Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Whisperwood Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dysphagia, Parkinson’s disease, and throat cancer had a care plan that continued to list a mechanical soft diet despite a current physician order for a fortified/enhanced pureed diet with nectar-thick liquids and shakes at all meals. While the resident was observed receiving and eating a pureed meal and a CNA confirmed pureed meals were provided, the written care plan was not revised to match the active diet order. The ADM and DON acknowledged that the DON was responsible for updating care plans with new MD orders and that the care plan should have reflected the pureed diet, in contrast to facility policy requiring timely review and revision of comprehensive care plans.
A resident with dementia, dysphagia, Parkinson’s disease, and throat cancer had a physician order and care plan for a fortified/enhanced pureed diet with nectar-thick liquids, large portions, and supplemental shakes with all meals for weight gain, but the meal ticket listed only a regular/pureed diet and no shake. During an observed lunch, the resident received a pureed meal without a shake, and the CNA confirmed no shake was served and that shakes were typically given only if the meal was not finished. The ADM and DON reported that dietary staff rely on meal tickets to follow therapeutic diet orders, that the DON is responsible for communicating diet orders to dietary, and that they were unaware the ordered shakes with all meals were not on the meal ticket; the facility could not provide a policy on therapeutic diets or following physician orders.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not have or enforce adequate policies and procedures to prevent abuse, neglect, and theft, leaving staff without clear guidance on how to identify, report, or prevent such incidents. This deficiency was identified through documentation review and staff interviews.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required by policy.
A facility failed to implement its abuse prevention policies when two residents, both with impaired cognition, were involved in an inappropriate incident. The male resident kissed the female resident, but the incident was not reported to HHSC, nor were family representatives notified. The DON and ADM did not conduct a thorough investigation, and the incident was not documented in the residents' progress notes, potentially placing residents at risk for abuse and neglect.
A LTC facility failed to report an incident of resident-to-resident inappropriate behavior involving a male resident with dementia kissing a female resident with severe cognitive impairment. The incident was witnessed by the Activity Director but was not documented or reported to HHSC as required by the facility's abuse policy. The DON and ADM did not perceive the incident as serious, citing the residents' cognitive impairments and lack of harm or intent.
A facility failed to investigate and document an incident where a resident with moderately impaired cognition kissed another resident with severely impaired cognition. The incident was not perceived as abuse or neglect by the facility's staff, leading to a lack of thorough investigation and documentation, contrary to the facility's abuse policy. This oversight could potentially place residents at risk, as the necessary steps to prevent future incidents were not taken.
A resident with severe cognitive impairment and a history of elopement risk was able to leave the facility unsupervised due to a gate malfunction and lack of direct supervision while smoking. The resident's care plan required direct supervision, but staff failed to provide it, leading to the resident's elopement. The incident was exacerbated by a lack of communication about ongoing gate repairs and the new CNA's inexperience.
The facility failed to ensure resident privacy and dignity, affecting four residents. A CNA entered a resident's room without knocking, while another resident was not fully covered during peri care. Two residents were left exposed, one during care and another in their room with the door open. These actions did not align with the facility's policy on resident rights.
The facility failed to provide adequate hydration to several residents, as observed through empty water pitchers and residents expressing thirst. Despite care plans indicating a risk for fluid deficit, staff did not consistently offer fluids or monitor hydration. Interviews revealed that hydration rounds were not regularly conducted, and there were delays in refilling water containers.
The facility failed to maintain food safety and storage standards in the kitchen. Observations revealed improperly sealed food, cleaning chemicals stored near food, and unclean kitchen equipment. Bowls, plates, and pots were stored incorrectly, increasing contamination risk. The Dietary Manager admitted to lapses in protocol adherence, and the administrator confirmed staff training on cleanliness and storage, yet deficiencies persisted.
Staff at the facility failed to adhere to proper hand hygiene practices, as observed during peri care for two residents. CNAs did not wash hands for the recommended duration, used the same paper towel to turn off faucets, and failed to wash hands before gathering supplies. These actions could lead to cross-contamination and increased infection risk for residents with vulnerabilities.
