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 West Oaks Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Maintain Resident Privacy and Dignity: Staff entered two residents’ rooms without knocking, despite resident rights and facility policy requiring knock-and-enter practices. Staff also left one resident’s catheter drainage bag uncovered, even though the care plan, MD orders, and facility policy required a privacy bag. Interviews with CNA staff, the DON, and the ADM confirmed that knocking before entry and covering catheter bags were expected to protect resident dignity and privacy.
Resident Council Meeting Not Held Privately: A group of residents reported repeated interruptions during their monthly council meeting because it was held in the activity room rather than a private space. The Activity Director and ADM both stated the facility was responsible for providing a private meeting area, but the meeting was interrupted multiple times by staff and other residents, and the residents said this upset them and left them feeling they had no privacy.
Improper Hair Restraints in Food Service: The facility failed to ensure proper hairnet use for 3 of 6 food service staff. CK A, CK B, and the DM were observed in the kitchen with hair not fully covered, including one staff member without a hairnet. Interviews confirmed the facility policy required full head coverage and that staff had recently received hair restraint training.
Infection control failures were observed with catheter care and medication preparation. Two residents with indwelling catheters had drainage bags hanging so that part of the bag touched the floor, despite care plans directing the bags to be kept below the bladder. During medication pass, an MA dropped a BP monitor on the floor, returned it to the med cart without disinfecting it, and continued preparing meds for a resident with severe cognitive impairment without performing hand hygiene until after the meds were given.
Inaccurate smoking status was documented on MDS assessments for two residents. One resident’s annual MDS marked tobacco use as no even though smoking assessments and the care plan identified him as a smoker, and another resident’s admission MDS also marked tobacco use as no despite a smoking assessment showing she smoked daily and needed help with smoking-related tasks. Staff interviews showed confusion over responsibility for the smoking section of the MDS, and the DON was unaware the entries were incorrect.
Care Plan Missing Smoking Status: A resident with COPD, ESRD, respiratory failure, asthma, DM2, and post-stroke hemiplegia had a care plan that did not include her smoking status. Although the MDS marked no current tobacco use, a smoking assessment documented that she smoked 3-4 times a day, could not light her own cigarette, had a dexterity problem, and was aware of smoking safety. Staff interviews confirmed smoking should have been included on the care plan, but it was omitted.
Expired Lactated Ringer's Injection was found stored in a medication room box with unexpired bags of solution. The DON removed the expired package during observation, and later stated nurses were expected to place expired meds in destruction bins, while the ADM said expired meds should be properly disposed of and that monitoring was part of a mixed audit of the med room. Facility policy stated outdated medications are to be immediately removed from stock and disposed of per destruction procedures.
A resident with a history of falls and significant mobility impairments used a wheelchair with a non-functional left brake for over a month, despite notifying several staff members. Staff interviews and record reviews revealed a lack of awareness and documentation regarding the wheelchair's safety checks, and the facility's policy requiring therapy to evaluate equipment for high fall risk residents was not followed.
A resident with diabetes and renal disease was rehospitalized due to hypoglycemia after a facility failed to follow hospital discharge orders. The facility continued administering discontinued diabetes medications and did not start prescribed blood sugar monitoring or an appetite stimulant. Staff interviews revealed communication lapses and inadequate verification of discharge orders.
Staff failed to consistently knock before entering the rooms of four residents, despite being trained on resident rights and facility policy. Observations showed an LVN and a CNA entering rooms without knocking, and interviews with the residents confirmed this practice, with all expressing a preference for staff to knock. Staff and facility leadership acknowledged the expectation to knock, and the facility's policy affirms residents' rights to personal privacy.
Medication Cart #1 was observed left unlocked and unattended with the keys in the lock on multiple occasions by an LVN, despite facility policy and staff training requiring medication carts to be locked and within staff line of sight at all times. Interviews with the LVN, ADM, and DON confirmed awareness of the policy, but the cart was still left unsecured during medication administration rounds.
Surveyors identified numerous deficiencies in food safety and sanitation, including improper labeling and dating of perishable foods, unclean equipment, improper hand hygiene, and staff not adhering to standards for jewelry and artificial nails. Food was found thawing incorrectly, dishwashing temperatures were inadequate, and personal items were stored with food. Staff interviews revealed gaps in training and inconsistent application of food safety policies.
