Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vista Hills Health Care Center during CMS and state inspections, most recent first.
The facility failed to maintain a full-time RN serving as DON, resulting in two distinct periods with no designated DON in place. After the prior DON left, a new DON was briefly hired but soon resigned for health reasons, leaving the position vacant again until another RN was promoted to DON. During these gaps, two ADONs attempted to oversee resident care. The Administrator acknowledged the absence of a DON, confirmed reliance on ADONs, and stated that the facility lacked a specific DON policy and was following state regulations, while recognizing that lack of DON oversight could affect nursing supervision, resident documentation, and response to changes in condition.
Two cognitively intact male residents with diabetes, one with additional psychiatric diagnoses, received blood glucose checks and, for one resident, an insulin injection in an open area near the nurse’s station rather than in a private setting, exposing their medical treatment to others. Facility leadership, including the DON and Administrator, acknowledged that facility policy and practice required such medical treatments to be performed in residents’ rooms to protect privacy and confidentiality of personal and medical records, and that providing these services in public areas was inconsistent with resident rights and privacy standards.
Dirty oxygen concentrator filters were observed on two residents' equipment, and a third resident's nasal cannula was found on the floor and wiped with a wipe instead of being replaced. The residents had orders for oxygen therapy, and staff interviews showed uncertainty about who was responsible for cleaning and monitoring filters, while one CNA stated a cannula that touched the floor should not be wiped and should be replaced.
A resident with severe cognitive and functional impairment and another resident with diabetes had unlabeled topical ointment left in their rooms, including a cup with an unknown white substance and a bedside medicine cup with cream-like substance. Staff stated the medication should not have been left behind and should have been disposed of after use. In addition, a wound care treatment cart was observed with an antimicrobial soap bottle on its side, showing red fluid spillage and dried drippings, and staff stated the condition was not acceptable because of contamination and infection concerns.
Unsanitary Kitchen Equipment and Improper Food Storage: Surveyors observed heavy grease buildup, grime, food particles, and corrosion on the fryer, oven, and refrigerator surfaces, along with an open bag of green beans in the freezer and moldy onions stored with other produce. DS G, DS H, the Dietary Director, and the Administrator stated that food must be sealed and kitchen equipment cleaned routinely, and the facility policy required food storage areas to be clean and open packages to be kept in sealed containers or bags.
A resident with severe cognitive impairment, aphasia, and total ADL dependence was observed in bed wearing a hospital gown with his lower body exposed and his room door open. Staff stated there was no known clinical reason for the gown and acknowledged that leaving him uncovered and visible compromised his dignity and privacy. Leadership later stated the resident had the right to wear personal clothing and have privacy protected.
Call Light Not Kept Within Resident Reach: A resident with a history including TBI, dementia, expressive aphasia, and a BIMS of 15 was observed unable to reach his call pad, which was hanging on the side of the bed by the headboard. His care plan included leaving the call light within reach, and interviews with CNA, LVN, DON, and the Administrator confirmed staff were responsible for keeping call lights within residents’ reach; the DON also stated there was no Call Light policy.
A resident with bipolar disorder and intact cognition kept her debit card in the BOC office because she felt it was safer there, then discovered $700 in unknown online charges. The BOC Manager helped check the account and contacted the bank and Amazon, but the Administrator did not report the incident to the State Survey Agency because she viewed it as a complaint rather than an allegation against staff, despite the facility policy requiring reporting of abuse, neglect, exploitation, and misappropriation concerns.
Failure to report possible misappropriation of a resident’s debit card charges to the State Survey Agency. A resident with bipolar disorder and intact cognition had unknown Amazon charges totaling $700 while her debit card was being stored in the BOM office. The BOM and resident contacted the bank and online store, but the Administrator did not report the incident because she viewed it as a grievance rather than an allegation against staff, despite the resident stating she believed the facility used her card.
A resident with Bell’s palsy, generalized weakness, hepatic encephalopathy, and bipolar disorder had a BIMS of 15, but the care plan did not include active orders for PRN Tramadol for pain or bedtime Alprazolam for anxiety. Staff interviews confirmed these medications should have been included so nursing could monitor pain, effectiveness, and side effects, and the facility policy required a comprehensive person-centered care plan with measurable objectives and timeframes.
A resident with intact cognition and limited upper-extremity ROM was observed with long fingernails and dark debris under both hands, and he stated his nails had not been cut and staff had not offered. The resident’s care plan included assistance with personal hygiene, and staff interviews showed CNAs and nurses were responsible for checking and trimming nails during showers and rounds, while the facility policy stated nail care should be performed regularly and safely.
A resident with advanced dementia and severe osteopenia, fully dependent on staff for care, sustained a spiral femur fracture during routine repositioning by a CNA using a one-person assist. The injury was discovered after the CNA heard a popping sound, and although a STAT x-ray was ordered, there was a delay in reviewing the results due to the night nurse's workload. The resident was later transferred to the hospital after the fracture was confirmed.
A resident with advanced dementia and recent orthopedic surgery experienced swelling and pain in the right knee, prompting a STAT x-ray that revealed a spiral femur fracture. Although the radiologist confirmed the fracture late at night, nursing staff did not review the results or arrange hospital transfer until the following morning, resulting in a seven-hour delay in emergency care. Facility staff and leadership acknowledged that the delay was due to lack of follow-up on critical diagnostic results.
A resident with heart failure did not receive four scheduled doses of Entresto due to the medication being unavailable, and staff failed to notify the physician or document the missed doses as required by facility policy. The medication aide recorded the missed doses in the MAR but did not inform the nurse, and the nurse did not notify the physician, resulting in a lack of physician awareness and intervention.
A resident with heart failure did not receive ordered Entresto due to lack of weekend pharmacy delivery and the medication not being available in the facility or from the family. The medication aide did not inform the nurse of the missed doses, and the nurse did not notify the physician or document the incident, contrary to facility policy.
