Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vidor Health & Rehabilitation Center during CMS and state inspections, most recent first.
Insufficient CNA staffing on the secured hall led to residents being left unattended during meals and care activities. Observations showed only 1 CNA with 1 LVN on the unit while residents were in the dining area, meal trays were not checked before service, and a resident was struck by a wheelchair arm and sustained a skin tear. Staff interviews and staffing sheets confirmed the unit was often staffed below the facility assessment requirement of 2 CNAs.
Food service sanitation deficiencies were observed in the kitchen, including unmarked and unsealed food in a freezer, spills and debris in a refrigerator, and wet, damaged conditions in the dish room with leaking pipes, loose floor tiles, and holes in the ceiling. Staff also observed food on the floor near the steam table, a personal drink on the food prep table, and an uncovered trash can placed next to clean food items.
Kitchen Pest Control Failure: The facility failed to keep the kitchen free of gnats. Staff observed gnats in the dish room around leaking pipes and later around a garbage box and over a prep table while an L was battering chicken. Dietary staff said the gnats were related to drained water over the prior 3 weeks, and the Maintenance supervisor said the kitchen issue had not been reported even though the exterminator had been there a week earlier.
Incomplete consent for antipsychotic medication: A resident with bipolar disorder and severely impaired cognition received Risperidone twice daily, but the HHSC Form 3713 in the EMR was incomplete. One form lacked required prescriber and medication details, and another lacked key resident/representative consent information and was signed by staff based on verbal consent from the POA. The DON and Administrator stated the consent documentation should have been completed before the medication was given.
Physician Not Notified When Scheduled Insulin Was Held: A resident with DM and acute kidney failure had scheduled Tresiba insulin held for three consecutive doses because blood sugars were within normal limits, but the MAR and nurse's notes showed no documentation that the MD/NP was notified. The DON stated staff were expected to notify the physician when meds were held three times in a row, and an LVN said she should have called the provider for possible med adjustments.
Damaged Resident Room Walls Not Maintained in Good Repair. Two resident rooms had damaged sheet rock with holes exposing wood framing and insulation, along with dust and torn material on the floor. A CNA said he caused the initial damage in one room and reported it verbally, while the Maintenance Supervisor said he knew about both damaged walls but had not repaired them yet because other work took priority. Maintenance logs did not show the wall damage had been reported.
A resident with a G-tube, dysphagia, and severe cognitive impairment received tube medication administration that did not follow facility policy when an RN pushed water through the tube with a syringe plunger instead of allowing it to flow by gravity. The RN acknowledged the error, and the DON, LVN, and Administrator stated the water should have been given by gravity per the facility’s enteral tube medication administration policy.
A facility failed to follow the menu for a lunch meal when the pureed diet did not include the roll listed on the menu. The cook stated he could not make pureed rolls to the right consistency and did not provide bread for the pureed diet, while the DM said she was unaware the item was omitted.
A resident’s pureed lunch tray contained solid pieces of chicken and a piece of green bean mixed into the pureed meat, even though the DM said pureed food should be smooth and pudding consistency. The cook was responsible for ensuring no solid pieces were present, and the recipe called for a mashed potatoes, pudding, or applesauce texture with no large lumps or particles.
Failure to Follow Contact Isolation and EBP: A WOC nurse handling a resident on Contact Isolation dropped a gown on the floor, then picked it up and wore it for direct care. RN G also entered another resident’s room and gave gastrostomy tube medication without donning a gown, despite the resident being on EBP for feeding tube care. Interviews confirmed both staff knew the infection control expectations, and facility policy required gown use for these precautions.
Antibiotic Stewardship Program Lacked 72-Hour Time-Out Protocol: The facility failed to include a 72-hour antibiotic time-out in its antimicrobial stewardship policy, and the IP was not completing time-outs for all residents on antibiotics for infections. Record review showed reviews were only done when a C&S specimen was collected, and the IP stated she did not realize the time-out was needed for all residents on antibiotics and did not remember seeing the protocol in the policy.
Dining room ceiling leaks and water damage were observed in the main dining room, with multiple discolored ceiling areas and a blocked-off wet area between tables. Two residents said they had to move during lunch because of the roof leaking and reported the problem had been ongoing for months. The ADM, Maintenance Supervisor, and Housekeeping Supervisor all described repeated leaks, ceiling discoloration, and frequent mopping when it rained.
Failure to Notify RP of Refusals and Resolve Grievance: A resident with CVA, MDD, anxiety, and moderate cognitive impairment had a grievance filed because her RP was not being notified when she refused care. After the grievance, an LVN documented a refusal to wash the resident’s face and called the emergency contact instead of the RP, with no documented attempt to contact the RP. The care plan did not include RP notification for refusals, and interviews confirmed the RP expected to be called for all refusals of care.
Surveyors found that kitchen staff failed to properly clean and maintain a deep fryer, which contained food particles and blackish brown cooking oil, and staff acknowledged the fryer should have been cleaned earlier and that no new cooking oil had been obtained or reported to the DM. The facility’s written dietary policies required that work surfaces, utensils, and large equipment be thoroughly cleaned and sanitized after use, and that equipment be sanitized with appropriate chemical solutions, but the condition of the deep fryer and staff statements showed these procedures were not followed.
A resident with a regular diet order and medical conditions including high blood sugar and a weak heart did not receive the ordered breakfast sausage with his meal after requesting meat such as bacon or sausage. A dietary staff member prepared the breakfast tray without using the resident’s tray card and later acknowledged that this caused the omission of meat, while the DM confirmed that residents are expected to receive items listed on their tray cards, consistent with facility dietary policies.
A resident with anoxic brain injury and epilepsy was maintained on phenytoin after a dose reduction ordered for a previously high level, with subsequent lab monitoring showing a subtherapeutic phenytoin level of 5.6 ug/ml. Nursing staff notified the NP about the abnormal level and documented "no new orders," but there was no evidence of further assessment, timely repeat labs, dose adjustment, or escalation to the attending physician or medical director, despite the care plan requiring monitoring and follow-up of subtherapeutic labs. The resident continued on the same phenytoin dose, later developed altered mental status and severe pain, and was transferred to the hospital, where he was diagnosed with status epilepticus and a very low/undetectable Dilantin level. Interviews with facility staff and family confirmed that the low level was recognized but not acted upon beyond NP notification, and that the abnormal lab was not effectively addressed in accordance with professional standards and facility policy for abnormal lab notification.
A resident with severe cognitive impairment alleged sexual abuse by another resident, but a CNA who overheard the allegation failed to report it to the appropriate facility leadership or state agency as required. The incident was not reported or investigated until surveyors intervened, resulting in a delay in protective measures and investigation.
Two staff members, an activity aide and a dietary aide, were found preparing food without current Texas Food Handler's Licenses. Personnel files lacked evidence of valid certifications, and interviews with the DM and Administrator confirmed the absence of current food handler credentials and a facility policy to ensure compliance. The facility's infection control policy required valid food handler cards, but this was not followed for these staff.
Surveyors identified multiple deficiencies in kitchen operations, including improper food storage with unlabeled, undated, and expired items, unsanitary conditions such as standing water and ice build-up in coolers, and inadequate cleaning of pots and pans. Additionally, several staff members failed to fully contain their hair with hairnets while preparing food, despite having received training on proper hygiene practices. These failures were confirmed by the Dietary Manager, Administrator, and Maintenance Supervisor during interviews.
The facility did not notify physicians when two residents experienced significant changes in condition: one resident had consistently high blood glucose levels without physician consultation or adjustment of insulin orders, and another had multiple instances of low heart rate resulting in held medication doses without physician notification or documentation. Staff interviews and facility policy confirmed that physician notification was required in these situations.
The facility did not maintain water temperatures at or below 110°F at hand sinks and a shower room, exposing several residents who required assistance with bathing and personal hygiene to water that exceeded the facility's documented standard. Although no residents reported burns or discomfort, and staff were aware of monitoring procedures, the absence of a written policy and inconsistent temperature control resulted in water temperatures above the recommended range.
A resident with multiple respiratory conditions and severely impaired cognition was diagnosed with pneumonia and prescribed antibiotics, but the care plan was not updated to address the new diagnosis or treatment. The DON, responsible for care plan updates, did not revise the plan after the previous Infection Control Nurse left, resulting in the omission of pneumonia-specific interventions.