A resident with severe cognitive impairment and hearing loss was not assisted in locating or replacing missing hearing aids, leading to communication challenges and frustration. Staff were unaware of the resident's need for hearing aids, and the facility's policy on sensory alteration was not effectively implemented, resulting in a delay in providing necessary auditory support.
The facility failed to develop and implement a comprehensive care plan for a resident's nail care needs, leading to overgrown and painful toenails. Despite the resident's requests and visible signs of discomfort, staff failed to communicate and address the issue adequately.
A resident with multiple diagnoses had overgrown, thick, and cracked toenails causing pain due to the facility's failure to ensure proper foot care. Despite awareness among CNAs and RNs, the issue was not adequately communicated or addressed, leading to severe foot conditions.
Failure to Update Care Plan to Reflect Current Diet Order
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident’s current dietary orders. The resident was an elderly male with dementia, age-related cognitive decline, dysphagia, Parkinson’s disease with dyskinesia and fluctuations, malignant neoplasm of the tonsillar pillar, and a cognitive communication deficit. His admission MDS showed a BIMS score of 01, indicating severe cognitive impairment. The facility’s care plan documented that the resident had a swallowing problem related to throat cancer, with goals to prevent injury related to aspiration and to maintain ideal weight and receive proper nutrition, and included various dysphagia-related interventions. The care plan, initiated and revised on specified dates, listed the resident’s diet as “Large Portions, Mechanical Soft texture, Regular consistency” and included interventions such as following the prescribed diet, determining food preferences, encouraging meal completion, providing house shakes three times daily, monitoring weights, offering substitutes and supplements, and using a red glass to identify the need for assistance. However, review of the active physician’s orders showed a current order for a fortified/enhanced diet with pureed texture, nectar consistency, shakes with all meals, and large portions for weight gain. The care plan was not updated to reflect this pureed diet order and continued to indicate a mechanical soft diet. Observation of the resident during a lunch meal showed he was receiving and consuming a pureed meal, and a lunch meal ticket indicated a regular/pureed diet. A CNA reported the resident received a pureed diet at every meal. Interviews with the ADM and DON confirmed that the DON was responsible for ensuring care plans were updated with changes in physician orders, that care plans were expected to be updated as soon as changes occurred, and that they were not aware the care plan still reflected a mechanical soft diet instead of the ordered pureed diet. The facility’s comprehensive care planning policy stated that care plans must include measurable objectives and time limits and be reviewed and revised based on changing goals, preferences, and needs identified in assessments, but this was not carried out for the resident’s dietary orders.
Failure to Provide Ordered Therapeutic Diet and Supplemental Shakes
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for a therapeutic diet and supplemental nutrition for one resident with significant swallowing and cognitive impairments. The resident was an older male with dementia, age-related cognitive decline, dysphagia, Parkinson’s disease with dyskinesia and fluctuations, malignant neoplasm of the tonsillar pillar, and a cognitive communication deficit. His admission MDS showed a BIMS score of 01, indicating severe cognitive impairment. The care plan identified swallowing problems related to throat cancer and a risk for unplanned weight change, with interventions including following the prescribed diet, informing all staff of special dietary needs, and providing house shakes three times daily. Record review showed an active physician order for a fortified/enhanced diet with pureed texture, nectar consistency, large portions, and shakes with all meals for weight gain, starting in early March. The care plan also specified house shakes TID and serving diet and snacks as ordered. However, the resident’s lunch meal ticket listed only a regular/pureed diet and did not include a supplemental shake. During a lunch observation, the resident received a pureed meal and ate all of it, but no shake was present, and the CNA assisting confirmed that no supplemental shake was served and that it was not listed on the meal ticket. The CNA stated she did not know why the shake was not on the ticket and reported that she typically provided a shake only if the resident did not finish his meal. Interviews with the ADM and DON revealed that dietary staff relied on meal tickets to follow therapeutic diet orders and that the DON was responsible for communicating physician diet orders to dietary. The ADM stated she was not aware the resident was not receiving supplemental shakes with every meal and did not know why the meal ticket did not reflect the physician’s order. The DON stated there was no Dietary Manager when the order for shakes with all meals was received and that she was unaware the order was not reflected on the meal ticket. Both acknowledged that inaccurate communication of dietary orders to dietary staff could impact a resident’s nutrition. The facility was unable to provide a policy related to therapeutic diets or following physician orders when requested.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Policies to Prevent Abuse, Neglect, and Theft
Penalty
Summary
The facility failed to develop and implement effective policies and procedures to prevent abuse, neglect, and theft. This deficiency was identified through review of facility documentation and interviews, which revealed that the required policies and procedures were either not in place or not followed. As a result, there was insufficient guidance for staff to prevent and respond to incidents of abuse, neglect, or theft involving residents. Surveyors found that the lack of comprehensive and enforced policies contributed to an environment where staff were not adequately informed or trained on how to identify, report, or prevent such incidents. The absence of these measures increased the risk of harm to residents, as staff were not provided with clear protocols to follow in situations where abuse, neglect, or theft might occur.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The report specifically notes the failure to provide prompt notification to all required parties when significant events impacting the resident occurred, as required by regulation.