A resident with a history of neurocognitive disorder and depression did not receive her lunch meal in a timely manner due to a lost and incorrectly printed meal ticket. While her table mates were served, she waited without food, eventually receiving a meal she did not want and later leaving the dining room upset. Staff interviews confirmed the delay and acknowledged the importance of serving residents together to maintain dignity.
A resident with severe cognitive impairment and dysphagia was left unsupervised with ice chips at the bedside, despite an active physician order requiring supervision due to aspiration risk. A nurse provided ice and left the room, unaware of the supervision requirement, and staff interviews revealed confusion about the resident's dietary status and failure to update care plans and orders after a recent swallow study.
A CNA failed to remove soiled gloves and perform hand hygiene after providing perineal care and before cleaning a resident's suprapubic catheter site and tubing, using the same gloves and wipes for both tasks. The resident had multiple medical conditions and a history of catheter-associated UTI. Staff interviews and policy reviews confirmed that proper infection control protocols, including glove changes and hand hygiene, were not followed during this care episode.
The facility failed to implement a comprehensive care plan for a resident with severe cognitive impairment and high fall risk. Despite the care plan's directive to place a fall mat at the bedside, the mat was found away from the bed, and staff were unaware of its incorrect placement. Multiple falls in the past months underscored the need for proper fall prevention measures, which were not consistently followed.
A resident with multiple sclerosis and chronic pain did not receive his scheduled Norco medication on time for 7 out of 10 days, causing increased anxiety and fear. The medication aide admitted to delays, and the DON was unaware of the extent of the issue until prompted by the surveyor.
A resident with multiple chronic conditions did not receive his 08:00 AM medications on time for 7 out of 10 days, causing significant distress and anxiety. The facility staff acknowledged the delays but did not take adequate steps to ensure timely administration, and the DON was unaware of the issue until prompted by the surveyor.
The facility failed to maintain the dignity of two residents. A PTA spoke loudly about a resident's need for incontinence briefs in a public hallway, and another resident was left exposed while waiting for a shower. Interviews revealed a lack of specific training for therapy staff on maintaining resident dignity.
A resident with a high-elopement risk eloped from the facility when the receptionist unlocked the front door without verifying the resident's identity. The resident was found over 24 hours later at a bus stop 12 miles away, highlighting a significant lapse in supervision and safety protocols.
The facility failed to provide a resident with showers according to his schedule, despite his dependence on staff for personal hygiene due to multiple medical conditions. Records showed he only received three showers in a month, and staff interviews revealed inconsistencies in the showering process, leading to the deficiency.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to treat residents with dignity and respect by not consistently honoring privacy practices for room entry and catheter coverage. During observation, CNA D entered Resident #27’s room without knocking, and CNA E entered Resident #109’s room without knocking. The report states that both residents had diagnoses including dementia or cognitive communication deficits, and Resident #109 also had parkinsonism and major depressive disorder. Resident #27 had a BIMS score of 0, indicating severe cognitive impairment, while Resident #109 had a BIMS score of 14, indicating intact cognitive response. Resident #109 told the surveyor that staff did not always knock before entering and that she would like staff to knock because it was the right thing to do. The facility also failed to ensure Resident #50’s catheter bag had a privacy cover. Resident #50 was described as having diagnoses including muscle wasting, neurogenic bladder, hypertension, pulmonary embolism, and tracheostomy status, and her quarterly MDS showed a BIMS score of 0. During observation, she was lying in bed with a catheter bag that did not have a privacy cover. Her care plan and physician orders directed that the catheter bag and tubing be positioned below the bladder and that a privacy bag be used. CNA D stated that catheter bags must always be sealed and covered with a blue bag, that CNAs were responsible for ensuring the privacy cover was in place, and that the resident may feel uncomfortable if it was not covered. Interviews with the DON and ADM confirmed that staff were expected to knock before entering residents’ rooms and that all catheter bags were to have privacy covers. The DON stated that staff should cover the catheter with a privacy bag and that all staff were responsible for ensuring this. The ADM stated that staff should knock and introduce themselves before entering any resident room and that all staff were responsible for doing so. The facility’s policies also stated that residents are to be treated with kindness, dignity, and respect, and that catheter drainage bags should be covered with a privacy bag to maintain dignity.