Expired over-the-counter medications, including antacids, laxatives, supplements, and vitamins, were found in the main medication storage room after their expiration dates. An LVN discovered 11 unopened bottles during an observation, and staff interviews revealed that the Medical Records Clerk was responsible for removing expired stock, with the Pharmacy Consultant as backup. The process for checking and organizing medications failed to prevent expired items from remaining in stock, and the most recent pharmacy review did not include the medication supply room.
Staff failed to accurately document and obtain daily vital signs for a resident with dementia, hypertension, and diabetes. Instead, identical vital sign readings were repeatedly entered into the MAR over several days, with staff and leadership confirming that actual assessments were not performed and previous values were copied or reused.
A wound care nurse failed to perform proper hand hygiene and change gloves during wound care for two residents with open wounds, resulting in contamination of clean fields and supplies. Despite being trained and aware of infection control protocols, the nurse did not follow required procedures, as confirmed by both the nurse and the DON. Facility policy mandates hand hygiene and glove changes during such care, but these were not adhered to during the observed incidents.
Surveyors found that the kitchen floors, including areas under the hand sink and behind the stove, had significant dust, grime, and food particle buildup. The Dietary Manager confirmed that deep cleaning had not yet been completed, and facility records showed that such cleaning should occur biweekly.
Two residents with significant physical and cognitive impairments did not receive scheduled bed baths as required by their care plans. Documentation and interviews confirmed that multiple scheduled baths were missed due to staffing shortages, despite both residents being unable to perform bathing independently and having no behaviors of care rejection that would prevent staff from providing assistance.
A resident with multiple chronic conditions did not receive her preferred breakfast sandwich with egg, bacon, and cheese as documented on her meal ticket, resulting in her not eating breakfast when her preferences were not met. The dietary manager confirmed the omission of the egg substitute, and the issue had occurred multiple times previously despite facility procedures to accommodate food preferences.
The facility failed to address grievances raised during residents' council meetings over three months. Complaints included staff using personal phones, untimely call light responses, and issues with food and bed making. Staff interviews revealed a lack of awareness and communication regarding grievance responsibilities, and residents reported dissatisfaction with the facility's handling of complaints.
The facility failed to provide palatable and attractive meals, serving cold and unappetizing food on disposable foam plates, contrary to policy. Staff used foam dishes to avoid using the dishwasher due to high kitchen temperatures, without informing management. Residents reported consistently cold meals, leading to potential decreased food intake.
A resident with multiple health conditions did not receive a scheduled shower, as required by her care plan, due to staff running out of time and failing to notify the charge nurse. The resident, at high risk for skin issues, reported not receiving a shower until three days later. The facility's policy highlights the importance of regular bathing for skin integrity and infection prevention.
A facility failed to ensure safe electrical outlet use in a resident's room, where a 6-outlet adapter powered multiple devices, risking circuit overload. The resident expressed concern about sparks, and the administrator was unaware of the non-compliance, attributing responsibility to the previous maintenance supervisor.
The facility failed to report abuse allegations in a timely manner, including a verbal abuse incident involving a resident and an LVN, and two separate incidents involving residents. The delays in reporting to the Abuse Coordinator and the State Agency could have placed residents at risk of continued abuse.
A facility failed to investigate and report a verbal abuse allegation involving a resident with Alzheimer's disease. A CNA reported that an LVN verbally abused the resident, but the incident was not communicated to the Administrator or the state promptly. The LVN continued working the next day, failing to protect the resident from potential further abuse. The delay in reporting and investigation placed residents at risk of undetected abuse.
A resident with severe cognitive impairment and specific care needs fell from the bed during a treatment due to inadequate supervision. The LVN, unaware of the requirement for two staff members for bed mobility, attempted the procedure alone, resulting in the resident sustaining injuries. The incident highlighted a failure in adhering to the care plan and facility policies.
The facility failed to designate a qualified infection preventionist with specialized training, as the current Infection Preventionist (LVN IC) had not completed the necessary training. The DON and Regional Compliance Nurse acknowledged the lack of training, which posed a risk to the facility's infection surveillance capabilities. The previous infection preventionist had completed the training but resigned months ago.
The facility failed to employ a qualified dietary manager, as the designated Dietary Supervisor did not have the necessary certification. Despite being appointed in June 2023, the Dietary Supervisor was still in school and expected to complete the certification by September 2024. This non-compliance was confirmed through interviews and record reviews.
The facility failed to provide a functioning call light system for residents in multiple halls, leading to the use of alternative methods like whistles and bells for calling assistance. Staff made frequent rounds to monitor residents, especially those with cognitive impairments, while the facility awaited repairs.
The facility failed to ensure proper storage and security of medications in two medication carts and one medication room, including expired medications and a non-affixed lock box for controlled drugs in the refrigerator. Staff interviews confirmed the lapses in following facility policies and procedures.
The facility failed to ensure that a dietary staff member had a current Food Handler's Certificate while working in the kitchen. This deficiency was confirmed through record review and interviews with the Administrator and Regional HR, who acknowledged the facility's responsibility to maintain such certificates to prevent foodborne illness.
The facility failed to maintain an infection prevention and control program. An LVN did not wash or sanitize her hands when entering a resident's room and between glove changes during medication administration. Additionally, two LVNs did not clean the glucometer device according to the required contact time of the disinfectant before and after use on three residents.
The facility failed to ensure resident privacy during incontinent care when two CNAs did not pull the privacy curtain, exposing a resident with severe cognitive impairment to her roommate. Both CNAs admitted to forgetting the procedure, despite being trained to provide privacy.
The facility failed to ensure comprehensive care plans were reviewed and revised for two residents. One resident's care plan did not address the need for a fire-resistant smoking apron, and another resident's care plan did not include the diagnosis related to an indwelling urinary catheter. These oversights were acknowledged by various staff members, including the MDS Nurse, SW, DON, and Administrator.
The facility failed to provide appropriate respiratory care for two residents. One resident received oxygen therapy without physician orders, and another received an incorrect oxygen dose. Both issues were confirmed by an LPN and the DON.
The facility failed to ensure proper medication administration for two residents. One resident did not have their g-tube placement checked before medication administration, and another received the wrong type of insulin. These deficiencies were observed and confirmed through interviews and record reviews.
Insufficient CNA Staffing on Secured Hall
Penalty
Summary
The facility failed to provide sufficient nursing staff on the secured 500 Hall in accordance with its facility assessment. The assessment stated that the unit required 1 licensed nurse and 2 CNAs on the day shift and 1 licensed nurse and 2 CNAs on the evening shift, but observations and staffing records showed that the unit was frequently staffed with only 1 CNA along with 1 licensed nurse. The resident roster provided by the Administrator showed 19 residents on the secured unit during the period reviewed, and the former DON confirmed the census for multiple dates during June and July. During observations on the morning shift, only 1 LVN and 1 CNA were present on the secured unit, with an RN orienting with the LVN. The nurse office on the secured unit did not have CCTV monitoring of the hall, dining area, or sitting room, and these areas were not visible from the office. While the CNA was attending to residents in rooms, residents in the dining area were left without direct staff presence. At one point, a resident stood up from a wheelchair and tried to walk around before the CNA returned and assisted the resident back to the wheelchair. Later, while lunch trays were being delivered, the LVN was not present to check the trays, and the trays remained unchecked until the RN began checking and passing them. Additional observations showed residents left unattended in the dining area when the CNA left to take the meal cart back to the kitchen and the nurses were in the office at the opposite end of the hall. During that time, a resident in a low sitting wheelchair rolled back and the metal arm attached to the headrest struck another resident in the left elbow, causing the resident to say, "That hurt," and the CNA later identified a skin tear and called for the LVN. Interviews with CNAs and LVNs confirmed that the secured unit often had only 1 CNA on duty, that residents could be left unattended when the CNA was in a room or away from the unit, and that the nurse office could not monitor the hall or dining room. Staffing sheets for multiple dates in June and July documented shifts on the secured unit with only 1 CNA, and on some shifts no CNA was listed at all.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
Food service safety deficiencies were identified in the kitchen, freezer, refrigerator, dish room, and food preparation areas. Freezer #2 contained 2 unmarked and unsealed gallon bags holding approximately 16 frozen cookies and approximately 20 frozen garlic bread rolls. Refrigerator #4 had clear liquid on the bottom shelf with spills and food debris, and it contained 2 cardboard boxes with 4 sealed bagged eggs and 8 one-pound butter blocks that were not bagged; the boxes were soaked with clear liquid. An undated inservice record stated that food items must be dated when received and that floors need to be kept clean, and an undated dietary food services policy stated to dispose of food fallen on the floor. The dish room ceiling had 3 holes around the air-conditioning vent, black substance around the sheetrock, and water damage. Water pipes and drainpipes under the dish machine were leaking, the floor was wet, 8 tiles were loose, and the grout was deteriorated. During observation in the food preparation area, approximately 1 cup of scrambled eggs was on the floor in front of the steam table while lunch items were being placed on it, a personal drinking cup was next to the mechanical processor on the food preparation table, and a 64-gallon rolling trash can without a lid was half full of garbage next to the preparation table and a clean food rack. Staff stated the ceiling had been like that for about a year, the leaking water had been reported, and the personal drink should not have been in the food preparation area.