A resident with an indwelling catheter did not have their catheter secured with a leg strap, as required by their care plan and physician's order. The resident reported discomfort due to the unsecured catheter, which had been an issue for two days. Nursing staff, including an RN and a CNA, were trained to secure catheters but failed to do so in this instance. The DON emphasized the importance of regular checks, which were not performed, increasing the risk of catheter-related injury.
The facility failed to address grievances and recommendations from the resident council, particularly regarding cold food temperatures and interference with council elections. Residents felt unheard as their concerns were not documented or acted upon, and they were denied access to meeting minutes. The administrator and staff did not effectively follow the grievance policy, leading to a lack of proper documentation and follow-up on resident issues.
The facility conducted care plan meetings in residents' rooms, compromising privacy and confidentiality. Residents felt embarrassed as discussions were overheard by roommates, staff, and visitors. An LVN and the Administrator were unaware of these concerns, despite the facility's policy emphasizing privacy rights.
The facility failed to resolve grievances, particularly those about cold meals, voiced during Resident Council Meetings. The Activities Director did not initiate grievance reports, and the Administrator did not document or resolve these issues. Residents consistently reported cold meals, but the facility lacked a system to ensure proper food temperatures. The grievance policy was not followed, and the Local Ombudsman confirmed residents felt their concerns were ignored.
A resident with a history of intracerebral hemorrhage and hemiparesis required assistance with ADLs, including nail care. Despite the care plan's instructions, the resident's fingernails were long and dirty, posing a risk of injury due to hand contractures. The DON and staff were either unaware or did not follow through with the necessary nail care, as confirmed by observations and interviews.
A resident with significant medical conditions, including diabetes and limited mobility, did not receive proper foot care due to the facility's failure to provide access to a podiatrist. Observations showed the resident had long, discolored toenails, and staff were not trained or aware of who was responsible for toenail care. The facility's policy required podiatrist care for diabetic residents, which was not provided, placing the resident at risk.
The facility failed to ensure proper documentation of controlled substance counts during shift changes, as three licensed staff members did not follow the established procedure. ADON L did not sign the Controlled Drugs-Count Record immediately after verifying the count, while RN A and LVN C signed the record before conducting the count. This deviation from policy could risk residents not receiving the intended therapeutic response and increase the risk of drug diversion.
The facility failed to ensure proper storage of medications, with oral and topical medications mixed in medication carts and opened Acidophilus Probiotic Dietary Supplements not refrigerated as required. Medication carts were also found to be unclean. In the medication room, oral and topical medications, as well as oral medications and ear drops, were improperly stored together. Staff interviews revealed a lack of awareness regarding proper storage protocols.
The facility failed to serve food at appropriate temperatures, as residents reported meals being delivered cold. The Director of Food and Nutrition confirmed improper food temperatures, and staff interviews revealed a lack of communication and documentation regarding grievances. The facility lacked insulated meal carts and a system to ensure prompt meal delivery, contributing to the issue.
The facility failed to maintain food safety standards, with issues such as unclean shelving, expired foods, and improper food storage. Dietary staff did not use gloves or sanitize thermometers when checking food temperatures. Residents reported cold food, and meal carts were left open, affecting food temperatures.
The facility failed to maintain a safe and sanitary environment, with splintered wood shelves in linen closets, missing baseboards, and chipped walls in the laundry room, and broken tiles and rusted drains in the shower room. Staff interviews revealed a lack of awareness and reporting of these issues, despite existing protocols for maintenance requests.
A facility failed to accurately document a resident's behaviors in her MDS assessment, despite her comprehensive care plan noting behaviors such as requesting HIPAA information and making false allegations against staff. Interviews with staff revealed awareness of these behaviors, but they were not included in the assessment due to their nature. This oversight could lead to inaccurate assessments and affect the care provided.
A facility failed to include a physician-ordered intervention in a resident's care plan, specifically the elevation of the head of the bed to at least 30 degrees during enteral feeding. This oversight was identified during a review of the care plan, despite the resident's medical condition requiring it to prevent aspiration. Observations and interviews revealed that the nursing staff were responsible for ensuring the correct positioning, but the care plan lacked this critical intervention, posing a risk to the resident.
A resident receiving continuous enteral feeding was found lying flat in bed, contrary to physician orders requiring a 30-degree head elevation to prevent aspiration. Despite training, staff failed to maintain this position, as observed during a survey. The facility's policy lacked specific guidance for continuous feeding, contributing to the deficiency.
A facility failed to ensure a resident's feeding tube bags were properly labeled, leading to potential risks. The resident's feeding tube was set correctly, but the enteral feeding bag lacked necessary information, and the water bag was mislabeled. The LVN admitted the mistake, and the DON confirmed no complications but acknowledged the risks.
Failure to Maintain a Full-Time DON Position
Penalty
Summary
The deficiency involves the facility’s failure to designate and employ a full-time registered nurse (RN) as the Director of Nursing (DON) as required by federal regulation 483.35(b)(2). Record review showed that the prior DON’s (DON E) last day worked was 03/03/2026, and the HR Coordinator confirmed his last day of employment as 03/04/2026. A job offer was extended to another RN (DON F) with a start date of 03/18/2026, but payroll records indicated that this DON resigned for health reasons with a termination date of 03/31/2026. A subsequent job offer was extended to another RN (DON D) with an effective date of 04/20/2026. During the surveyor’s on-site investigation on 04/29/2026, DON D was not present at the facility and was reported by the Administrator to be at a sister facility for training. Interviews with the Administrator and DON D confirmed that there was no DON in place from 03/04/2026 through 03/17/2026 and again from 04/01/2026 through 04/19/2026. During these gaps, the facility relied on two Assistant Directors of Nursing (ADONs) to assist with overseeing residents and to compensate for the lack of a DON. The Administrator acknowledged that the facility did not have a DON for the identified periods and stated that the facility had advertised for the position but was seeking candidates with nursing facility experience. The Administrator also stated there were possible barriers for residents when there is no DON, including lack of supervision over nursing staff, issues with residents’ documentation, and potential problems if residents experienced a change in condition. The Administrator further stated that the facility did not have a specific policy for the DON requirement and followed state regulations instead.