Failure to Report and Investigate Resident-to-Resident Incident
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse and neglect for two residents involved in an incident of inappropriate sexual activity. The incident involved a male resident with moderately impaired cognition due to dementia and a female resident with severely impaired cognition. The male resident was witnessed kissing the female resident on the lips, an act that was not documented in their progress notes, nor was it reported to the Health and Human Services Commission (HHSC) as required by the facility's abuse policy. The Director of Nursing (DON) and the Abuse Preventionist (ADM) did not follow the facility's abuse policy by failing to report the incident to HHSC, notify the family representatives, or conduct a thorough investigation. The Activity Director, who witnessed the incident, separated the residents and informed the DON and ADM, but did not document the incident or inform the staff in the male-locked unit. Interviews with staff revealed that they were unaware of the incident and had not been given specific instructions regarding the male resident's behavior. The facility's policy requires all allegations of abuse, neglect, and exploitation to be reported and investigated. However, the ADM and DON did not perceive the incident as reportable or harmful, and thus did not take the necessary steps to address it. The lack of documentation and failure to follow protocol could place residents at risk for abuse and neglect, as the facility did not ensure a safe environment free from abuse as mandated by their policy.
Failure to Report Resident-to-Resident Inappropriate Behavior
Penalty
Summary
The facility failed to report an alleged incident of resident-to-resident inappropriate sexual activity to the appropriate authorities, as required by their abuse policy. The incident involved a male resident with dementia, major depressive disorder, and anxiety, who was witnessed kissing a female resident with dementia and chronic hepatitis C. The male resident had a moderately impaired cognitive status, while the female resident's cognition was severely impaired. The incident was not documented in the residents' progress notes, and the facility's Director of Nursing (DON) and Abuse Preventionist did not report the incident to the Health and Human Services Commission (HHSC) as mandated. The Activity Director, who witnessed the incident, separated the residents and explained to the male resident that such behavior was inappropriate due to potential health risks. Despite this, the incident was not documented, and the information was not communicated to the staff of the male-locked unit where the male resident resided. The Activity Director reported the incident to the DON and the Administrator (ADM) the same day it occurred, but neither took further action to report it to HHSC. The ADM and DON did not perceive the incident as serious or reportable, citing the lack of harm or intent and the residents' cognitive impairments as reasons for their inaction. Interviews with facility staff revealed a lack of consensus on the seriousness of the incident and whether it warranted reporting. The DON and ADM acknowledged their familiarity with the facility's abuse policy and the importance of reporting to HHSC but chose not to report the incident, believing it to be a minor issue. The facility's policy requires immediate reporting of any suspected abuse, neglect, or exploitation, but this protocol was not followed, potentially placing residents at risk for abuse and neglect.