Kitchen Pest Control Failure
Penalty
Summary
The facility failed to maintain an effective pest control program and the kitchen was not free of gnats. During an observation on 07/13/2026 at 9:05 a.m., 4 to 6 gnats were seen in the kitchen dish room flying around leaking pipes. During an interview later that morning, dietary staff K said the gnats were present because of drained water over the last 3 weeks. On 07/14/2026 at 11:50 a.m., approximately 5 to 6 gnats were observed flying around a box on the floor containing garbage and over the preparation table where [NAME] L was battering chicken; he stated insects can cause spread of germs. During an interview on 7/15/26 at 3:30 p.m., the Maintenance supervisor said no one had reported pests in the kitchen and stated the exterminator company had been there a week earlier, but the kitchen gnats had not been reported.
Incomplete consent for antipsychotic medication
Penalty
Summary
The facility failed to ensure a resident was fully informed in advance of the risks and benefits of antipsychotic treatment and that proper consent documentation was completed for Risperidone. Resident #3 was a female admitted and readmitted to the facility with diagnoses including bipolar disorder, and her quarterly MDS showed a BIMS score of 03 out of 15, indicating severely impaired cognition. Her care plan identified the need for antipsychotic medications related to bipolar disorder and included an intervention to educate the resident, family, and caregivers about risks, benefits, and side effects. Record review showed Resident #3 had a physician order for Risperidone 0.5 mg by mouth twice daily for bipolar disorder and received the medication daily during May, June, and July 2026. The EMR contained an HHSC Form 3713 dated 04/07/24 and another dated 01/14/25 for Risperidone, but both forms were incomplete. The earlier form lacked a vendor number, dosage and frequency in Section I, and the prescriber signature. The later form lacked a vendor number, the resident's SS number, dosage and frequency in Section I, information identifying who was giving consent and on whose behalf in Section II, and the signature of the resident or resident representative; it was signed by a staff member with verbal consent from the POA. During interview, the RCN/former DON stated the form should have been completed with all missing information before upload and said she did not realize verbal consent could not be obtained for HHSC Form 3713. She also stated she could not make out which staff member signed as receiving verbal consent. The Administrator stated nursing staff were responsible for ensuring medication consents were signed and in place for psychotropic medications, and that not obtaining completed consents before administering psychoactive medications could take away the resident's right to be informed regarding medications and possibly the right to refuse treatment.
Physician Not Notified When Scheduled Insulin Was Held
Penalty
Summary
The facility failed to consult the resident's physician when there was a need to alter treatment significantly for Resident #9, specifically when her scheduled Tresiba FlexTouch insulin was held on 07/08/2026, 07/09/2026, and 07/10/2026. Resident #9's record showed diagnoses including acute kidney failure and diabetes, and her physician's orders included Tresiba 20 units subcutaneously daily with no hold orders. Her MAR showed blood sugars of 80, 90, and 97 on those dates, and the insulin was held with a code indicating blood sugar was within normal limits. Review of the nurse's notes from 06/26/2026 through 07/14/2026 found no documented evidence that the physician was notified that the insulin had been held for three consecutive doses. During interview, the DON stated nurses were expected to notify physicians when medications were held three times in a row so the physician could adjust the medication or prevent negative outcomes. An LVN stated she held the insulin for three days in a row and should have called the NP or physician in case medication adjustments were needed.
Damaged Resident Room Walls Not Maintained in Good Repair
Penalty
Summary
The facility failed to ensure two resident rooms were maintained in good repair and in a safe, clean, comfortable, and homelike condition. During observation on 07/13/2026, room 104A had friction marks on the door wall, torn and peeling sheet rock exposing the white chalky core, and a large hole in the sheet rock exposing the brown wood frame and insulation. Chalky white dust was observed on the floor. Room 112B had 4-5 linear abrasion grooves on the window wall, a large hole in the sheet rock exposing the brown wood frame and insulation, a visible gap where the outside wall could be seen, and chalky white dust and torn paper on the floor. During interview, CNA-J stated he had caused the initial damage in room 104A while adjusting the bed and said he verbally reported the wall damage to the Maintenance Man the day it occurred. He stated the damage worsened over time and that all staff could verbally report maintenance issues or enter them in the maintenance log. CNA-J also stated that not repairing the sheet rock could affect the facility's appearance and cleanliness. He said he did not know about the wall damage in room 112B. The Maintenance Supervisor stated he was responsible for repairs, checked the maintenance logs daily if possible, and expected repairs to be completed the day they were submitted unless parts were needed. He said he was aware of the damaged walls in rooms 104A and 112B since he had been hired, but the issues had not been logged in the maintenance binder. He said he had planned to repair them but had not gotten to those rooms yet because he was working on other areas that took priority. The Administrator stated repairs were expected to be completed the next day unless parts were needed and said she expected the facility and resident rooms to be homelike. Review of maintenance logs from 02/01/2026 through 07/13/2026 did not show reports for the wall damage in either room.
Improper G-tube Water Flush Administration
Penalty
Summary
The facility failed to ensure a resident with a gastronomy tube received enteral tube medication and water flushes according to policy when RN G administered water by pushing it through the tube with a syringe plunger instead of allowing it to flow by gravity. Resident #54 was a male with diagnoses including cerebral infarction, gastronomy status, and dysphagia, and his MDS indicated severely impaired cognition with a feeding tube. His orders included flushing the tube with water before and after medications and feeding, and a separate order for a 300 ml water flush three times daily. During observation on 07/14/2026, RN G administered medication through the gastronomy tube by gravity flow, then drew up water in a syringe and, after being asked whether she would give it by gravity, pushed the water slowly through the tube with the plunger. RN G stated she should have inserted the water by gravity instead of pushing it with the syringe and said she had been educated to give medication and water by gravity. The DON, LVN H, and the Administrator all stated the water should have been given by gravity and that RN G had been educated on gastronomy tube medication administration. The facility policy titled Enteral Tube Medication Administration directed staff to flush the tube with water and allow medication to flow down the tube via gravity.
Menu Not Followed for Pureed Diet Lunch
Penalty
Summary
The facility failed to follow the menu for 1 of 2 meals reviewed when the 07/15/2026 lunch menu listed chicken, mashed potatoes, gravy, vegetables, a honey kissed roll, and pudding, but the pureed diet served did not include rolls. The recipe for the honey kissed roll pureed item dated 07/15/2026 indicated the pureed diet should have included a pureed roll with chicken base and a texture of mashed potatoes or pudding. During observation on 07/15/2026 at 11:40 a.m., the cook pureed meat, potatoes, vegetables, and pudding for the pureed diet, but did not puree rolls or bread for the pureed diets. During interview, the cook said he was unable to make pureed rolls to the right consistency and was unable to provide bread for the pureed diet. The DM stated she was new, was unaware the cook was unable to process bread or rolls to the right consistency, and was unaware the pureed diet did not have rolls that day.
Pureed Meal Contained Solid Pieces
Penalty
Summary
The facility failed to serve each resident food prepared in a form to meet individual needs for one lunch meal reviewed for pureed food preparation. During observation, [NAME] L pureed chicken, green beans, and mashed potatoes for pureed diets. When the pureed lunch tray was observed and tasted later that day, the test meal contained 2 solid pieces of chicken measuring about 1/4 by 1/4 inch and a piece of whole green bean approximately 1/2 inch in the pureed meat, even though the DM said the bite should be smooth. The DM stated pureed food should be smooth and pudding consistency to prevent choking, and that the cook was responsible for ensuring no solid pieces were in the pureed food. Record review showed 9 residents had pureed diet orders, and the recipe for fried chicken for pureed diet stated the desired texture should be mashed potatoes, pudding, or applesauce texture with no large lumps or particles.