Resident Council Meeting Not Held Privately
Penalty
Summary
The facility failed to ensure residents had the right to organize and participate in resident groups by not providing the Resident Council with a private meeting area for its monthly meetings. During a confidential group interview and observation, ten residents stated they wanted a meeting without interruptions, but the meeting was held in the activity room. Residents reported that staff walked in during the council meeting and that they had to constantly stop their meeting or vote because people interrupted them. During the hour-long meeting, the discussion was interrupted six times by residents and staff, and the residents stated that this upset them and made them feel like they did not have privacy. The Activity Director stated she was responsible for ensuring the Resident Council had a private meeting space and said the facility only had one area large enough for the council. The ADM stated the Activity Director was responsible for providing a private meeting space and said he monitored this by talking with her, but he was not sure why staff and residents were interrupting the meeting. The facility's Resident Rights Policy stated residents have the right to organize and participate in resident groups and have family members meet with them.
Improper Hair Restraints in Food Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 3 of 6 staff reviewed in food and nutrition services. During observations, CK A was seen preparing lunch with a hairnet that did not fully cover the hair, with the back exposed; CK B was observed in the kitchen without a hairnet and with full head hair exposed; and the DM was observed in the kitchen with her hair not fully covered by her hairnet, with the back exposed. The report states that CK A and the DM had their hair in buns, but the back of the hair was hanging to the neck, and CK B’s hair was hanging down past the shoulders. Interviews with CK A, CK B, and the DM confirmed that the facility had a hair restraint policy requiring full head coverage and that exposed hair placed residents at risk of hair in their food. CK A stated she had been in-serviced on hair restraints about 2 weeks earlier, and CK B stated she had been trained when she started in June 2018 and again a couple of weeks earlier. The DM stated she was responsible for ensuring staff wore proper hair restraints and acknowledged that she had not conducted an in-service herself, although staff reported one had been done by the Dietitian about 2 months earlier. Record review showed the facility’s Hair Restraints policy required hair restraints to be worn so hair would not contact exposed food, equipment, utensils, linens, or single-service items, and the facility’s in-service record showed a 02/23/26 hairnet training with 5 of 6 kitchen staff signed in.
Infection Control Failures With Catheter Care and Medication Preparation
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for residents with indwelling catheters and for medication administration practices. Resident #50, a female with diagnoses including nontraumatic intracerebral hemorrhage in the cerebellum, acute respiratory failure with tracheostomy status, speech and language deficits following cerebral infarction, and gastrostomy status, had an indwelling catheter and was completely dependent on all tasks. Her care plan directed staff to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. During observations on 02/23/2026, her catheter drainage bag was hung on the left side of the bed rail with part of the bag touching the floor. Resident #11, a male with diagnoses including acute and chronic respiratory failure with hypoxia, tracheostomy status, COPD, type 2 diabetes mellitus, lung cancer, and gastrostomy status, also had an indwelling catheter. His care plan directed staff to position the catheter bag and tubing below the level of the bladder. During an observation on 02/24/2026, his catheter drainage bag was hung on the left side of the bed rail with the bottom part of the bag touching the floor. Staff interviews reflected that the urine collection bag should be kept below the bladder and off the floor, and that if it touched the floor it could lead to cross-contamination or bacteria exposure. Resident #99, a female with type 2 diabetes mellitus, essential hypertension, and unspecified dementia, had a BIMS score of 06 indicating severe cognitive impairment. During medication administration observation, the medication aide used a blood pressure monitor on the resident, dropped it on the floor, picked it up, and placed it on the medication cart without disinfecting it. The medication aide then continued preparing the resident's medications without performing hand hygiene and later performed hand hygiene after the medications were administered. The aide stated she forgot to disinfect the monitor and perform hand hygiene because she was nervous, and the DON stated that failure to perform proper hand hygiene and disinfect shared equipment could cause resident infections.