Failure to Investigate and Document Resident-to-Resident Incident
Penalty
Summary
The facility failed to thoroughly investigate and document allegations of abuse, neglect, or mistreatment involving two residents. The incident in question involved a resident with moderately impaired cognition who kissed another resident with severely impaired cognition. The facility's Abuse Preventionist and Director of Nursing did not follow the facility's abuse policy, as they did not conduct a comprehensive investigation or document the incident appropriately. The incident was reported to the Director of Nursing by the Activity Director, but no specific date of occurrence was recorded, and the incident was not documented in the residents' progress notes. Interviews revealed that the Activity Director witnessed the incident and separated the residents, explaining to the male resident the potential health risks. However, the Activity Director did not document the incident in the progress notes and did not inform the staff in the male-locked unit. The Director of Nursing and the Administrator did not perceive the incident as abuse, neglect, or exploitation, and therefore did not conduct a thorough investigation or document it as required by the facility's policy. The Administrator and Director of Nursing both acknowledged their familiarity with the facility's abuse policy but failed to apply it in this situation. The facility's policy requires comprehensive investigations of all allegations of abuse, neglect, exploitation, and mistreatment, including resident-to-resident incidents. Despite this, the incident was not reported to the Health and Human Services Commission, and no witness statements were collected. The lack of documentation and investigation could potentially place residents at risk, as the facility did not take the necessary steps to prevent similar incidents from occurring in the future.
Failure to Supervise Resident Leads to Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident reviewed for elopement. The resident, who had a severe cognitive impairment and a history of neuroleptic induced parkinsonism, dementia, schizoaffective disorder, and other conditions, was not properly supervised while outside smoking. On the day of the incident, the resident was able to exit through a gate and leave the facility grounds when the gate was inadvertently left open due to ongoing repairs. The resident's care plan indicated a high risk for wandering and elopement, requiring direct supervision while smoking. However, on the day of the incident, the staff failed to provide the necessary supervision. The CNA responsible for the resident was called away to assist with another resident, leaving the resident unsupervised. The gate, which was supposed to be secure, was left disengaged due to a voltage issue being addressed by a repair company, allowing the resident to exit the facility. Interviews with staff revealed a lack of communication regarding the gate repairs and the need for direct supervision. The CNA involved was new and unaware of the gate's malfunction, and the staff had previously allowed the resident to smoke unsupervised, assuming the gate was secure. This oversight led to the resident's elopement, which was only discovered after the resident was found off-campus by a staff member.
Removal Plan
- Medical Director was notified of the elopement.
- All exit doors and gates were checked by the Administrator for proper alarming and functioning.
- Repair company was in the facility to assess power voltage.
- Repair company returned to the facility to continue assessment and repairs and repairs were completed.
- Staff were posted at the exit doors and gates until repair company completed all repairs.
- Elopement risk assessments were completed on all residents.
- Staff were in-serviced on elopement response protocol and smoking policy by DON/Designee.
- All staff not present will be in-serviced prior to their next scheduled shift by DON/Designee.
- An AD Hoc QAPI meeting was held with the medical director, facility Administrator, Director of Nurses, and Social Services Director to review the plan of correction.
- The facility will monitor exit and gates for functioning 5x per week for 4 weeks, and prn thereafter to identify any potential future failures.
- The DON/Designee will monitor resident smoke breaks for staff supervision 5x a week for 4 weeks and, then prn thereafter.
- The DON/Designee will monitor elopement risk assessments to ensure completion 5x per week for 4 weeks, then prn thereafter.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect, dignity, and care in a manner that promotes their quality of life. This deficiency was observed in four residents. For Resident #41, a CNA entered the room without knocking during wound care, which was confirmed by the resident who expressed that staff rarely knock before entering. Resident #41 has intact cognition and was bothered by this lack of privacy. Resident #9, who has severe cognitive impairment, was not provided full privacy during peri care as the CNA did not pull the privacy curtain completely, leaving the resident partially exposed. Similarly, Resident #231, who is cognitively intact, was left exposed during peri care when the door was left open by a CNA who went to get more wipes, failing to ensure the resident's privacy. Resident #26, who also has severe cognitive impairment, was observed multiple times over two days in his room with no clothes on, only wearing a brief and one sock, with the door open. This lack of privacy was noted by staff, who acknowledged the potential for residents to feel embarrassed or anxious due to these actions. The facility's policy mandates respect and dignity for residents, which was not upheld in these instances.