Failure to Protect Resident Privacy During Glucose Monitoring and Insulin Administration
Penalty
Summary
The facility failed to ensure residents' rights to personal privacy during medical treatment and personal care for two residents who received glucose monitoring and insulin administration in public areas. On a specified date, staff obtained blood glucose readings for both residents and administered an insulin injection to one resident in an open setting rather than in a private location. These actions occurred despite facility expectations that such care be provided in residents' rooms to protect personal and medical information. Resident #1 was an adult male, initially admitted in January 2025, with a diagnosis of Type 2 diabetes mellitus and prescription orders for multiple diabetic medications, including Insulin Aspart, Tresiba, metformin, and glucagon. His Quarterly MDS showed a BIMS score of 13, indicating he was cognitively intact, and he required insulin injections six days per week. Physician orders directed Insulin Aspart administration three times daily at set times. On the cited date, his glucose reading and insulin injection were provided in a non-private setting, contrary to his care plan focus on diabetes management and the facility’s stated practice. Resident #2 was an adult male with an initial admission in 2019 and readmission in 2024, with diagnoses including diabetes mellitus, dementia, bipolar disorder, and schizophrenia. His Comprehensive MDS documented a BIMS score of 15, indicating he was cognitively intact, and he required insulin injections seven days per week. He also had orders for Insulin Aspart three times daily. On the same date, his glucose reading was obtained in an open area rather than in his room. Interviews with the DON and Administrator confirmed that facility practice and policy required treatments such as glucose checks and insulin injections to be completed in residents’ rooms to maintain privacy and confidentiality of medical information, and that providing such care in open areas was inconsistent with the facility’s resident rights and privacy policy. Record review of the facility’s undated Resident Rights policy stated that residents have the right to personal privacy and confidentiality of personal and medical records, and that personal privacy includes accommodations, medical treatment, and personal care. The DON stated that privacy protections included administering orders in a private setting and that care needed to be completed in residents’ rooms, describing provision of such care in open areas as a HIPAA violation because it could share diagnosis information with others nearby. The Administrator similarly stated that glucose readings and insulin injections should be completed in residents’ rooms due to privacy concerns and that performing these treatments at the nurse’s station exposed residents’ diagnoses and treatments. Documentation from the HR coordinator showed the last facility-wide in-service on resident rights occurred in November 2025.
Dirty oxygen equipment and improper nasal cannula handling
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for residents receiving oxygen therapy. During observations, Resident #33 and Resident #43 were both found with oxygen concentrator air filters that had dust and lint collected on them while the oxygen was in use. Resident #33 was a male admitted on 01/13/2026 with a history of acute bronchitis, intact cognition, and an order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. Resident #43 was a female admitted on 06/19/2025 with a history of COPD, intact cognition, and an order for oxygen at 3 liters per minute via nasal cannula for shortness of breath. Resident #68 was observed lying in bed with his nasal cannula on the floor. CNA F picked up the cannula and cleaned it with a wipe, stating she did so because she did not have anything else to clean it with. Resident #68 stated that was the first time he had seen staff clean the nasal cannula with a wipe. Resident #68 had a history that included dysphagia, traumatic brain injury, diabetes mellitus type II, cognitive communication deficit, dementia, seizure disorder, tracheostomy status, and expressive aphasia, and his care plan included oxygen therapy per physician orders. Interviews showed CNA E stated nasal cannulas found on the floor were to be replaced and the nurse notified, and that dirty oxygen concentrator filters were a risk for infection and illness. CNA F stated it was not correct to wipe a nasal cannula that touched the floor and that it should be replaced. LVN I stated night shift nurses were responsible for cleaning oxygen concentrator filters, but he was not sure who monitored them. The Administrator stated filters were checked weekly and on weekends, central supply staff were assigned to ensure they were clean, and weekend nurses oversaw maintenance. The DON and Corporate Compliance Regional Nurse stated there was no policy addressing oxygen concentrator filters or nasal cannulas.
Unlabeled topical medications left at bedside and contaminated treatment cart
Penalty
Summary
The facility failed to provide pharmaceutical services for two residents by leaving topical medications unsecured and unlabeled in resident rooms. One resident had a history of Alzheimer’s disease, aphasia following cerebral infarction, hemiplegia, chronic kidney disease stage 4, end stage renal disease on dialysis, chronic respiratory failure with hypoxia, dysphagia following cerebral infarction, and gastrostomy status, and was documented as severely cognitively impaired, non-ambulatory, and dependent on staff for care. During an observation in the resident’s bedroom, a cup containing a white substance and a tongue depressor was found on top of the dresser, and the cup was not labeled and the contents were unknown. A second resident with a history of high blood pressure and type II diabetes had a care plan for bowel incontinence with barrier cream to be applied after each incontinent episode. During an observation in the resident’s room, a clear plastic medicine cup containing a white cream-like substance was found on the bedside table and was not labeled. The resident stated the nurse had given him the ointment for a rash on his thigh and that he sometimes applied it himself and staff applied it as well, but he did not know the name of the ointment. Staff interviews stated the cream should not have been left in the room, should have been disposed of after application, and was not labeled or identifiable. The facility also failed to maintain the treatment cart in a clean condition. During observation of the wound care treatment cart, the antimicrobial soap bottle was on its side with red fluid spillage and red-dried drippings on the bottle cap. Staff interviews stated the cart and supplies were to be kept clean, that the spillage was not acceptable, and that using a soap bottle with observed spillage was a risk for contamination and infection to residents. The DON stated the wound care nurse on shift was responsible for cleanliness of the treatment cart and that the antimicrobial soap should have been thrown away.