Inaccurate Smoking Status on MDS Assessments
Penalty
Summary
The facility failed to ensure assessments accurately reflected residents’ smoking status for two residents reviewed. Resident #91’s annual MDS listed current tobacco use as no, even though the record also included smoking assessments showing he smoked 3-4 times a day and was aware of smoking safety. His care plan identified him as a smoker with a remote history of suspected smoking in his room, with interventions to remind him of smoking rules and that smoking was only during designated times. Resident #88’s admission MDS also listed current tobacco use as no, despite the smoking assessment showing she had a dexterity problem, smoked 3-4 times a day, could not light her own cigarette, and was aware of smoking safety. Her care plan identified her as not a smoker, but during interview she stated she was a smoker, smoked daily, and needed help pushing her wheelchair to the smoking area. The Smoking Residents list identified both Resident #88 and Resident #91 as smokers. During interviews, the SW stated she did not handle the smoking portion of the MDS because that was the MDSN’s responsibility. The MDSN stated the MDS nurse was ultimately responsible for completing the MDS and acknowledged Resident #88’s smoking status was coded in error; she did not know why Resident #91’s smoking status was not on the MDS. The DON stated she was unaware the smoking status was incorrect for either resident and was not sure a resident’s smoking status went on the MDS. The ADM stated incorrect information on the MDS would potentially affect the quality of care and would not reflect an accurate picture of residents’ needs.
Care Plan Missing Smoking Status
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #88 that included measurable objectives and timeframes to meet her identified needs. Resident #88 was a [AGE]-year-old female admitted and readmitted to the facility with diagnoses including COPD, end stage renal disease, acute and chronic respiratory failure with hypoxia, asthma, type 2 diabetes mellitus with diabetic nephropathy, and hemiplegia and hemiparesis following cerebral infarction affecting her right dominant side. Her care plan, dated 12/03/2025 and revised on 01/30/2026, did not include smoking information. Record review showed the admission MDS marked current tobacco use as no, but the Smoking Assessment dated 12/19/2025 documented that Resident #88 had a dexterity problem, smoked 3-4 times a day, could not light her own cigarette, and was aware of the safety associated with smoking. During interviews, the SW stated smoking was not her responsibility, the MDSN stated smoking should have been listed on the care plan and that she was the one who completed it, and the DON stated smoking should be listed on the care plan and that staff would not know the resident's smoking-related needs if it was omitted. The facility policy stated the IDT shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs.
Expired Medication Stored With Unexpired Supplies
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals for one medication storage room. During observation of the medication storage room, one bag of Lactated Ringer's Injection USP (500 mL) with an expiration date of 11/2025 was found stored inside a box along with five unexpired bags of solution. The DON, who was present during the observation, removed the expired package from the room and stated that medications would be disposed of per facility policy. During interview, the DON stated her expectation was that all nurses place expired medications in medication destruction bins, but she could not explain how the expired medication was found stored with unexpired medications. The DON stated a nurse might have placed it there by mistake thinking it was a destruction bin, and that the supply person monitored expiration dates when supplies were restocked. The ADM stated expired medication should be properly disposed of and that monitoring expired medications was a mixed audit of the medication room. The facility policy stated that outdated, contaminated, or deteriorated medications are to be immediately removed from stock and disposed of according to medication destruction procedures.
Failure to Ensure Functional Wheelchair Brakes for High Fall Risk Resident
Penalty
Summary
A deficiency was identified when a resident's wheelchair was found to have non-functional brakes on the left side, which had not been addressed for over a month despite the resident notifying multiple staff members. The resident, who had a history of falls, hemiplegia, hemiparesis, impaired balance, and was part of the facility's Fall Star program, reported the issue to staff including the Director of Rehabilitation (DOR) but the problem persisted. Observations confirmed that the left brake did not prevent the wheelchair from moving, and the brake mechanism appeared loose. Interviews with staff revealed that neither the Certified Nursing Assistant (CNA) nor the Registered Nurse (RN) assigned to the resident were aware of the brake issue. The CNA could not recall the last time the wheelchair was checked, and the RN stated that she had not been informed of the problem. The DOR acknowledged being told about the issue by the resident on the day of the survey and intended to refer it to Occupational Therapy (OT), but there was no documentation or evidence that the wheelchair had been assessed for functionality or safety in the preceding months. Further interviews with the Occupational Therapist (OT), Assistant Director of Nursing (ADON), and Administrator (ADM) indicated that there was no clear record of regular wheelchair safety checks or assessments for this resident. The facility's policy required therapy to evaluate wheelchair appropriateness and functionality, especially for residents identified as high fall risks. However, documentation and staff interviews confirmed that these evaluations had not been consistently performed, resulting in the resident using a wheelchair with faulty brakes for an extended period.