Failure to Provide Adequate Hydration
Penalty
Summary
The facility failed to ensure adequate fluid intake for five residents, leading to potential risks of dehydration and health decline. Observations revealed that residents were not provided with sufficient fluids, as evidenced by empty water pitchers and residents expressing thirst. For instance, Resident #26 was observed in the dining room stating he was thirsty, and Resident #49 had an empty pitcher and expressed a need for water on multiple occasions. The care plans for these residents indicated a potential for fluid deficit due to various medical conditions and medication use, such as diuretics. Despite these care plans, the facility did not consistently provide fluids or monitor hydration status effectively. Observations showed that hydration stations were not always set up, and staff were not proactive in offering fluids, as seen with Resident #67, who repeatedly had an empty pitcher and expressed thirst. Interviews with staff, including CNAs and the DON, highlighted a lack of consistent hydration rounds and delays in providing water. Staff mentioned being busy as a reason for not fulfilling hydration needs, and there were issues with the timely cleaning and refilling of water containers. The facility's policy on hydration was not adhered to, as it required regular hydration rounds and monitoring of fluid intake, which were not consistently performed.
Food Safety and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. Several deficiencies were noted, including improperly sealed food in the refrigerator, specifically a pack of King Hawaiian Rolls. Additionally, a bottle of Liquid Steel cleaning solution was found stored on top of the refrigerator, contrary to the facility's policy of storing cleaning supplies separately from food products. Kitchen equipment, such as the microwave and deep fryer, were found to be unclean, with dried substances on the microwave handle and buttons, and on the fryer basket and surrounding areas. Furthermore, bowls, plates, and pots were improperly stored right side up, which could lead to contamination. Interviews with the Dietary Manager (DM) revealed a lack of adherence to proper storage and cleaning protocols. The DM acknowledged responsibility for ensuring proper storage of food and chemicals, and admitted that the cleaning solution was likely left out from the night cleaning. The DM also noted that the microwave and deep fryer should have been cleaned after use, and expressed a lack of training on the correct storage orientation for kitchenware. The facility's administrator confirmed that all kitchen staff had been trained on cleanliness and storage protocols, yet the observed practices did not align with these standards. The facility's policies from 2012 emphasize maintaining clean and organized storage areas, and ensuring equipment sanitation, which were not followed in this instance.
Inadequate Hand Hygiene Practices Observed
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices observed among staff members. Specifically, CNA I did not use proper hand washing techniques before and after assisting Resident #9 with peri care. CNA I washed her hands for only 15 and 17 seconds, respectively, and used the same paper towel to turn off the faucet, which is against the facility's hand washing policy. Additionally, CNA I did not wash her hands or use hand sanitizer before gathering peri care supplies. Similarly, CNA E and CNA F were observed not adhering to proper hand hygiene protocols while providing peri care to Resident #231. CNA E failed to wash her hands before gathering supplies, and CNA F did not wash her hands for the recommended duration, using only six seconds of friction. Furthermore, CNA E put on a new pair of gloves without washing her hands or using hand sanitizer, and CNA F used the same paper towel to turn off the faucet after washing her hands. The residents involved in these observations, Resident #9 and Resident #231, both had conditions that made them vulnerable to infections. Resident #9, a female with severe cognitive impairment, was incontinent and at risk for pressure ulcers. Resident #231, a male who was cognitively intact, was occasionally incontinent and also at risk for pressure ulcers. The failure to follow proper hand hygiene practices could lead to cross-contamination and increased risk of infection for these residents.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to assist a resident, identified as Resident #47, in accessing necessary hearing services and devices. Resident #47, a male with severe cognitive impairment and multiple health conditions including dementia and sensorineural hearing loss, was not provided with adequate support to locate or replace his missing hearing aids. Despite having a care plan that acknowledged his hearing deficit and the need for hearing aids, staff were unaware of his requirement for these devices, leading to significant communication challenges for the resident. Interviews and observations revealed that staff, including CNAs and the Social Worker, were not informed about the resident's need for hearing aids. The resident expressed frustration and depression due to his inability to hear, which was exacerbated by the staff's lack of awareness and assistance. The Social Worker mentioned that the resident's hearing aids went missing shortly after his admission, and there was a delay in scheduling an appointment for replacement due to Medicaid policies. This lack of timely intervention left the resident struggling to hear, affecting his social interactions and overall quality of life. The facility's policy on sensory or perceptual alteration was not effectively implemented, as evidenced by the absence of an initial inventory list for the resident's belongings and the incomplete documentation in the resident's medical records. The Speech-Language Pathologist eventually found the hearing aids in the resident's room, but by then, the resident had already experienced significant distress. The deficiency highlights a breakdown in communication and procedural adherence within the facility, impacting the resident's ability to receive appropriate auditory support.