Unsanitary Kitchen Equipment and Improper Food Storage
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen. During observations on 02/09/2026, surveyors found the deep fryer with significant grease accumulation along the upper edges, including dry adhered food particles and darkened old grease. The wall behind the deep fryer and adjacent oven had visible grease splatter, layered grime, and dry food particles. The oven exterior also had green and white discoloration consistent with corrosion and visible grease buildup. Surveyors also observed sanitation issues inside the refrigerator and freezer. The refrigerator next to the pantry door had white dried smeared residue on the back interior wall and dried smeared stains with scattered dry food particles on the bottom interior surface. In the freezer, a one-gallon zip-top bag of green beans was open and unsealed, with ice particles inside the bag. Under the kitchen sink, a sack of onions contained three large onions with visible dark circular mold growth, and the moldy onions were stored among other onions intended for food preparation. During interviews, DS G, DS H, the Dietary Director, and the Administrator stated that food stored in the freezer must be sealed or properly closed, that contaminated food could be served to residents and potentially make them sick, and that refrigerators, ovens, and deep fryers were required to be cleaned routinely. The Dietary Services Policy and Procedure Manual stated that storage areas must be clean and protected, open packages of food must be stored in closed containers or sealed bags, and refrigerators must be maintained in a clean, sanitary condition. It also stated that if possible food spoilage is observed prior to the best by date, the product will be discarded.
Resident Left in Hospital Gown and Exposed With Door Open
Penalty
Summary
The facility failed to treat Resident #12 with respect and dignity by not ensuring he was dressed in personal clothing and by leaving him partially exposed in bed with his bedroom door open. Resident #12 was a male resident admitted to the facility with a history that included Alzheimer's disease, aphasia following cerebral infarction, left-sided hemiplegia and hemiparesis, chronic kidney disease stage 4, end stage renal disease on dialysis, chronic respiratory failure with hypoxia, dysphagia following cerebral infarction, and gastrostomy status. His record also showed a BIMS score of 0, severe cognitive impairment, and dependence on staff for upper and lower body dressing, with extensive assistance needed for mobility and total assistance for dressing tasks. On observation, Resident #12 was found lying in bed in his bedroom wearing a hospital gown, with his lower body and brief exposed and the door open. He was non-verbal and unable to communicate. Staff interviewed at the time stated they were unaware why he was in a hospital gown or why his door was open while he was partially exposed, and they stated residents are expected to wear personal clothing unless there is a specific medical order. They also stated that leaving him exposed with the door open could negatively affect dignity, cause embarrassment, and compromise privacy. A later observation showed Resident #12 wearing regular clothing. During interviews, the ADON, SW, DON, and Administrator all stated that residents have the right to wear their own clothing and have privacy protected, and that it was unacceptable for Resident #12 to be in a hospital gown, partially uncovered, with the door open. The facility policy cited in the record stated that residents have a right to a dignified existence and that the facility must treat each resident with respect and dignity and protect and promote resident rights.
Call Light Not Kept Within Resident Reach
Penalty
Summary
The facility failed to ensure Resident #68’s call light was within reach. Resident #68 was a [AGE]-year-old male admitted on 03/31/23 with a history that included dysphagia, traumatic brain injury, diabetes mellitus type II, cognitive communication deficit, dementia, seizure disorder, tracheostomy status, and expressive aphasia. His quarterly MDS documented a BIMS of 15, indicating he was cognitively intact. His care plan identified a communication problem related to expressive aphasia and included the intervention of leaving the call light within the resident’s reach. During observation on 02/09/26 at 09:01 a.m., Resident #68 was unable to reach the call pad, which was found hanging on the side of the bed by the headboard and was then provided to him. Interviews with CNA E, CNA F, LVN D, the DON, and the Administrator confirmed that call lights were to remain within residents’ reach and that all staff were responsible for ensuring this. On 02/11/26 at 9 AM, the DON stated there was no Call Light policy.
Failure to Report Possible Misappropriation of Resident Funds
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property for one resident reviewed for abuse and neglect. The deficiency involved a resident with bipolar disorder and intact cognition, as shown by a BIMS score of 15, who managed her own money but sometimes asked the Business Office Manager to hold her debit card in the business office because she felt it was safer there. Record review showed the resident filed a grievance after noticing unknown Amazon charges on her bank card totaling $700. The grievance documented that the resident and the facility contacted the bank and the online store, and that the card would be replaced and the charges reimbursed. In interviews, the Business Office Manager stated she helped the resident check her account, saw the charges, and contacted Amazon and the bank. She also stated the resident occasionally asked her to store the card and that she would make an exception, keeping it in a filing cabinet with a key. The DON stated that if a resident made an allegation of misappropriation or exploitation, it would be reported to the state survey agency, but if it was only a complaint, a grievance form would be completed. The Administrator stated she did not report the incident to the State Survey Agency because the resident had a history of compromised bank accounts and did not make an allegation against facility staff. The facility policy stated that any person with reasonable cause to believe an elderly or incapacitated adult is suffering abuse, neglect, or exploitation must report it, and that facility employees must report allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injury of unknown source to the Administrator, who would then report all allegations to HHSC.
Failure to Report Possible Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report an allegation involving possible misappropriation of a resident’s property to the State Survey Agency. Resident #15, a 70-year-old female with bipolar disorder and a BIMS score of 15 indicating intact cognition, had a grievance related to unknown Amazon charges on her debit card while she was a resident at the facility. Her record showed she managed her own money, and her care plan addressed mood issues related to bipolar disorder. The resident grievance form documented that on 1/30/26 the resident and the Business Office Manager identified unknown charges totaling $700 on the resident’s debit card. The form stated the facility and resident contacted the bank and the online store, and the incident was marked resolved the same day. During interview, the Business Office Manager stated the resident sometimes asked her to hold the debit card in the business office and that she helped the resident contact Amazon and the bank after the charges were discovered. The resident stated the card was kept in the business office because she felt it was safer there and that she believed the facility used her card and lied about the charges. The DON stated that if a resident made an allegation of misappropriation or exploitation, it would be reported to the State Survey Agency, but if it was only a complaint, a grievance form would be completed. The Administrator stated she did not report the incident to the State Survey Agency because the resident had a history of compromised bank accounts and did not make an allegation against facility staff. The facility policy required employees to report allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, or injury of unknown source to the Administrator, and required the Administrator or designee to report all allegations to HHSC.