Failure to Follow Discharge Orders Leads to Medication Errors
Penalty
Summary
The facility failed to ensure that a resident's hospital discharge orders were followed, leading to significant medication errors. The resident, who had a history of end-stage renal disease, type 2 diabetes mellitus, and other health conditions, was readmitted to the facility after a hospital stay for hypoglycemia. Despite discharge instructions to discontinue diabetes medications and start an appetite stimulant, the facility continued administering metformin and glyburide, which were supposed to be stopped, and failed to initiate blood sugar monitoring or the prescribed appetite stimulant. The resident's medical records indicated that metformin and glyburide were administered on multiple occasions after the resident's return from the hospital, contrary to the discharge instructions. This oversight resulted in the resident experiencing dangerously low blood sugar levels, leading to another hospitalization. Interviews with facility staff revealed a lack of proper communication and verification of discharge orders, with some staff unaware of the medication changes or unable to obtain the necessary documentation from the hospital. The facility's failure to properly reconcile medications upon the resident's readmission and to follow the hospital's discharge instructions directly contributed to the resident's rehospitalization due to hypoglycemia. The staff's reliance on incomplete or incorrect information, such as verbal assurances from EMS or the resident, without proper documentation or verification, further exacerbated the situation, highlighting significant gaps in the facility's medication management and communication processes.
Removal Plan
- Medical Director notification
- Audit all admissions/readmissions to ensure all medications were correctly verified
- Inservice DON on admission requirements to verify orders. If the sending facility does not provide discharge summaries or orders: a. The admitting nurse will call the hospital and/or facility resident is returning from to obtain discharge orders. b. In the event orders are unable to be obtained, the NP/DON/ADON/MD will be notified by the admitting nurse to assist in retrieving discharge summaries/orders. c. These steps will remain in the permanent admission/readmission protocol.
- Inservice Nursing and Nursing Leadership staff on admission requirements to verify orders. If the sending facility does not provide discharge summaries or orders: a. The admitting nurse will call the hospital and/or facility resident is returning from to obtain discharge orders. b. In the event orders are unable to be obtained, the NP/DON/ADON/MD will be notified by the admitting nurse to assist in retrieving discharge summaries/orders. c. These steps will remain in the permanent admission/readmission protocol.
- Ad hoc QA1 meeting. Attendees will include ED, DON, Clinical Resource, Cluster Partners, Medical Director. Meeting will include the Plan of Removal and inventions.
- Admissions Coordinator inservice on notification of pharmacy consultant of all admissions/readmissions for medication review.
Failure to Knock Before Entering Resident Rooms Compromises Privacy
Penalty
Summary
The facility failed to ensure the personal privacy of four residents by not consistently knocking on their doors before entering their rooms. Observations revealed that an LVN entered the rooms of three residents without knocking, and a CNA entered another resident's room without knocking. These actions were witnessed during routine activities in the facility's 100 and 300 halls. Interviews with the affected residents indicated that staff did not always knock before entering their rooms. While some residents stated that it did not bother them, all expressed a preference for staff to knock before entering, citing reasons such as wanting to know when someone is coming in or concerns about privacy while changing. The residents involved had various medical conditions, including dementia, hypertension, depression, cognitive communication deficits, and required assistance with personal care. Most were cognitively intact according to their BIMS scores. Staff interviews confirmed that they had been trained on resident rights and acknowledged the expectation to knock before entering a resident's room, regardless of whether the door was open or if the call light was on. Both the LVN and CNA involved admitted to not knowing why they failed to knock on these occasions. Facility leadership, including the administrator and DON, reiterated the policy and the importance of knocking to maintain resident privacy and a homelike environment. Review of the facility's resident rights policy confirmed residents' rights to personal privacy.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency was identified when Medication Cart #1 on the 100 hall was repeatedly left unattended, unlocked, and with the keys in the lock by an LVN. Multiple observations showed the LVN walking away from the cart to enter resident rooms or check on residents, leaving the cart out of her line of sight and unsecured. The cart contained medications and was accessible to anyone passing by during these times. The facility's policy, revised in May 2007, requires that medication carts remain locked and within the staff member's line of sight at all times when not locked. Interviews with the LVN, the Administrator (ADM), and the Director of Nursing (DON) confirmed that all staff had been trained on proper medication storage procedures, including the requirement to keep carts locked when not in direct view. Both the ADM and DON acknowledged that leaving the cart unlocked could result in unauthorized access to medications. Despite this training, the LVN left the cart unlocked and unattended on at least three occasions, contrary to facility policy and accepted professional standards.