Failure to Follow Contact Isolation and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 of 18 residents reviewed for infection control. Resident #43 had diabetes mellitus with a left foot ulcer, a BIMS score of 8, and a care plan and physician order for Contact Isolation related to the wound. During an observation, the Wound Care Nurse prepared supplies outside the room, performed hand hygiene, then grabbed a gown from a PPE drawer, dropped it on the floor, picked it up, and put it on before assisting a CNA with gowning and moving the supply table toward the resident’s room. Resident #54 had a history of cerebral infarction, gastrostomy status, dysphagia, and a BIMS score of 2. His orders and care plan indicated enhanced barrier precautions for enteral feeding care and other high-contact activities, including the use of gloves and a gown. During an observation, RN G performed hand hygiene and entered the resident’s room to give gastrostomy tube medication without wearing a gown, despite the EBP sign and PPE cabinet being present at the doorway. Interviews with the Wound Care Nurse, RN G, the ADON, the DON, and the Administrator confirmed that both staff members were expected to follow the facility’s infection control procedures. The Wound Care Nurse stated she should not have used the gown after it fell on the floor, and RN G stated she should have worn a gown for direct patient care for a resident on EBP. The facility policies reviewed stated that gowns are used for barrier protection and that EBP requires gown and glove use during high-contact resident care activities, including feeding tube care.
Antibiotic Stewardship Program Lacked 72-Hour Time-Out Protocol
Penalty
Summary
The facility failed to implement an antibiotic stewardship program that included antibiotic use protocols. Record review of the undated Antimicrobial Stewardship Policy showed the facility’s mission statement for an infection prevention and control program that included an antimicrobial stewardship program, but there was no indication in the policy of a protocol addressing the 72-hour Antibiotic Time Out. The Infection Control Tracking and Trending Book for 2026 showed that the IP was not conducting a 72-hour Antibiotic Time Out on residents with antibiotics ordered for infections. The reviews that were completed were only done on residents who had a specimen collected for a C&S. During interview, the IP stated she did not realize she needed to conduct a 72-hour antibiotic time out on all residents on antibiotics for infections to ensure they were improving on the antibiotic they were prescribed, and said she did not remember seeing the protocol in the policy. She stated she would review residents if a C&S specimen was obtained. The Administrator stated she expected staff to follow protocol/policy for what they had been assigned and said not following protocol/policy regarding antibiotics could cause resident infections not to be addressed appropriately.
Dining Room Ceiling Leaks and Water Damage
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in 1 of 2 dining rooms. During observation, the main dining room ceiling had 6 areas of discolored tan sheet rock, including one oblong area about 3 feet long and 1 1/2 feet wide and 5 additional round areas ranging from about 1 foot to 6 inches, all located in the center of the room. On another observation, the middle of the dining room was blocked off with wet floor signs, a mop bucket, and a blanket on the floor between 2 rows of tables. Resident #4 was admitted with diagnoses including blood in urine and chronic kidney failure, and her quarterly MDS showed a BIMS of 12, indicating moderate cognitive impairment. Resident #80 was admitted with diagnoses including stroke and heart disease, and her quarterly MDS showed a BIMS of 13, indicating she was cognitively intact. During interview, both residents said they had to move to another table during lunch because of the roof leaking, and they said the ceiling had been leaking for a few months. The Administrator, Maintenance Supervisor, and Housekeeping Supervisor each described ongoing leaks and ceiling discoloration in the dining room, with housekeeping mopping several times a day when it rained and the ceiling previously sagging enough that the dining room had to be shut down.
Failure to Notify RP of Refusals and Resolve Grievance
Penalty
Summary
The facility failed to make prompt efforts to resolve a grievance related to a resident’s refusals of care for 1 of 7 residents reviewed for grievances. The resident was a [AGE]-year-old female with diagnoses including cerebral infarction, major depressive disorder, and anxiety, and her quarterly MDS indicated she was usually able to make herself understood, usually understood others, and had moderate cognitive impairment (BIMS-11). Her RP, listed ahead of emergency contact #2, filed a grievance stating he was frustrated that he was not being notified when the resident did not get out of bed. The grievance record stated the resident was care planned for refusals, staff were inserviced on documenting refusals, and staff would call the RP when there was a refusal. After the grievance, a progress note documented that the resident refused to have her face washed, and LVN A called emergency contact #2 and reported the refusal, with no documented attempt to contact the RP. The resident’s revised care plan identified her as resistive to care and refusing ADL care, showers, bipap at night, and getting up out of bed, but it did not include RP notification for refusals. During interviews, the RP stated he was not notified of the refusal and said he expected to be called for all refusals of care, while the SW stated the RP wanted to be called 100% of the time for all refusals and the emergency contact would be called only if the RP was not available. The DON stated the care plan did not include RP notification and could not explain why the staff training did not specify that the RP was to be notified first for refusals.
Improper Cleaning and Maintenance of Deep Fryer and Cooking Oil
Penalty
Summary
Surveyors identified a deficiency in dietary services related to improper storage, preparation, and sanitation of cooking equipment in the kitchen. During an observation and interview, the deep fryer was noted to contain food particles and blackish brown cooking oil. A staff member (identified as [NAME] A) stated the deep fryer should have been cleaned the previous week and acknowledged that there was no new cooking oil available, further admitting he had not reported the need for cooking oil to the Dietary Manager (DM). The DM stated that the deep fryer should be kept clean to prevent foodborne illnesses. Review of the facility’s 2012 Dietary Services Policy & Procedure Manual showed requirements that work surfaces be kept neat and clean during preparation and service, that all utensils, pots, and pans be properly washed and sanitized after use, that all work areas be thoroughly cleaned and sanitized after use, and that large equipment be sanitized with a chemical sanitizing solution at least twice the minimum strength needed for immersion sanitizing. The observed condition of the deep fryer and the staff’s statements demonstrated noncompliance with these written policies. No specific residents or their medical histories were mentioned in the report, but the deficiency pertained to the kitchen that provides food and beverages to residents.
Failure to Follow Tray Card Resulting in Omission of Ordered Breakfast Protein
Penalty
Summary
The deficiency involves the facility’s failure to provide a nourishing, palatable, well‑balanced diet that met a resident’s daily nutritional and special dietary needs, including preferences, for one breakfast meal. Record review showed that the resident, who was admitted in April 2026 with diagnoses including high blood sugar, a weak heart, and uncontrollable worry, had a physician’s order for a regular diet. The resident reported in an interview that he did not receive any meat with his breakfast and had requested bacon or sausage. He stated this had happened before, though he could not recall how often or when, and said he had informed a staff member of his desire for meat but could not remember which staff member. In a separate interview, a dietary staff member stated that someone had requested meat for the resident that morning, but breakfast had already been put away. He acknowledged that he had prepared the resident’s breakfast tray without using the resident’s tray card and therefore did not provide meat. The Dietary Manager stated that residents should receive what is listed on their tray cards and provided the printed tray card for the resident, which indicated the resident was to receive breakfast sausage along with cereal, egg, and a biscuit. The facility’s Dietary Services Policy & Procedure Manual stated that diets are to be ordered and provided in accordance with the approved Diet Manual and that the department’s role is to serve attractive, appetizing, nourishing, high‑quality food to help keep residents healthy.