Care Plan Missing Pain and Anxiety Medications
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #10 that included measurable objectives and timeframes to meet the resident’s medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment. Resident #10 was a female admitted on 04/09/2025, with a medical history that included Bell’s palsy, generalized muscle weakness, hepatic encephalopathy, and bipolar disorder. Her comprehensive MDS showed a BIMS of 15, indicating she was cognitively intact. Record review showed the resident had active orders for Tramadol 50 mg by mouth every 8 hours as needed for pain, with an order start date of 05/12/25, and Alprazolam 0.5 mg by mouth at bedtime, with an order start date of 11/12/25. The care plan did not include either medication. During interviews, LVN staff stated pain and anxiety medications should be included in the care plan so staff could monitor pain, medication effectiveness, and side effects, and the DON stated medications for pain and anxiety were to be added to the care plan so staff could monitor for side effects. The facility policy stated the comprehensive care plan must include measurable objectives and timeframes to meet the resident’s identified needs.
Unclean, Untrimmed Fingernails Not Addressed
Penalty
Summary
The facility failed to ensure Resident #58 received necessary ADL assistance to maintain good grooming and personal hygiene when his fingernails were observed to be long and to have dark debris under the nails on both hands. Resident #58 was a [AGE]-year-old male admitted on [DATE] and readmitted on [DATE], with a history of atrial fibrillation. His five-day MDS showed a BIMS score of 13, indicating intact cognition, and Section GG showed functional limitation in upper extremity range of motion on both sides. His care plan identified an ADL self-care deficit and included assistance with personal hygiene, hair, shaving, and oral care as needed. During observation and interview on 02/09/2026 at 11:37 a.m., Resident #58 was seen with long nails and dark debris under the nails on both hands. He stated his nails had not been cut and that it would be nice if someone would cut them, and he said staff had not offered to cut them. Staff interviews indicated that fingernails were supposed to be checked during showers, rounds, and champion rounds, and that CNAs and nurses were responsible for ensuring nails were clean and trimmed. The DON and Administrator stated nails were checked as needed and that residents with long dirty fingernails were at risk for infection; the Administrator also stated residents were asked if they wanted their nails trimmed and refusals were to be documented. The facility policy stated nail care would be performed regularly and safely and that the resident would be free from abnormal nail conditions and infection.
Failure to Provide Adequate Supervision and Safe Handling During Repositioning
Penalty
Summary
A deficiency occurred when a resident with advanced dementia, severe osteopenia, and a history of multiple comorbidities, including PEG-tube dependence and prior bilateral knee and hip arthroplasties, sustained a spiral fracture of the distal right femur during routine repositioning in bed by a CNA. The resident was completely dependent on staff for activities of daily living and ambulation, and was nonverbal, rarely or never understood, and always incontinent. During incontinence care, the CNA reported hearing a popping sound from the resident's right knee while using a one-person assist technique, after which the resident did not vocalize pain but was later found to have swelling, redness, and pain in the right knee. The CNA had previously performed care for the resident independently and was unaware of the subsequent hospital transfer. Following the incident, the nurse on duty was notified and assessed the resident, noting signs of pain and swelling in the right knee. A STAT x-ray was ordered, and pain medication was administered. However, there was a delay in reviewing the STAT x-ray results, as the night shift nurse did not access the provider portal to check for results, citing workload and being the only nurse for 30 patients. The x-ray provider did not call the facility with critical findings during the night shift, and the results were not reviewed until the following morning by the incoming nurse, who then promptly contacted the provider and arranged for the resident's transfer to the hospital. Interviews with staff confirmed that the resident did not fall and that the injury likely resulted from minimal movement due to underlying bone fragility. The facility's policies required prompt notification of changes in resident status and timely review of diagnostic results. The delay in reviewing the STAT x-ray and the use of a one-person assist for a highly dependent, nonverbal resident contributed to the failure to provide adequate supervision and safe handling techniques, resulting in the resident's injury.
Delay in Emergency Transfer Following Missed STAT X-ray Result
Penalty
Summary
A deficiency occurred when facility staff failed to act in a timely manner to transfer a resident to the hospital after a radiologist confirmed a spiral femur fracture. The resident, an elderly female with advanced dementia, PEG tube dependence, and a history of recent right distal femur fracture, was identified as having swelling, redness, and pain in her right knee during evening care. A STAT x-ray was ordered, and the radiologist signed off on the diagnosis of a spiral femur fracture late that night. However, the resident was not transferred to the hospital until the following morning, resulting in a delay of approximately seven hours from the time the critical finding was available. The delay was due to a lack of follow-up by the night shift nurse, who did not check the x-ray provider portal for results during his shift, despite being aware that STAT x-rays had been ordered and that the resident had a significant change in condition. The nurse stated he was the only nurse for 30 patients and was busy, but acknowledged that it was good clinical practice to follow up on pending x-ray results. The morning shift nurse discovered the x-ray results, contacted the provider, and arranged for the resident's transfer to the hospital. Interviews with other staff confirmed that all nurses had access to the x-ray provider portal and were trained to check for STAT results, and that a fracture was considered a critical finding requiring immediate action. Facility policies required staff to provide timely care and follow up on significant changes in condition, including obtaining and acting on diagnostic results. The failure to review and act on the STAT x-ray results in a timely manner resulted in a delay in emergency care for the resident, who remained in the facility with a confirmed femur fracture for several hours before being transferred for appropriate medical treatment. This delay was acknowledged by facility leadership and staff as not meeting the standard for rapid response to critical findings.