Multiple Food Safety and Sanitation Deficiencies in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Surveyors observed multiple instances of improper food labeling and dating, including undated bags of bacon, cheese, containers of peaches and applesauce, sandwich bread, and wilted lettuce emitting a foul odor. Expired items such as Italian pasta salad, orange Jello, mayonnaise, raw sausage, and whipped topping were also found in the kitchen refrigerator. Additionally, ground beef was observed thawing under hot running water next to dirty dishes, and dented cans were stored with undamaged cans. Personal items, such as a soda bottle, were found in the food refrigerator, and the dishwasher was operating below the required temperature for disinfection. The ice machine and its scoop holder, as well as microwaves in both the kitchen and nourishment room, were found to be unclean. Margarine was left out at an improper temperature, and the nourishment and activities rooms contained dirty dishes, unlabeled and undated food items, and personal cups without names. Staff were observed not following proper hygiene and food safety protocols. The dietary manager and cook failed to wash their hands before food preparation tasks, and gloves were not changed after cleaning or switching tasks. The cook was seen wearing long false nails and large hoop earrings, contrary to food safety standards. A registered nurse was observed touching his face and scratching his back before handling resident trays without sanitizing his hands. Interviews with staff revealed gaps in training and understanding of food safety policies, with some staff unaware of the requirements for hand hygiene, jewelry, and nail standards. The dietary manager and dietitian both referenced the Texas Food Establishment Rules as their guiding policy, but inconsistencies in implementation were evident. The facility's management structure assigned responsibility for cleaning and food safety to various staff, but interviews indicated confusion and lack of clarity regarding specific duties. The dietary manager was responsible for kitchen cleaning and expired foods, while nursing staff were tasked with cleaning the nourishment room. The dietitian conducted periodic in-services and quality assurance rounds, but issues persisted. The administrator was not fully aware of the policies regarding jewelry and nails. The report references the 2022 Food Code, highlighting specific requirements for hand hygiene, glove use, nail maintenance, food thawing, and temperature control, all of which were not consistently followed in the facility.
Delayed Meal Service Compromises Resident Dignity
Penalty
Summary
A deficiency occurred when a female resident with a history of spinal fracture, subdural hemorrhage, mild neurocognitive disorder, and depression did not receive her lunch meal in a timely manner. The resident, who was cognitively intact and at risk for nutritional problems, was observed sitting in the dining room without a meal tray while her table mates received their food. After a significant delay, she was given a tray that she sent back because it contained fish, which she did not like. She eventually left the dining room visibly upset and later received two slices of pizza in her room. Interviews with staff revealed that the delay was due to a lost meal ticket and an error in printing the correct ticket, which prolonged the process of getting her meal. Staff acknowledged that residents should be served together and that such delays could make residents feel neglected. The facility's policy requires staff to respect residents' preferences and dignity, including timely meal service and honoring individual choices.
Resident Left Unsupervised with Ice Chips Despite Physician Order
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dysphagia, and a history of being NPO with a feeding tube was left unsupervised with ice chips at the bedside, contrary to active physician orders. The resident's care plan and physician order specified that ice chips could be given every two hours for dry mouth, but the resident was not to be left alone with ice due to the risk of aspiration. During an observation, a nurse provided a fresh cup of ice and left it at the bedside without supervision. The nurse later stated she was unaware of the specific order requiring supervision and relied on the electronic chart for such information. Further interviews revealed confusion among staff regarding the resident's current dietary status and the discontinuation of the supervision order following a recent swallow study. The MDS nurse and ADT indicated that the order for supervision with ice should have been discontinued after the resident was transitioned from NPO to a mechanical soft diet, but this had not been updated in the system. The facility's documentation policy required timely updates to care plans and orders, but the lack of communication and failure to update records led to the resident being left unsupervised with ice chips, in violation of the physician's order.