Failure to Implement Comprehensive Care Plan for Nail Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1, specifically regarding her need for nail care. Despite multiple observations and interviews, it was found that Resident #1's toenails were overgrown, thick, curved, ragged, chipped, uneven, cracked, and had a yellowish color. The toenails were causing discomfort and had reddened areas around the nail bed. The resident had expressed her desire to have her toenails trimmed, but the facility staff had not adequately addressed this need. Interviews with various staff members, including CNAs, RNs, and the DON, revealed a lack of communication and follow-through regarding Resident #1's nail care. CNA A mentioned that Resident #1's toenails had been long since March 2024, but she had stopped reporting it to the charge nurse. RN A and LVN A were unaware of the resident's need for nail care, and the DON confirmed that Resident #1 had not been scheduled to see a podiatrist since her admission. The facility's policy required CNAs to report the need for nail care to the charge nurse, who would then escalate it to the wound care nurse or social worker if necessary. However, this process was not followed. The facility's documentation, including the Weekly Skin Assessments and Progress Notes, did not reflect any refusal for nail care by Resident #1. The care plan for Resident #1 included interventions for her refusal of showers and changing clothes but did not address her nail care needs. The lack of a comprehensive care plan and failure to follow the facility's policy for nail care led to Resident #1's toenails becoming severely overgrown and causing her discomfort.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to ensure proper foot care for a resident, leading to discomfort and poor foot hygiene. The resident, who had multiple diagnoses including Alzheimer's Disease, major depressive disorder, and generalized anxiety disorder, had overgrown, thick, and cracked toenails that were causing her pain. Despite the resident's cooperation during an interview and observation, her toenails had not been trimmed for an extended period, and the issue was not adequately communicated among the staff members responsible for her care. Certified Nurse Aides (CNAs) and Registered Nurses (RNs) were aware of the resident's long toenails but failed to take appropriate action or inform the necessary personnel. The CNAs reported the issue to the charge nurse inconsistently, and the charge nurse did not follow up with the wound care nurse or social worker to ensure the resident was placed on the podiatrist's list. The resident had refused nail care on previous occasions, but there was no documentation of these refusals in her progress notes, and the interdisciplinary team did not update her care plan to address the ongoing issue. The facility's policy and procedure for nail and foot care were not followed, resulting in the resident's toenails becoming severely overgrown and infected. The Director of Nursing (DON) and other staff members were unaware of the resident's need for nail care until the surveyor's observation. The lack of communication and adherence to established protocols led to the resident's deteriorating foot condition, highlighting a significant deficiency in the facility's care practices.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 144 citations issued within 25 miles in the last 12 months — including the 10 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carillon Inc | 0.2 mi | ★★★★★ | 7 | 0 |
| The Plaza At Lubbock | 1 mi | ★★★★★ | 9 | 0 |
| The Mildred & Shirley L. Garrison Geriatric Educat | 1.7 mi | ★★★★★ | 14 | 5 |
| Mi Casita Nursing And Rehabilitation Center | 1.8 mi | ★★★★★ | 15 | 0 |
| Mesquite Post Acute Care | 1.9 mi | ★★★★★ | 11 | 0 |
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