Failure to Follow Up on Subtherapeutic Phenytoin Level Leading to Status Epilepticus
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices, specifically related to management of an anti-seizure medication (phenytoin/Dilantin) and associated lab monitoring. The resident was an adult male with anoxic brain damage, epilepsy with status epilepticus, and severe cognitive impairment. His care plan identified a seizure disorder and directed staff to administer seizure medication as ordered, monitor and document side effects and effectiveness, monitor labs, report any subtherapeutic or toxic results to the physician, and obtain and follow up on lab/diagnostic work as ordered. The resident had an order for phenytoin, initially at 250 mg daily, with phenytoin levels to be checked every three months. After a critically high phenytoin level of 23.4, the physician decreased the dose from 250 mg to 200 mg daily and increased lab monitoring to every two months. A subsequent phenytoin lab result showed a level of 5.6 ug/ml, below the therapeutic range of 10.0–20.0 ug/ml. This low result was documented on the lab report and in the record, including a medication regimen review noting the low level and recommending a redraw and possible dose adjustment, with the physician checking a box agreeing with the recommendation. Progress notes indicated that the NP reviewed the resident’s BMP, CBC, and phenytoin labs and documented “no new orders” at that time. Despite the documented subtherapeutic phenytoin level of 5.6, there was no evidence in the record that nursing staff implemented additional assessments, obtained repeat labs in a timely manner, or followed up beyond notifying the NP. Interviews with the DON and nursing staff confirmed that the NP was contacted twice regarding the abnormal lab value and that no new orders were received, with no further escalation to the attending physician or medical director. The DON stated that the lab value was low but not critical and that it was beyond the nurse’s scope to question the NP’s response. The NP later stated she had missed the low level and that, given the resident’s seizure history and low level, she would normally have ordered a repeat lab and subsequent dose adjustment. The resident continued to receive 200 mg of phenytoin daily as documented on the MAR, and there was no documentation of seizure symptoms prior to his transfer to the hospital for screaming in severe pain, where he was diagnosed with status epilepticus and a subtherapeutic/undetectable Dilantin level. Interviews with family members indicated they were told by a hospital neurologist that the hospitalization and seizures were preventable and related to the decrease in medication and low phenytoin levels. The attending physician acknowledged that the first recheck level after the dose decrease was “5 something,” which he described as on the low side, and stated that the NP had missed the lab. He also stated he did not recall being notified of this specific lab value and that he would not “chase the numbers” in the absence of symptoms. Another physician interviewed stated that changes in phenytoin dosing or lab values should be followed by more frequent lab monitoring and that changes should not be based on old labs. The facility had a policy requiring physician notification of abnormal labs and documentation of such notifications and interventions, but there was no documentation that the low phenytoin level was escalated beyond the NP or that any clinical interventions or additional monitoring were implemented in response to the subtherapeutic result prior to the resident’s hospitalization. An Immediate Jeopardy (IJ) was identified related to this failure, based on the facility’s lack of follow-up after notifying the NP twice about the subtherapeutic phenytoin level and the absence of interventions or assessments in response to that abnormal lab value. The IJ was later removed, but the facility remained out of compliance at a lower severity level while it continued to monitor implementation and effectiveness of its corrective actions.
Removal Plan
- Transferred Resident #1 to the hospital for treatment of status epilepticus and subtherapeutic Dilantin level.
- Completed a 100% audit of anticonvulsant medications to ensure therapeutic lab values and communicated any abnormal findings to the attending physician.
- Notified the provider of an abnormal lab identified during the audit, awaited new orders, and monitored the resident for signs/symptoms of seizures.
- Provided 1:1 in-service to the DON and ADON by the Regional Compliance Nurse on provider notification of abnormal lab values, documentation of provider notification for changes in condition including abnormal labs, escalation process when the NP/attending does not address non-therapeutic labs, and abuse/neglect implications of failure to intervene on abnormal labs.
- Notified the Medical Director of the Immediate Jeopardy.
- Completed an ad hoc QAPI meeting with the interdisciplinary team including the Medical Director.
- Initiated facility-wide in-services for all charge nurses and ensured staff not present would not be permitted to work until in-serviced, new hires would be in-serviced during orientation, and agency staff would be in-serviced prior to working floor assignment, covering provider notification of abnormal labs, documentation of provider notification for changes in condition including abnormal labs, escalation process when the NP/attending does not address non-therapeutic labs, and abuse/neglect implications of failure to intervene on abnormal labs.
- Reviewed the facility-wide anticonvulsant audit, reviewed documentation of Resident #2’s follow-up to an abnormal lab, reviewed in-service documentation for the ADON/DON/all staff, and ensured any incomplete in-services would be completed before the staff member’s next shift.
- Conducted individual staff interviews across shifts/weekends/PRN to confirm staff understanding of training and reporting requirements for lab results including reporting to the DON, MD, and family.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required. Specifically, a resident with severe cognitive impairment and a history of dementia alleged that another resident touched her breast. This allegation was overheard by a CNA, who did not report the incident to the charge nurse, Administrator, or DON, despite having been trained to do so. The CNA admitted to overhearing the allegation one to two weeks prior but did not act, believing the resident was confused. The incident was not reported to the facility's abuse coordinator or to the state agency within the required timeframe. The deficiency was identified when a non-staff person relayed the resident's allegation to surveyors, prompting further investigation. Interviews confirmed that neither the Administrator nor the DON had been informed of the allegation until surveyor intervention. The facility's own policy required immediate reporting of abuse allegations, especially those involving serious bodily injury or abuse, within two hours. However, the required notifications and investigation were not initiated until the surveyors became involved. The residents involved both had severe cognitive impairment and were admitted to a secure unit due to elopement risk and dementia. The alleged perpetrator denied the incident, and the alleged victim was unable to provide specific details about when the event occurred or which staff were aware. The lack of timely reporting and investigation meant that no interventions were initiated to protect the resident or prevent further abuse until after the surveyor's discovery.
Failure to Ensure Dietary Staff Maintained Required Food Handler Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, one activity aide and one dietary aide were found to be preparing food in the kitchen without having a current Texas Food Handler's License. Observations confirmed that the activity aide was preparing shredded cheese at the prep table, and record reviews of both aides' personnel files showed no evidence of current or prior food handler certifications at the time of review. Interviews with the Dietary Manager and Administrator confirmed that these staff members did not have current food handler certifications and that there was no facility policy in place to ensure compliance with food handler certification requirements. The Administrator acknowledged the importance of food handler certification for all staff involved in food preparation to ensure adherence to best practices, proper sanitation, and prevention of cross-contamination. The activity aide also confirmed that her certification was expired at the time she was preparing food and recognized the risk this posed to residents. The facility's infection control policy required valid food handler cards for dietary associates, but this was not followed for the staff in question.
Multiple Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as evidenced by multiple observations in the kitchen. Food items in Icebox #1 were found to be unlabeled, undated, unsealed, and in some cases, expired. Specific items included cantaloupe slices and pudding in unmarked containers, undated tomatoes, an opened and exposed bag of broccoli, and sliced tomatoes with visible spoilage. Additionally, the dry pantry contained expired juice containers, dented cans stored with non-dented cans, an unsealed bag of vanilla wafers, and an expired jar of horseradish. The Dietary Manager (DM) confirmed these findings and acknowledged that expired or spoiled foods had not been removed as required by facility policy. The facility also failed to maintain sanitary conditions in food storage and preparation areas. Icebox #2 had standing water on the floor, with cases of milk cartons sitting in the water, and unpackaged food present. The milk box cooler exhibited a significant ice build-up and accumulation of food crumbs and debris along the wall and rubber gasket. The DM and Maintenance Supervisor confirmed these conditions, with the Maintenance Supervisor attributing the issues to a clogged drain and a dirty rubber seal. Additionally, the storage area for pots and pans contained multiple items with baked-on black and brown residue, indicating inadequate cleaning practices. Staff hygiene and use of hair restraints were also deficient. Observations revealed that Activity Aide B, Dietary Aide G, and another dietary staff member were working in the kitchen with hairnets that did not fully contain their hair, leaving portions of hair exposed around the face and nape. Staff interviews confirmed that they had received training on proper hair restraint use, but were unaware that their hair was not fully covered. The DM and Administrator both acknowledged the importance of proper hair restraint to prevent contamination, and the DM stated it was her responsibility to ensure compliance with these standards.
Failure to Notify Physician of Changes in Condition and Medication Holds
Penalty
Summary
The facility failed to consult with physicians regarding significant changes in condition for two residents. For one resident with diabetes and severe cognitive impairment, blood glucose levels were consistently elevated on multiple dates, as documented in the medication administration record. Despite these abnormal readings, there was no evidence that the physician was notified or that sliding scale insulin was considered or ordered. Nursing staff and the DON confirmed that physician notification should have occurred for these abnormal results, and that an order for sliding scale insulin was needed to manage the resident's blood glucose levels. For another resident with congestive heart failure and hypertension, the medication Digox was held on several occasions due to low heart rates, as per physician orders. However, there was no documentation that the physician was consulted about the repeated low heart rates or the pattern of the medication being withheld. Staff interviews confirmed that the physician should have been notified and that such notifications should be documented in the resident's medical record. Facility policy also required physician notification when a dose of medication was not given.
Failure to Maintain Safe Water Temperatures for Resident Use
Penalty
Summary
The facility failed to maintain safe water temperatures at or below 110 degrees Fahrenheit at hand sinks and a shower room used by several residents. During observations, the Maintenance Supervisor measured water temperatures ranging from 111.3 to 115 degrees at the hand sinks in the rooms of three residents and in the shower room between two halls. These temperatures exceeded the facility's stated standard for water temperature, which was documented as 100 to 110 degrees in the water temperature logs. The Maintenance Supervisor acknowledged that water temperatures had been fluctuating and that a plumber had provided an estimate for a new mixing valve, but the issue persisted at the time of the survey. The residents involved had varying degrees of cognitive function and required substantial or maximal assistance for bathing and personal hygiene. None of the residents reported having been burned or experiencing discomfort from the water temperature, and no burns or pressure wounds were documented in their medical records. Staff interviewed were aware of the need to monitor water temperatures to prevent burns and stated they routinely checked water temperatures when assisting residents with grooming or showering. Despite these precautions, the facility did not have a written policy regarding water temperature, and the Administrator relied on external resources for guidance. Water temperature logs from earlier in the month showed compliance, but logs from the days of the survey indicated temperatures above the acceptable range. The lack of a consistent and documented approach to monitoring and maintaining safe water temperatures led to the deficiency, as residents were exposed to water temperatures above the recommended maximum.