Failure to Follow Infection Control Protocol During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper catheter care provided to a resident with a suprapubic catheter. During observed care, a CNA did not remove soiled gloves or perform hand hygiene after cleansing the resident's perineal area before proceeding to clean the suprapubic catheter site and tubing. The CNA used the same gloves and wipes for both areas, which was confirmed during an interview where the CNA acknowledged forgetting to change gloves and perform hand hygiene between tasks. The resident involved was an elderly male with multiple medical conditions, including dementia, chronic obstructive pulmonary disease, bradycardia, chronic pain syndrome, hypertension, obstructive and reflux uropathy, and neuromuscular dysfunction of the bladder. He had a history of urinary tract infection related to his suprapubic catheter, as documented in his care plan. The care plan did not include specific interventions for cleansing the catheter tubing. Interviews with facility staff, including the CNA, LVN, DON, and ADM, confirmed that the expected protocol was to change gloves and perform hand hygiene when moving from a contaminated to a clean area during resident care. Policy reviews indicated that hand hygiene and glove changes are required before and after handling invasive devices and after removing gloves. Training records showed the CNA had previously received instruction on hand hygiene, but could not recall recent training. The facility's infection preventionist position was vacant at the time of the incident, with the DON temporarily overseeing infection control.
Failure to Implement Comprehensive Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for Resident #1, who had severe cognitive impairment and was at high risk for falls. Despite being dependent on staff for assistance with toileting, bed mobility, and transfers, the resident's care plan included a fall mat at the bedside as an intervention. However, during an observation, the fall mat was found away from the bedside, and the resident confirmed that it had been left in that position for an unknown duration. This failure to ensure the fall mat was correctly placed could compromise the resident's safety and well-being. Interviews with various staff members, including CNAs, RNs, PT, ADONs, and the DON, revealed inconsistencies in the monitoring and documentation of fall risk interventions. While staff were trained and in-serviced on falls and fall mat placement, there was a lack of adherence to these protocols. Staff members were unaware that the fall mat was not in the correct position, and there was no policy and procedure for rounding on residents, which contributed to the oversight. The facility's records indicated that Resident #1 had multiple falls in the past months, highlighting the critical need for proper fall prevention measures. Despite the care plan's directive to place a floor mat at the bedside, the facility's failure to consistently implement this intervention was evident. The lack of a comprehensive and consistently followed care plan for Resident #1, as well as the absence of a clear policy for regular checks, led to the deficiency noted in the report.
Failure to Administer Pain Medication on Time
Penalty
Summary
The facility failed to ensure that Resident #3 received his scheduled Norco medication on time for 7 out of 10 days between 04/01/24 and 04/10/24. Resident #3, a [AGE] year-old male with multiple sclerosis, chronic pain syndrome, and other significant health issues, was dependent on timely administration of his pain medication to manage his condition. Despite the care plan and physician orders specifying the administration times, the medication was consistently given late, causing the resident to experience increased anxiety and fear about his pain management. Observations and interviews revealed that Resident #3 was aware of the delays and expressed fear that his medications might be taken away. He reported staying awake at night to ensure he received his morning dose on time. The medication aide admitted to administering the medications late and cited being slower than usual and occasionally being asked to perform other tasks as reasons for the delays. The Director of Nursing (DON) acknowledged the issue but had not reviewed the medication audit sheet until prompted by the surveyor. The facility's policy on pain management emphasized the importance of timely medication administration, yet the DON and other staff members were not fully aware of the extent of the delays. The DON stated that the policy allowed for medications to be administered within one hour before or after the scheduled time, but this was not adhered to in Resident #3's case. The Administrator also confirmed that the DON was responsible for ensuring timely medication administration and recognized the potential negative outcomes of the failure, including increased pain and anxiety for the resident.