Failure to Notify Physician of Missed Heart Failure Medication Doses
Penalty
Summary
The facility failed to consult with a resident's physician when there was a significant change in the resident's physical status, specifically when four doses of a prescribed heart failure medication (Entresto) were not available and therefore not administered as ordered. The resident, an elderly female with diagnoses of congestive heart failure and sick sinus syndrome, was admitted from home and required Entresto twice daily. Documentation showed that the medication was not administered on four occasions, and the Medication Administration Record (MAR) indicated this with a code, but there was no written documentation in the resident's electronic progress notes that the physician or nurse practitioner was notified of the missed doses. Interviews with facility staff revealed that the process for handling unavailable medications involved notifying the family to bring in medications from home and checking the facility's medication supply system (pyxis). In this case, the family did not provide the medication, and it was not available in the pyxis. The medication aide documented the missed doses in the MAR but did not inform the assigned nurse, and the nurse did not notify the physician. Both the Director of Nursing (DON) and the regional compliance nurse confirmed that staff were trained to notify physicians when medications were not administered as ordered and to document this notification, but this did not occur in this instance. Further interviews with the medical doctor and medical director confirmed that they were not notified about the missed doses, and facility policy required physician notification when medications were not administered. The lack of communication and documentation regarding the missed medication doses resulted in the physician not being able to provide alternative instructions or treatment for the resident.
Failure to Administer Ordered Medication and Notify Physician
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering Entresto Oral Tablet as ordered for a resident with congestive heart failure and sick sinus syndrome. The resident was admitted on a Friday evening, and the facility's pharmacy did not deliver medications on weekends. The facility requested the resident's family to bring in the medication from home, but the Entresto was not provided. The medication was also not available in the facility's pyxis system. As a result, the medication was not administered on multiple scheduled occasions, as documented in the Medication Administration Record (MAR). Interviews with the DON, LVN, and medication aide revealed that the medication aide did not inform the nurse that the medication was not administered, and the nurse did not notify the physician or document the missed doses as required by facility policy. The facility's policy states that if a regularly scheduled medication is withheld or refused, an explanatory note must be entered in the nursing notes or the PRN nurses notes section of the MAR. The medical director confirmed that staff are required to notify physicians when medications are not administered as ordered.
Failure to Secure Catheter Leg Strap
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence. Specifically, the facility did not secure the resident's catheter with a leg strap, as required by the physician's order and the resident's care plan. The resident, who was alert and oriented, reported that the catheter strap had not been in place for two days, causing discomfort due to the catheter shifting. Despite the resident's ability to communicate, the issue was not addressed by the nursing staff, who were responsible for ensuring the catheter was secured. Interviews with the nursing staff, including an RN and a CNA, revealed that they were trained to secure catheters with leg straps and check them regularly. However, the RN admitted to forgetting to verify the leg strap during her assessment, and the CNA was not assigned to the resident but had assisted with perineal care. The Director of Nursing (DON) stated that all staff were required to conduct regular rounds and check catheter placement, but this was not done in this case. The failure to secure the catheter properly increased the risk of it being pulled out accidentally, potentially causing injury or trauma to the urethra.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to consider the views of the residents and act promptly upon the grievances and recommendations of the resident council concerning issues of resident care and life in the facility. The residents felt that the administrator did not make any efforts to address their concerns and grievances discussed in previous months at the resident council meetings. The residents requested copies of the Resident Council minutes to see what efforts had been made to resolve the grievances but were denied access by the administrator. It was reported that the administrator retaliated against the Resident Council President for reporting concerns about her interference with Resident Council Elections, concerns with cold food temperatures, and requests to review Resident Council Minutes. The Activities Director stated that after the resident council meetings, she would complete the grievance form for all concerns voiced and give them to the administrator. However, the administrator claimed to be unaware that not all concerns were being documented in the Resident Council Minutes. The Director of Food and Nutrition acknowledged receiving sporadic concerns about cold food temperatures but did not document these concerns or conduct regular checks on food temperatures. The facility's grievance policy outlines that the administrator is responsible for maintaining a system to keep records of all complaints and ensuring timely responses, but this was not effectively implemented. The facility's QAPI meetings, which are supposed to address various concerns, did not consistently include all relevant department heads, and the issues discussed did not reflect the residents' grievances about cold food temperatures. The review of Resident Council Minutes from May to October did not document any concerns related to cold food temperatures, indicating a lack of proper documentation and follow-up on resident grievances. The facility's failure to document and address the residents' concerns could lead to residents feeling unheard and unvalued in their place of residence.
Violation of Resident Privacy During Care Plan Meetings
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records by conducting care plan meetings in residents' rooms. This practice was revealed during a confidential group interview with residents, who expressed feelings of embarrassment and a violation of their privacy due to the presence of roommates, staff members, and visitors who could overhear the discussions. An interview with an LVN MDS Nurse confirmed that care plans were conducted in resident rooms, and she was unaware of any resident concerns about this practice. The facility's Administrator was also unaware of the issue and acknowledged that care plans should be discussed individually and in private. The Nursing Facility Residents' Rights document from November 2021 emphasizes the right to privacy and confidentiality, which was not upheld in this instance.
Failure to Address Resident Grievances and Cold Meal Service
Penalty
Summary
The facility failed to ensure the prompt resolution of grievances, particularly those voiced during Resident Council Meetings. The Activities Director did not initiate grievance reports for concerns raised by residents, and the Administrator did not document or resolve grievances related to quality of care. This lack of action resulted in residents not receiving responses to their grievances, which included ongoing issues with meals being delivered cold. Interviews with residents revealed that meals were consistently served cold, a problem that had not been addressed despite being reported. The Administrator was unaware of these grievances, and the Director of Food and Nutrition acknowledged occasional complaints but lacked a system to ensure food was served at appropriate temperatures. The facility did not have insulated meal carts, and meal trays were not promptly served, contributing to the issue. The facility's grievance policy was not followed, as the Administrator did not complete grievance forms for all concerns expressed by residents. The policy required that all adverse events be investigated and documented, but this was not done. The Local Ombudsman confirmed that residents felt their grievances were not being addressed, and the facility's QAPI meetings did not document concerns about cold food, indicating a failure in the grievance resolution process.