Failure to Update Care Plan for New Pneumonia Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's recent diagnosis of pneumonia. The resident, an elderly female with a history of pleural effusion, chronic obstructive pulmonary disease, and severely impaired cognition, was admitted with multiple respiratory conditions and was dependent on continuous oxygen therapy. Despite a physician's order for Doxycycline to treat pneumonia and documentation of the resident's ongoing respiratory symptoms, the care plan was not updated to include interventions specific to the new pneumonia diagnosis or the antibiotic treatment. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for updating care plans for new infections but had not done so for this resident following the resignation of the previous Infection Control Nurse. The DON acknowledged being aware of the pneumonia diagnosis and the antibiotic order but did not revise the care plan, believing existing respiratory care plans were sufficient. The administrator confirmed that the omission occurred during the transition between staff roles. The facility's policy requires comprehensive care plans with measurable objectives and timeframes for all identified needs, but this was not followed in this case.
Expired Over-the-Counter Medications Found in Main Medication Storage Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals in the main medication storage room were labeled and stored in accordance with professional standards, specifically by allowing 11 unopened over-the-counter medication bottles to remain in stock past their expiration dates. During an observation, an LVN identified these expired medications, which included antacids, laxatives, supplements, and vitamins, all with expiration dates ranging from several months prior to the survey. The LVN explained that the process for organizing medications involved placing older stock in front, but acknowledged that expired items may have been overlooked or accessed out of order. Interviews with facility staff revealed that the Medical Records Clerk was responsible for ordering, stocking, and removing expired medications, with the Pharmacy Consultant serving as a backup. The DON confirmed this arrangement and stated that the expired medications were likely missed during routine checks. The Medical Records Clerk reported conducting monthly checks for expired medications, with the last check occurring the previous month, and noted that nurses were also expected to help identify and remove expired stock. The Pharmacy Consultant indicated that her inspections of the medication rooms were periodic and not comprehensive, with her most recent check of the medication carts occurring the previous month. The Executive Summary of the Consultant Pharmacist's Medication Regimen Review documented a medication cart audit but did not indicate a review of the medication supply room. Staff interviews consistently acknowledged the risk that expired medications could be administered to residents, potentially resulting in reduced effectiveness.
Failure to Accurately Document and Obtain Daily Vital Signs
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident by not properly documenting daily vital signs as required by physician orders. Review of the resident's Medication Administration Record (MAR) for May 2025 revealed that staff repeatedly documented identical vital sign readings over consecutive days, rather than recording new measurements. Both the LVN and the DON confirmed during interviews that the vital signs were not being taken daily as ordered, and staff appeared to be copying previous entries or using an electronic record feature to repeat prior values instead of performing actual assessments. The resident involved had diagnoses including dementia, hypertension, and diabetes, and was severely cognitively impaired according to a recent assessment. Physician orders required daily vital signs to be obtained on the morning shift, and the care plan specified regular blood pressure monitoring. Despite these requirements, the MAR showed repeated, identical entries for vital signs over multiple days, indicating that staff did not follow proper procedures for assessment and documentation.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper wound care practices observed for two residents. For one resident, a 66-year-old male with diabetes, edema, kidney disease, and an arterial ulcer of the left great toe, the wound care nurse donned gloves and prepared a clean field but then contaminated the field by touching the resident's wound and subsequently retrieving clean supplies with the same gloves. The nurse placed used gauze and dirty gloves on the same surface as clean dressings and did not perform hand hygiene before donning new gloves and continuing care. For another resident, a female with a stage 4 pressure ulcer on the coccyx and a history of surgery, anxiety disorder, and kidney failure, the wound care nurse did not perform hand hygiene before starting care and failed to change gloves or wash hands at multiple points during the dressing change. The nurse removed a soiled dressing, handled clean supplies with contaminated gloves, and applied medication and a new dressing without appropriate hand hygiene or glove changes, thereby contaminating the clean field and supplies. Interviews with the wound care nurse confirmed awareness of the correct procedures, including the need for hand hygiene and glove changes, but acknowledged these steps were not followed during the observed care. The Director of Nursing, who also serves as the Infection Control Preventionist, stated that staff are expected to follow hand hygiene protocols and that training is provided during orientation and as needed. Facility policy also requires hand hygiene before and after dressing changes and after removing gloves.
Failure to Maintain Kitchen Floor Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to maintain clean floors in the kitchen, specifically under the hand washing sink, juice area, and behind the stove. There was a buildup of dust, grime, and food particles along the floor under the hand sink area, which extended the length of the wall, and behind the stove, which extended approximately six inches from the baseboard. The Dietary Manager acknowledged that she had not yet had the opportunity to deep clean the floors and confirmed that the kitchen should not have grime or buildup to prevent contamination of food. The Administrator also stated a desire for the kitchen to be clean. Review of the facility's deep clean list indicated that cleaning under sinks and scrubbing floors with a floor machine should occur every two weeks.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing, to two residents who were unable to perform these tasks independently. One resident, a female with diagnoses including cardiomegaly, dementia with behavioral disturbance, morbid obesity, urogenital candidiasis, and rheumatoid arthritis, required substantial to maximal assistance for bathing and had no behaviors of care rejection. Her care plan specified a bed bath on Monday, Wednesday, and Friday with one staff assist. However, CNA flowsheets and resident interviews confirmed that scheduled bed baths were missed on multiple occasions, with only one bath documented over a one-week period. Staffing shortages were cited by CNAs as a reason for not completing all scheduled baths. Another resident, also a female with heart disease, dementia, morbid obesity, schizophrenia, and heart failure, required moderate assistance from two staff for bathing and was noted to be occasionally resistive to care. Her care plan included strategies for negotiating ADL times and re-approaching if she was initially resistive. Despite this, CNA documentation and resident interviews indicated that scheduled bed baths were not consistently provided, with only two baths given in a week and several missed on scheduled days. The DON acknowledged staffing challenges and the impact on the ability to provide scheduled baths, while the administrator confirmed the expectation that residents receive their scheduled hygiene care.
Failure to Provide Resident with Preferred Breakfast Items
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's stated preferences. Specifically, a resident with diagnoses including cardiomegaly, dementia with behavioral disturbance, morbid obesity, urogenital candidiasis, and rheumatoid arthritis, who was on a regular diet, did not receive a breakfast sandwich with egg, bacon, and cheese as requested and documented on her meal ticket. During breakfast service, the resident received a sandwich without egg, which she reported had happened one to two times per week previously. The resident stated that when her breakfast was not prepared as requested, she would not eat breakfast. The dietary manager confirmed that the omission was due to forgetting the egg substitute, which was used in place of real eggs due to supply issues. The resident's care plan included offering the diet as ordered and updating food preferences as needed. The facility's meal service policy required dietary staff to interview residents about food preferences upon admission and periodically thereafter, and to serve breakfast to order. Despite these procedures, the resident's preferences were not consistently met.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances over a three-month period. During this time, grievances voiced during residents' council meetings were not thoroughly investigated or addressed. Specific complaints included staff using personal phones while providing care, call lights not being answered timely, lack of fresh water and evening snacks, untimely bed making, food not matching meal tickets, cold food, incorrect meals, and irregular provision of clean bedsheets. Despite these issues being raised in meetings, no grievances were documented or addressed in the facility's records for the months reviewed. Interviews with staff revealed a lack of awareness and communication regarding the grievance process. The Social Worker (SW) was unaware of any unaddressed grievances and did not know she was responsible for writing up or addressing grievances from the residents' council meetings. Similarly, the Activity Director did not document grievances from the meetings and only emailed the minutes to the Administrator, without informing the SW. The Administrator admitted to not reviewing the residents' council minutes to ensure complaints were addressed, attributing the oversight to the SW being new and possibly unaware of her responsibilities. Residents expressed dissatisfaction with the facility's handling of grievances, stating that complaints were not addressed and that issues such as cold and unappetizing food, particularly on weekends, persisted. The facility's grievance policy mandates that residents have the right to voice grievances without fear of reprisal and that the facility must make prompt efforts to resolve them. However, the facility did not adhere to this policy, as evidenced by the lack of documented grievances and unresolved complaints from the residents' council meetings.
