirmed that the resident received CPAP treatment every night at bedtime since admission. The MDS coordinator stated that Section O would not be coded if the resident had not used the CPAP during the 7-day look-back period and acknowledged that failing to code the treatment could place the resident at risk of missing physician-ordered treatments. The Administrator stated it was her expectation that staff code treatments accurately on assessments and that she was not aware of the risk to residents if treatment was not coded. The surveyor repeatedly requested the facility’s MDS assessment policies from the DON and Administrator on multiple occasions, but no policy was provided prior to survey exit.
Failure to Include CPAP Therapy in Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan that included CPAP treatment for a resident with obstructive sleep apnea. The resident was an elderly male with diagnoses of Alzheimer’s disease, obstructive sleep apnea, depression, and vertigo, and had a BIMS score of 02 indicating severe cognitive impairment. His quarterly MDS showed he required partial to moderate assistance with bed mobility and transfers, supervision for walking, and used a walker or wheelchair, with a history of falls. Despite medical orders dated 08/07/2025 for daily CPAP equipment cleaning and an order dated 02/10/2026 specifying CPAP use at night with a setting of 8.0 cm H2O for obstructive sleep apnea, the comprehensive care plan dated 02/03/2026 did not address his CPAP treatment. Surveyor interviews and record reviews showed that multiple staff members acknowledged the resident received nightly CPAP treatments but were unaware that this treatment was not reflected in the care plan. The MDS coordinator stated she relies on the TAR during the 7‑day look‑back period to code the MDS and would not address a treatment if it was left off the TAR. Nursing staff, including LVNs and an RN, confirmed the resident’s CPAP use and, upon review, recognized that omission from the care plan could result in missed care and treatment. The DON and Administrator both stated their expectation that care plans reflect current treatments, including CPAP, and the facility’s written policy required an interdisciplinary, resident-centered comprehensive care plan that identifies care needs, measurable goals, and approaches, to be developed and revised based on assessments. Despite these expectations and policies, the resident’s CPAP treatment was not incorporated into the care plan.
Lack of Physician Order and Care Plan Integration for CPAP Use
Penalty
Summary
The facility failed to ensure that a resident who required respiratory care received such care in accordance with professional standards and a comprehensive person-centered care plan. A male resident with diagnoses including Alzheimer's disease, obstructive sleep apnea, depression, and vertigo, and with a severely impaired BIMS score of 02, was using a CPAP machine at night for obstructive sleep apnea. The quarterly MDS did not reflect any special treatments or programs for non-invasive mechanical ventilation and did not address the resident's use of a CPAP machine. The resident's care plan, dated 02/03/2026, addressed cognitive impairment, risk for falls, dependence on staff for needs, and communication problems, but did not address CPAP treatments per medical orders. Record review showed that existing physician orders dated 08/07/2025 only addressed cleaning and maintenance of the CPAP equipment, including wiping masks and nasal pillows daily, emptying humidifier chambers, filling with warm soapy water, shaking, rinsing, and air drying. There was no physician order in place at that time for the actual use of the CPAP machine, including settings or administration as a respiratory treatment. During observations and interviews, nursing staff, including an LVN and an RN, confirmed that the resident received CPAP treatments nightly for obstructive sleep apnea and reported no concerns with its daily administration, but review of the electronic medical record revealed only cleaning orders. The ADON stated that nursing staff were responsible for ensuring MD orders were entered into the EMR and was not aware that there was no order for CPAP treatments, acknowledging that failing to have an MD order could place the resident at risk of not receiving treatment.