Failure to Provide Adequate Nail Care for Resident with ADL Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform them independently. The resident, a 61-year-old female with a history of intracerebral hemorrhage, non-verbal status, and hemiparesis, required maximal assistance with personal hygiene and bathing. Despite the care plan indicating the need for regular nail care, the resident was observed to have long and dirty fingernails, which had not been trimmed since her admission. This oversight was confirmed by the resident's family member, who expressed concern about potential injury from the long nails. During observations and interviews, the Director of Nursing (DON) and other staff members acknowledged the resident's long fingernails and the associated risk of injury due to her hand contractures. The DON was unaware of any doctor's order for hand rolls to alleviate pressure on the resident's palms. Additionally, staff members, including an LVN and a CNA, were either unaware of the responsibility for nail care or confirmed the need for trimming. The facility's policy on nail care, which emphasizes regular maintenance to prevent infection and injury, was not adhered to in this case.
Failure to Provide Proper Foot Care for Resident
Penalty
Summary
The facility failed to provide proper foot care for a resident, identified as Resident #27, who was at risk due to her medical conditions. Resident #27, a 61-year-old female with a history of intracerebral hemorrhage, diabetes, and other significant health issues, required assistance with personal hygiene and bathing. Despite her need for specialized foot care due to her diabetes and limited mobility, the facility did not provide access to a podiatrist. The Director of Nursing (DON) confirmed that there was no in-house podiatrist and that Resident #27 had not been seen by one since her admission, as her tracheotomy prevented her from leaving the facility. Observations and interviews with staff, including a Licensed Vocational Nurse (LVN) and a Certified Nursing Assistant (CNA), revealed that Resident #27 had long, discolored toenails, which posed a risk of injury. The LVN admitted to not being trained in toenail care and was unaware of who was responsible for trimming the resident's toenails. The facility's policy stated that nail care, especially for residents with diabetes, should be performed by a podiatrist. However, this standard was not met, placing Resident #27 at risk of poor foot hygiene and potential physical decline.
Failure to Properly Document Controlled Substance Counts
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring that controlled substances were properly accounted for and documented during shift changes. Specifically, three licensed staff members, including ADON L, RN A, and LVN C, did not adhere to the established procedure of signing the Controlled Drugs-Count Record immediately after verifying the controlled substances with the on-coming or off-going nurse. This lapse in procedure was observed during a record review and interviews, where it was noted that ADON L did not sign the record immediately after the count, while RN A and LVN C signed the record before conducting the count, contrary to the facility's policy. The facility's policy, revised in 2017, mandates that a narcotics audit be conducted at each shift change to prevent discrepancies, with the involved nurses signing the Narcotic Checklist at the time of the audit. However, the actions of the staff members deviated from this policy, potentially placing residents at risk of not receiving the intended therapeutic response of prescribed medications and increasing the risk of drug diversion. The report highlights the failure of the staff to follow proper procedures for controlled substance counts, which is crucial for ensuring the safety and well-being of the residents.
Improper Medication Storage in Facility
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications across multiple areas, including three medication carts and one medication room. Observations revealed that oral and topical medications were not stored according to their routes of administration in the medication carts on halls E, B, and C. Additionally, opened bottles of Acidophilus Probiotic Dietary Supplement were not refrigerated as required, and medication cart drawers were found to be dusty and filled with paper particles. Interviews with staff, including LVNs and Medication Aides, confirmed a lack of awareness regarding the need to refrigerate certain medications after opening, despite the manufacturer's instructions. In the medication room, medications were also improperly stored, with oral and topical medications mixed together, as well as oral medications and ear drops stored in the same container. The facility's Pharmacy policy and procedure manual from 2003 was reviewed, which outlined the proper storage requirements for medications, including the separation of orally administered medications from those used externally. The Regional Compliance Nurse acknowledged that it is the responsibility of the nursing staff to ensure proper medication storage, highlighting a systemic issue in adherence to established protocols.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature, as evidenced by observations, interviews, and record reviews. During a confidential interview with 13 residents, it was revealed that meals were consistently delivered cold, and this issue had not been addressed by the facility. The Director of Food and Nutrition confirmed that the guacamole was not at the appropriate temperature, measuring 43.3 degrees F instead of less than 41 degrees F. Additionally, a test tray revealed that the pozole was 125 degrees F, the quesadilla was 104 degrees F, and the cheesecake was 62 degrees F, indicating that the food was not served at the correct temperatures. Interviews with staff members, including the Activities Director and the Administrator, highlighted a lack of communication and documentation regarding residents' grievances about cold food. The Activities Director mentioned that residents had voiced concerns during council meetings, but these were not documented in the meeting minutes. The Administrator was unaware of these grievances and stated that the corporate staff did not allow residents to review the council minutes, which may have contributed to the lack of awareness and action on the issue. The Director of Food and Nutrition admitted to occasionally receiving complaints about cold food but could not recall when food temperatures were last checked on a test tray. The facility lacked insulated meal carts and a system to ensure prompt meal delivery to residents eating in their rooms. Additionally, it was noted that CNAs were leaving meal carts open, which could affect food temperatures. The facility's Dietary Services Policy & Procedure Manual outlined procedures for maintaining food temperatures, but these were not being followed, as evidenced by the temperature logs and interviews.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The inspection revealed multiple deficiencies, including the presence of food particles on metal shelving in the food preparation area, expired perishable foods in the refrigerator, and improperly stored food in unsealed containers. Additionally, food containers in the refrigerators were not labeled, and the tile floor in the dry food storage area was covered with dust, white stains, and food particles. Containers in the dry storage room were also found to be dusty and unsealed, and a water bottle was found on the floor under the metal shelving. Further observations highlighted that dietary staff did not use gloves while taking food temperatures and failed to sanitize the food thermometer between uses. The Director of Food and Nutrition was observed not washing hands before checking food temperatures and inconsistently cleaning the thermometer, sometimes using a paper towel or stabbing the plastic cover on food trays. Interviews revealed that residents occasionally complained about cold food temperatures, and there was no system in place to ensure meal trays were promptly served. The facility lacked insulated meal carts, and meal carts were left open in resident halls, potentially affecting food temperatures.