Deficiency in Food Palatability and Presentation
Penalty
Summary
The facility failed to provide palatable and attractive food for residents, as evidenced by observations, interviews, and record reviews. Over a period from December 19, 2024, to February 8, 2025, meals were consistently served cold and unappetizing, often on disposable foam plates and bowls, contrary to the facility's policy. Photos and interviews revealed meals such as cold grilled cheese sandwiches, flavorless tuna on unbuttered bread, and cold, unseasoned meat, all served in disposable foam containers. These meals were described as lacking flavor and being served at inappropriate temperatures, which could lead to decreased food intake and potential weight loss among residents. Interviews with staff and residents confirmed the issues with meal temperatures and presentation. Dietary staff admitted to using disposable foam dishes to avoid using the dishwasher due to high kitchen temperatures, without informing management of the air conditioning issues. Residents consistently reported that food served on disposable foam was always cold. The facility's policy stated that meals should be served on regular dining plates and bowls with warmer covers to maintain proper temperatures, but this was not adhered to, leading to the deficiencies noted in the report.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received necessary services to maintain good hygiene. Specifically, the resident did not receive a scheduled shower or bath on February 7, 2025, as per her care plan, which required assistance from one staff member. The resident, who had multiple diagnoses including cardiomegaly, dementia, morbid obesity, and rheumatoid arthritis, was at high risk for skin issues due to her impaired mobility and co-morbid conditions. The resident reported not receiving a shower until February 10, 2025, and expressed concern about her skin breaking out due to missed showers. Interviews with staff revealed that the CNA responsible for the resident's care on February 7, 2025, ran out of time and did not complete the shower, failing to notify the charge nurse or the Director of Nursing (DON). The subsequent shift also did not complete the shower, and the charge nurse was not informed. The DON confirmed that it was the facility's expectation for residents to receive showers as scheduled and acknowledged the risk of skin breakdown and infections when showers are missed. The facility's policy emphasized the importance of regular bathing for maintaining skin integrity and preventing infections.
Improper Use of Electrical Outlets in Resident Room
Penalty
Summary
The facility failed to ensure the safe use of electrical outlets in a resident's room, leading to a potential risk of overloading the electrical circuit. Observations revealed that a duplex outlet was equipped with a 6-outlet adapter to power multiple devices, including an electric bed, mini refrigerator, television, cell phone charger, oxygen humidifier, and fans connected through extension cords. The resident expressed concern about the potential for sparks but had not witnessed any. The facility's administrator was unaware of the non-compliance with regulations and indicated that the previous maintenance supervisor was responsible for ensuring electrical safety. The new maintenance supervisor, hired recently, was expected to address these issues.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report a verbal abuse allegation immediately to the Abuse Coordinator. A CNA alleged witnessing an LVN verbally abusing a resident, but the incident was not reported to the Administrator, who was the Abuse Coordinator, until the following day. The CNA reported the incident to two ADONs, who did not immediately inform the Administrator. This delay in reporting resulted in the LVN continuing to work until the next day, potentially placing residents at risk of continued abuse. In another incident, the facility failed to report an allegation of abuse to the State Agency within the required 2-hour timeframe. A resident was reported to have hit another resident with a soft plastic urinal, but the incident was not reported to the state until 12 hours later. The delay in reporting such incidents could lead to residents being at risk of further harm or abuse. Additionally, the facility did not report a verbal abuse allegation involving another resident within the required timeframe. A CNA was reported to have spoken rudely to a resident, but the incident was not reported to the state until more than 16 hours later. These failures in timely reporting of abuse allegations highlight significant lapses in the facility's procedures for handling and reporting such incidents, potentially compromising resident safety.
Removal Plan
- Resident #1 was assessed for emotional distress by the DON. A trauma informed care assessment was completed by the DON. No additional emotional distress was noted.
- LVN B was terminated and ADON D resigned. Both are no longer employed at the facility.
- The Administrator, DON, and ADON C were in-serviced 1:1 by the Area Director of Operations and Regional Compliance Nurse on following topics: Abuse and Neglect, reporting immediately to the abuse coordinator, suspension of alleged perpetrators, reporting to HHS, investigation delegation, and notification procedures if the Administrator is unavailable.
- The medical director was informed of the immediate jeopardy citation by DON.
- An ADHOC QAPI meeting was held to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal.
- All staff will be in-serviced on abuse and neglect, reporting procedures, and the role of the abuse coordinator. Staff not present will not assume duties until in-serviced. PRN staff will be in-serviced prior to assignments. New hires will be in-serviced on hire date. Agency staff will be in-serviced prior to assignment. Completion date.
Failure to Investigate and Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident with Alzheimer's disease, anxiety, and heart failure. The incident occurred when a CNA reported that an LVN verbally abused the resident after finding her on the floor. The CNA reported the incident to two ADONs, but the allegation was not immediately communicated to the Administrator or the state as required. The resident, who was cognitively impaired with a BIMS score of 5, did not recall the incident when interviewed. The facility's records did not document the fall or any concerns on the day of the incident, and no incident report was completed. The LVN involved continued to work at the facility the following day, which failed to protect the resident from potential further abuse. The Administrator was not informed of the incident until the day after it occurred, delaying the investigation and reporting process. The ADONs did not ensure the allegation was reported to the Administrator, leading to a delay in suspending the LVN and initiating a thorough investigation. This failure placed residents at risk of undetected abuse and compromised their feelings of safety and well-being.
Removal Plan
- Resident #1 was assessed for emotional distress by the DON. A trauma informed care assessment was completed by the DON. No additional emotional distress was noted.
- LVN B was terminated and ADON D resigned. Both are no longer employed at the facility.
- The Administrator, DON, and ADON C were in-serviced 1:1 by the Area Director of Operations and Regional Compliance Nurse on following topics: Abuse and Neglect, reporting immediately to the abuse coordinator, suspension of alleged perpetrators, reporting to HHS, thorough investigation, delegation of responsibilities, and notification procedures if the Administrator is unavailable.
- The medical director was informed of the immediate jeopardy citation by DON.
- An ADHOC QAPI meeting was held to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal.
- All staff will be in-serviced on abuse and neglect, reporting procedures, and suspension of alleged perpetrators. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment.
Failure to Provide Adequate Supervision and Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to an accident. The resident, who had severe cognitive impairment and required two staff members for bed mobility, fell from the bed during a pressure ulcer treatment. The incident occurred when an LVN attempted to perform the treatment alone, without the required assistance, resulting in the resident sustaining a skin tear and bruises. The resident, who had a history of high blood pressure, kidney disease, stroke, and morbid obesity, was admitted to the facility with specific care needs documented in her care plan and Kardex. Despite these documented needs, the LVN proceeded with the treatment without assistance, citing an inability to find help. This action was contrary to the facility's policy and the resident's care plan, which clearly indicated the necessity of two staff members for bed mobility. Interviews with staff revealed that the LVN was not adequately oriented to the Kardex system, which led to the misunderstanding of the resident's care requirements. The incident was witnessed, and the resident was assessed for injuries before being sent to the hospital. The facility's failure to provide the necessary supervision and adhere to the care plan placed the resident at risk of harm, as evidenced by the injuries sustained during the fall.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist with specialized training in infection prevention and control. The designated Infection Preventionist (LVN IC) had not completed the necessary specialized training, which was acknowledged by both the Director of Nursing (DON) and the Regional Compliance Nurse. The LVN IC, who was also serving as the Assistant Director of Nursing (ADON), admitted to not having completed the specialized training and expressed concerns about the potential risk this posed to the facility's infection surveillance capabilities. The DON, who was new to the facility, also confirmed that she had not completed the specialized training and was unsure if the LVN IC had done so. Interviews revealed that the previous infection preventionist, LVN E, had completed the specialized training but had resigned from the role two to three months prior. The facility's infection control policy required the Infection Preventionist, DON, and Administrator to complete a CDC training course for infection control and prevention, which had not been fulfilled. The Regional Compliance Nurse acknowledged the importance of having a certified individual responsible for the infection control program and noted that both the DON and LVN IC had only started the training recently.