Failure to Administer Medications on Time
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #3, specifically in the accurate administration of medications. Resident #3, a [AGE] year-old male with multiple diagnoses including multiple sclerosis, chronic pain syndrome, and high blood pressure, did not receive his 08:00 AM medications on time for 7 out of 10 days between 04/01/24 and 04/10/24. The medications involved were Norco, Baclofen, Cozaar, and Cipro, which were consistently administered late, sometimes by more than an hour past the scheduled time. This failure was observed through a review of the Medication Administration Record (MAR) and confirmed by interviews with the resident and staff members. Resident #3 expressed significant distress over the late administration of his medications, particularly his pain medication, Norco. He reported staying awake at night out of fear that he would not receive his morning dose on time, which exacerbated his anxiety and pain. The resident's care plan indicated that he was completely dependent on assistance for all activities of daily living (ADLs) and required timely medication to manage his chronic pain and other conditions. Despite this, the facility staff, including Medication Aide B and the Director of Nursing (DON), acknowledged the delays but did not take adequate steps to ensure timely administration. Interviews with the DON and the Administrator (ADM) revealed a lack of oversight and awareness regarding the late medication administrations. The DON admitted to not reviewing the medication audit sheet for Resident #3 until prompted by the surveyor and acknowledged the need for a system to ensure timely medication administration. The ADM also confirmed that the DON was responsible for overseeing medication administration but was unaware of any grievances or complaints from Resident #3 regarding his medication schedule. The facility did not provide a policy on medication administration times when requested by the surveyor, indicating a potential gap in their procedural documentation and adherence.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure the residents' right to a dignified existence for two residents. In the first instance, a Physical Therapy Assistant (PTA) spoke loudly to a resident in a public hallway about her need for incontinence briefs, using language that compared the briefs to baby diapers. This conversation was overheard from another room, and the resident, who has severe cognitive impairment and communication difficulties, was unable to respond verbally or indicate understanding. The care plan for this resident included specific communication techniques to maintain her dignity, which were not followed by the PTA. In the second instance, another resident was left exposed in a public area while waiting for a shower. The resident, who has moderate cognitive impairment and requires assistance with bathing, was observed in a wheelchair with her hospital gown open in the back, revealing her back and incontinence brief. The resident expressed that this exposure happened frequently and that staff often left her waiting in this state. The PTA who interacted with this resident did not notice her exposed state and did not take steps to cover her. Interviews with the PTA, Director of Nursing (DON), and Administrator (ADM) revealed a lack of specific training for therapy staff on maintaining resident dignity. The DON acknowledged that the way the PTA spoke to the first resident could be embarrassing and potentially a HIPAA violation. The ADM emphasized the importance of treating residents with respect and acknowledged that the situation with the second resident needed a solution to prevent her from being exposed in the hallway.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards and provided adequate supervision for a resident who was a high-elopement risk. The resident, who had a history of cerebral infarction, hypertension, type II diabetes, and cognitive impairment, eloped from the facility when the receptionist used a remote-control door opener to unlock the front door. The resident was found over 24 hours later at a bus stop approximately 12 miles from the facility, indicating a significant lapse in supervision and safety protocols. The resident's admission care plan and elopement evaluation identified him as a high risk for elopement, yet the receptionist, who was aware of this risk, failed to verify the resident's identity before allowing him to exit. The facility's administrator confirmed that the receptionist was fully aware of the resident's elopement risk and that his information was included in an elopement binder kept at the receptionist's desk and the nurses' station. Despite these measures, the receptionist's actions led to the resident's unsupervised departure. Interviews with various staff members revealed that they had been in-serviced on the elopement policy, the use of elopement binders, and the importance of verifying residents before allowing them to leave. However, the incident highlighted a critical failure in the implementation of these protocols. The facility's documentation and timeline of the elopement incident further underscored the breakdown in communication and supervision that allowed the resident to elope and remain missing for an extended period.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received necessary services to maintain personal hygiene. Specifically, the facility did not provide showers to a resident in compliance with his shower schedule. The resident, who had diagnoses including pressure ulcer, major depressive disorder, and multiple sclerosis, was dependent on staff for showering and bathing. Despite his care plan indicating he required assistance with bathing three days a week, records showed he only received three showers in the month of March 2024. The resident expressed dissatisfaction, stating he felt grimy and gross and had to beg staff for showers. Additionally, he mentioned that on one occasion, an aide was too busy to shave his face, which he disliked intensely. Interviews with staff revealed inconsistencies in the showering process. The Director of Nursing (DON) acknowledged that residents should be showered according to their schedules and that failure to do so could result in negative outcomes like skin breakdown. The Shower Coordinator (SC) and a Certified Nursing Assistant (CNA) confirmed that residents were supposed to be showered three times a week and that shower sheets were used to document this. However, the SC was unaware that the resident was not being bathed according to his schedule. The facility's policies and job descriptions emphasized the importance of assisting residents with personal hygiene, but the implementation was evidently lacking, leading to the deficiency.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 339 citations issued within 25 miles in the last 12 months — including the 19 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brodie Ranch Nursing And Rehabilitation Center | 2.2 mi | ★★★★★ | 3 | 1 |
| Southpark Meadows Nursing And Rehabilitation Cente | 2.8 mi | ★★★★★ | 5 | 0 |
| Brush Country Nursing And Rehabilitation | 3.1 mi | ★★★★★ | 23 | 1 |
| Marbridge Villa | 3.1 mi | ★★★★★ | 0 | 0 |
| Onion Creek Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.