Environmental Deficiencies in Facility's Laundry and Shower Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in several areas, including the laundry room, linen closets, and shower room. Observations revealed that the wood shelves in the clean linen closets had splintered edges, which could potentially cause injury to staff or contaminate linens. Additionally, the laundry room was found to have missing floor baseboards and walls with chipped paint and multiple holes. In the shower room, multiple tiles were either missing or broken, and the water drains were rusted, posing a risk of injury to residents. Interviews with facility staff, including the Housekeeping Supervisor, Maintenance Supervisor, and Administrator, indicated a lack of awareness and reporting of these environmental issues. The Housekeeping Supervisor was unaware of the splintered shelves, while the Maintenance Supervisor, who was new to the role, acknowledged the challenges in addressing these issues due to limited assistance. The Administrator expressed concern over the potential harm to residents from the broken tiles and rusted drains and noted that staff had been trained to report such issues using a QR code system. However, it was unclear why these specific issues had not been reported, suggesting a gap in the reporting process or staff adherence to the protocol.
Failure to Accurately Reflect Resident Behaviors in MDS Assessment
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the status of a resident, specifically regarding her behaviors. The resident, a female with diagnoses of generalized anxiety, major depressive disorder, and mild cognitive impairment, was not listed as having behaviors on her annual MDS assessment. Despite having a BIMS score indicating intact cognition, her comprehensive care plan noted behaviors such as frequently requesting HIPAA information on other residents and attempting to get staff in trouble. These behaviors required interventions like providing clear explanations of daily care activities and redirecting the resident. Interviews with the MDS Nurse, DON, and Administrator revealed that they were aware of the resident's behaviors, which included asking questions about other residents and making false allegations against staff. The MDS Nurse admitted to not including these behaviors in the MDS assessment, as they were not considered aggressive or combative enough to warrant a medical diagnosis with medication. The Administrator, although not well-versed in MDS assessments, acknowledged the resident's behaviors and the need for redirection and education. The failure to document these behaviors in the MDS assessment could lead to inaccurate and incomplete assessments, potentially affecting the care and services provided to the resident.
Failure to Include Critical Intervention in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically neglecting to include the physician-ordered intervention of elevating the head of the bed to at least 30 degrees during enteral feeding. This oversight was identified during a review of the resident's care plan, which did not address this critical intervention despite the resident's medical condition requiring it. The resident, who was severely cognitively impaired and on continuous enteral feeding, had a physician's order mandating the head of the bed elevation to prevent aspiration. Observations and interviews revealed that the nursing staff, including CNAs and charge nurses, were responsible for ensuring the resident's head of bed was elevated as required. However, during an observation, it was noted that the resident's head of bed was not elevated as per the physician's order. The ADON acknowledged the risk of aspiration if the head of the bed was not elevated and stated that staff were trained to maintain the correct positioning during their rounds. Interviews with the MDS nurse and the DON confirmed that the care plan lacked the necessary intervention for head of bed elevation, which was an oversight. The MDS nurse admitted to overlooking this intervention, and the DON emphasized the importance of including all physician-ordered interventions in the care plan to ensure proper monitoring and prevent risks such as aspiration. The facility's policy on comprehensive care planning mandates the inclusion of all necessary interventions to meet the resident's needs, which was not adhered to in this case.
Failure to Maintain Proper Bed Elevation for Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding had their head of bed elevated at least 30 degrees as per physician's orders. This deficiency was observed during a survey when the resident was found lying flat in bed while receiving continuous enteral feeding. The resident, who was severely cognitively impaired and had a history of dysphagia, was at risk of aspiration due to this oversight. Interviews with staff, including the Assistant Director of Nursing (ADON), Registered Nurse (RN), and Director of Nursing (DON), revealed that it was the responsibility of CNAs and charge nurses to maintain the head of bed elevation for residents on continuous enteral feeding. Despite receiving training on enteral feeding care, the staff failed to ensure the resident's bed was properly positioned, which was a critical component of the care plan to prevent complications such as aspiration. The facility's policy on gastronomy tube care required residents to be maintained in a semi-high Fowler's position for a specified time following feeding, but did not specify positioning for continuous feeding. The lack of adherence to the physician's order and facility policy contributed to the deficiency, as staff did not consistently check and maintain the required bed elevation during their rounds, increasing the risk of aspiration for the resident.
Failure to Properly Label Feeding Tube Bags
Penalty
Summary
The facility failed to ensure that a resident's feeding tube bags were properly labeled with the resident's name, date, and time the administration began. This deficiency was observed in a resident who had a feeding tube due to dysphagia and gastrostomy status. The resident's feeding tube was set at the correct rate of 60 ml/hr, but the enteral feeding bag was not labeled with the necessary information. Additionally, the water bag had an incorrect label indicating a different feeding formula and rate. The LVN responsible for changing the feeding bag admitted that the label might have fallen off and acknowledged the mistake in labeling the water bag incorrectly. The Director of Nursing (DON) confirmed that the resident had not experienced any significant weight loss or gain or any complications related to the tube feeding. However, the DON acknowledged the risks associated with failing to label the enteral feeding bag, including the possibility of using an expired or incorrect product. The facility's policy on gastrostomy tube care, which requires labeling and dating of formula and feedings, was not followed in this instance.
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Illustrative
What surveyors actually found near you
We read the 340 citations issued within 25 miles in the last 12 months — including the 8 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
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| El Paso Health & Rehabilitation Center | 1.8 mi | ★★★★★ | 11 | 0 |
| Pebble Creek Nursing Center | 1.9 mi | ★★★★★ | 10 | 0 |
| Edgemere Estates | 2.4 mi | ★★★★★ | 4 | 0 |
| St. Teresa Nursing & Rehab Center | 2.8 mi | ★★★★★ | 18 | 0 |
| Oasis Nursing & Rehabilitation Center | 3.7 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.