Failure to Employ Qualified Dietary Manager
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility did not designate a person to serve as the dietary manager who met the required qualifications. The designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials from 06/14/23 to 04/10/24. This deficiency was identified through interviews and record reviews, which revealed that the Dietary Supervisor was still in school and expected to complete the certified Dietary Manager course by September 2024. Despite being appointed as Dietary Supervisor on 06/14/23, she had not yet completed the necessary certification at the time of the survey. During interviews, the Dietary Supervisor confirmed that she had not completed the dietary manager classes and was working in the role until she became certified. The Administrator acknowledged that her expectation was for the Dietary Manager to be certified to oversee dietary services, monitor staff's dietary certifications, and ensure diets were followed. The Regional HR also confirmed that the Dietary Supervisor was not a certified dietary manager. The facility's policy for the Dietary Manager was requested but not provided prior to the exit. The Texas Food Establishment Rules require at least one employee with supervisory and management responsibility to be a certified food protection manager, which the facility failed to comply with.
Facility Fails to Provide Functioning Call Light System
Penalty
Summary
The facility failed to provide a functioning call light system for residents in Halls 100, 200, 300, 500, and 600 from 04/05/24 to 04/10/24. During this period, residents were using alternative methods such as whistles, bells, and maracas to call for assistance. Staff members were observed responding to these alternative call tools and making frequent rounds to monitor residents, especially those with cognitive impairments. The lack of a functioning call light system was confirmed through multiple observations and interviews with staff and the Administrator, who acknowledged the issue and mentioned that the facility was in the process of obtaining bids to repair or replace the system. The Administrator stated that the call lights went out on a Friday, and the facility had implemented temporary measures such as extra staffing and frequent monitoring to ensure residents' needs were met. Despite these efforts, the call light system remained non-functional throughout the survey period. The Administrator also mentioned that the regional office had decided to repair the old call light system, with repairs scheduled to be completed by the following Tuesday. However, there was no existing policy on call lights available at the time of the survey.
Improper Storage and Security of Medications
Penalty
Summary
The facility failed to ensure proper storage and security of drugs and biologicals in two medication carts and one medication room. Specifically, the Hall 6 Nurse Cart contained an opened Insulin Glargine kwik pen with an open date of 03/08/24, two cards of expired Acetaminophen with codeine, two opened inhalers of Trelegy without open dates, and an opened bottle of fluticasone nasal spray without an open date. Additionally, the MA cart had a card of expired escitalopram. The facility also failed to provide a separately locked, permanently affixed compartment for controlled drugs in the refrigerator of the medication room, which contained a removable locked metal box for controlled medications that had not been affixed since a new refrigerator was installed three months prior. Interviews with staff, including an LVN, MA, and the DON, confirmed that expired medications should be removed from the carts to prevent administration to residents and potential drug diversion. The LVN acknowledged that insulin should be used within 28 days of opening, and inhalers and nasal sprays should have open dates to ensure timely disposal. The DON and Administrator confirmed that the lock box in the refrigerator should be permanently affixed to prevent drug diversion. The facility's policies and procedures for medication storage and controlled substances were not followed, leading to the observed deficiencies.
Failure to Ensure Dietary Staff Had Required Food Handler's Certificate
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, Dietary Staff G did not have a current Food Handler's Certificate while working in the facility's kitchen from April 8, 2024, to April 10, 2024. This deficiency was identified through record review and interviews. The Administrator confirmed that Dietary Staff G's certificate was not found, and the Regional HR acknowledged that the facility was responsible for ensuring all dietary staff had the necessary certificates to prevent foodborne illness. The Texas Food Establishment Rules require that food handler training certificates be maintained on the premises, effective since September 1, 2016. The facility's policy on food handler certificates was requested but not provided prior to the survey exit.
Infection Control Deficiencies in Hand Hygiene and Glucometer Cleaning
Penalty
Summary
The facility failed to ensure an infection prevention and control program was maintained for four residents. Specifically, LVN C did not wash or sanitize her hands when entering Resident #31's room and between glove changes during medication administration via g-tube. LVN C acknowledged that she should have washed her hands upon entering the room and sanitized her hands between glove changes. Additionally, LVNs J and K did not clean the glucometer device according to the required contact time of the disinfectant before and after use on Residents #72, #7, and #82. Both LVNs acknowledged that the disinfectant wipes required a 1-minute contact time, which they did not adhere to. The facility's Glucometer policy and procedure indicated that the meter should be cleaned with a germicidal and allowed to air dry between patient testings.
Failure to Ensure Resident Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure resident rights for personal privacy for one resident. During an observation, two CNAs provided incontinent care to a resident without pulling the privacy curtain between the resident and her roommate. The resident, who had severe cognitive impairment and was dependent on staff for toileting hygiene, was exposed during the care procedure. The CNAs admitted to forgetting to pull the privacy curtain, despite being trained to do so. The Director of Nursing confirmed that the expectation was for all nursing staff to provide privacy when exposing residents' private areas. The facility's policy on resident rights emphasized the importance of treating residents with respect and dignity, including ensuring personal privacy. The failure to pull the privacy curtain during the care procedure was a clear violation of this policy.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for two residents. For one resident, the care plan did not accurately address the need for a fire-resistant smoking apron despite multiple assessments indicating its necessity. This oversight was acknowledged by various staff members, including the LVN, MDS Nurse, SW, DON, and Administrator, who all admitted that the requirement for the fire-resistant smoking apron was overlooked in the care plan updates. The risk identified was that staff might be unaware of the need for the apron, potentially leading to safety hazards during smoking activities. For another resident, the care plan failed to address the diagnosis of benign prostatic hyperplasia and urinary retention related to his indwelling urinary catheter. Although the resident had an indwelling catheter and no cognitive impairment, the care plan did not include the necessary diagnosis, which was also acknowledged as an oversight by the MDS Nurse, DON, and Administrator. The risk identified was that staff might not be aware of the reason for the catheter, which could affect the quality of care provided. The facility's policies on comprehensive care plans and smoking safety were not followed, leading to these deficiencies. The interdisciplinary team, including the MDS Nurse, SW, ADON, and DON, were responsible for ensuring care plans were accurate and updated, but failed to do so in these instances. The Administrator confirmed that the care plans should be accurate and updated appropriately, but acknowledged that the care plans for these residents had not been reviewed properly.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that two residents who needed respiratory care were provided such care consistent with professional standards of practice and their comprehensive person-centered care plans. Resident #14, who had multiple sclerosis and neoplasm of the meninges and was on hospice services, was observed receiving oxygen therapy without any physician orders. Despite receiving oxygen for several months, there were no orders documented for the administration of oxygen, and the care plans did not reflect the oxygen therapy. LVN A confirmed that the resident had been receiving oxygen without orders and acknowledged that it was the nurse's responsibility to ensure orders were in place and to check the oxygen settings every shift. Similarly, Resident #41, who had heart failure and emphysema, was ordered oxygen at 2L nasal cannula continuously but was observed receiving oxygen at 3L nasal cannula on multiple occasions. LVN A confirmed that the resident's oxygen was set incorrectly and should have been at 2L as ordered. The DON acknowledged that Resident #14 should have had orders for oxygen and that Resident #41 should have received the correct dose of oxygen. The facility's Oxygen Administration policy indicated that oxygen therapy should be administered as ordered by the physician, but this was not followed in these cases.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for two residents. For Resident #31, a male with a gastrostomy tube, the Licensed Vocational Nurse (LVN) did not check the placement of the g-tube before administering medications. The LVN claimed to have checked the placement earlier in the day, but this did not align with the facility's policy, which requires checking the placement before each medication administration. This oversight was observed during a medication administration session and confirmed through interviews and record reviews. For Resident #72, a female with type 2 diabetes mellitus, the facility failed to administer the correct type of insulin as per physician orders. The LVN administered Humulin N instead of the prescribed regular insulin. The Director of Nursing (DON) confirmed that the resident should have received regular insulin and was unaware of why the pharmacy sent Humulin N. The discrepancy was discovered during an observation and subsequent interviews with the LVN and DON, who later contacted the pharmacy consultant to clarify the issue.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 172 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Vidor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakwood Manor Nursing Home | 0.9 mi | ★★★★★ | 5 | 0 |
| Harmony Care At Beaumont | 7.2 mi | — | 35 | 2 |
| College Street Health Care Center | 8.9 mi | ★★★★★ | 0 | 0 |
| Beaumont Nursing And Rehabilitation | 9 mi | ★★★★★ | 16 | 1 |
| Avir At Beaumont | 9.1 mi | ★★★★★ | 4 | 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 October 2026) and official state health department websites.