Failure to Remove Previous Rivastigmine Patch Before Applying New Dose
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate dispensing and administration of medications, specifically Rivastigmine (Exelon) transdermal patches, for one resident. The resident was an elderly male with Alzheimer’s disease, PTSD, GERD, and a BIMS score of 5 indicating severe cognitive impairment. His care plan identified risk for adverse side effects related to medications and noted ADL self-care deficits and impaired cognition, with interventions to administer medications as ordered and monitor for side effects and effectiveness. Physician orders directed that a 9.5 mg/24 hr Rivastigmine patch be applied transdermally once daily and removed per schedule, and the MAR specified daily removal and application times. Record review showed that on one date the Rivastigmine patch was documented as removed from the right scapula and a new patch applied to the left scapula by a medication aide, with no documentation of any patch application to the left arm. During a subsequent observation, an LVN entered the resident’s room to administer the Rivastigmine patch and, after removing the resident’s jacket and performing a skin assessment, found an existing Rivastigmine patch on the back of the resident’s upper left arm with an illegible date. The LVN then located a second Rivastigmine patch on the resident’s left scapula dated the previous day. Both patches were removed and a new patch was applied to the right upper arm. The resident, observed later in a common area, was a poor historian and unable to answer questions but did not appear to be in distress. In interviews, the LVN confirmed finding two Rivastigmine patches on the resident at the same time and stated there was an order to remove the old patch prior to applying a new one, and that staff were to document removal time, application time, and patch location. She reported she did not routinely administer medications, had not applied the patch the previous day, and routinely removed the resident’s shirt to ensure old patches were removed. The medication aide who applied the patch the prior day stated she removed a patch from the right scapula and applied a new one to the left scapula, did not recall seeing a patch on the left arm, and acknowledged she could have missed it. Facility leadership, including the ADON, Medical Director, and Interim DON, stated their expectation that staff remove old patches before applying new ones and administer medications according to physician orders and pharmacy instructions. The facility’s medication administration policy required medications to be administered as ordered by the physician, in accordance with professional standards and manufacturer specifications, and to follow the six rights of medication administration.
Failure to Prevent Resident-to-Resident Abuse Resulting in Serious Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from abuse, resulting in a serious incident involving two residents on the memory care unit. One resident, who had a documented history of behavioral symptoms including physical aggression, moderate cognitive impairment, and multiple triggers such as loud noises and perceived threats to personal space, was not under one-on-one supervision at the time of the incident. Despite care plans identifying the resident's risk for aggression and outlining interventions such as monitoring for signs of agitation and providing a quiet environment, the resident was able to approach another resident and physically assault him without immediate intervention from staff. The assaulted resident, who also had moderate cognitive impairment and no history of behavioral symptoms, was punched in the face, causing him to fall against a wall and then to the ground. This resulted in a facial laceration and a fractured hip, requiring hospitalization and surgical admission. Staff present at the time were engaged in routine activities such as passing breakfast trays and administering medication, and although they were aware of the aggressor's behavioral risks, the supervision provided was not sufficient to prevent the incident. Multiple staff interviews confirmed that while staff were generally attentive to the resident's behaviors, there was no dedicated one-on-one monitoring in place at the time of the assault. The facility's failure to implement adequate supervision and preventive interventions for a resident with known aggressive behaviors directly led to the physical abuse and injury of another resident. The incident was witnessed by staff, and immediate actions were taken to separate the residents and provide first aid, but the lack of proactive measures to prevent such an occurrence constituted noncompliance with regulations requiring protection from abuse. The event was identified as past noncompliance and resulted in Immediate Jeopardy due to the risk of harm and severe injury to residents.
Failure to Prevent Resident-to-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, resulting in a physical altercation between two residents. One resident, who had a history of Alzheimer's disease, dementia, moderate cognitive impairment, and documented behavioral symptoms including physical aggression, was sitting at a dining room table with an LVN. Despite being known for behavioral triggers such as loud noises and paranoia about personal space, the resident was not on 1:1 supervision at the time. The resident got up from the table, approached another resident, and punched him in the face, causing the second resident to fall against the wall and then to the ground. The second resident, who also had Alzheimer's disease, dementia, moderate cognitive impairment, and a history of poor balance and unsteady gait, sustained a facial laceration and a fractured hip as a result of the fall. The incident was witnessed by staff who were present in the dining room, but the supervision provided was not sufficient to prevent the altercation. Staff interviews revealed that although they were aware of the first resident's behavioral history and triggers, and all staff were responsible for monitoring residents, the level of supervision was not adequate to prevent the incident. The care plan for the aggressive resident included interventions for behavioral management, but these were not effectively implemented at the time of the event. The deficiency was identified as past non-compliance and was determined to have placed residents at risk of harm and/or severe injury. The incident led to Immediate Jeopardy, as the lack of adequate supervision and failure to maintain a safe environment directly resulted in a resident sustaining significant injury. The facility's policies required staff to monitor residents with behavioral health needs and to provide person-centered care, but these measures were not sufficiently executed to prevent the altercation and subsequent injury.
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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 Fort Worth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Estates Healthcare And Rehabilitation Center | 3.1 mi | ★★★★★ | 29 | 3 |
| Immanuel's Healthcare | 3.3 mi | ★★★★★ | 3 | 0 |
| Village Creek Nursing & Rehabilitation | 3.7 mi | ★★★★★ | 11 | 0 |
| Avir At Kennedale | 5 mi | ★★★★★ | 25 | 2 |
| Dfw Nursing & Rehab | 5 mi | ★★★★★ | 13 | 4 |
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