Parkview Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Big Spring, Texas.
- Location
- 3200 Parkway, Big Spring, Texas 79720
- CMS Provider Number
- 675462
- Inspections on file
- 27
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Parkview Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility did not ensure that residents and their representatives were invited to participate in care plan meetings, as required by policy. Several residents with varying levels of cognitive impairment and complex medical needs, as well as their family members, reported not being informed or involved in care planning. Documentation lacked evidence of invitations or attendance, and staff could not provide proof of communication regarding care plan meetings.
Twelve residents reported not having access to grievance forms, not knowing about the option to file grievances anonymously, and not being informed about the grievance process. Grievance forms were only available through the DON or AD, and the locked box intended for anonymous grievances was labeled for payments. The grievance procedure was not discussed in Resident Council meetings, and there was no established process for anonymous submissions.
Two residents with documented mental illness diagnoses did not receive accurate PASRR Level I assessments, resulting in the absence of required PASRR Level II evaluations. Both residents had active diagnoses of depression and PTSD, with one also having dementia, but their PASRR Level I forms were incorrectly marked as negative for mental illness. Facility staff confirmed the inaccuracies and the lack of a PASRR policy.
Staff failed to ensure hot foods, specifically tater tots from an outside source, were held and served at the required temperature, as food was placed on the steam table below 135°F and served without verifying temperatures, despite staff training and facility policy requiring hot food to be held at or above 140°F.
A resident with severe cognitive impairment and multiple diagnoses had PRN orders for Lorazepam without a required 14-day stop date or documented justification for extension. Facility staff, including the DON and QA Nurse, confirmed the oversight and indicated that the orders remained active without proper review or discontinuation, contrary to facility policy.
A resident with gastroparesis did not receive metoclopramide as ordered before meals; instead, the medication was administered after breakfast, outside the facility's required time window. The medication aide reported being unable to give the medication before meals due to her schedule, and the DON confirmed the timing did not meet policy requirements.
A CNA failed to change gloves and perform hand hygiene during incontinence care for a resident with multiple chronic conditions, handling clean linen after cleaning the resident without following infection control protocols as required by facility policy.
A LTC facility failed to implement effective abuse prevention policies, resulting in the mishandling of an alleged abuse incident involving a resident with dementia. The resident reported being hurt by an LVN, but the facility did not document or report the incident to the State Agency. The ADM and DON reviewed video footage and concluded no abuse occurred, but did not follow policy to report all allegations. Staff interviews revealed inconsistencies in handling the incident, highlighting deficiencies in the facility's abuse prevention procedures.
A resident with dementia and a pacemaker was allegedly bumped by an LVN, leading to chest pain and swelling near the pacemaker. Despite the resident's distress and a CNA's report, the facility administrator did not report the incident to HHSC, believing it was not abuse. The administrator reviewed video footage and concluded there was no intentional harm, failing to notify the resident's family or implement protective measures.
A resident with severe cognitive impairment and a history of psychotic disorders was subjected to care by a CNA and a nurse aide despite her resistance and combative behavior. The staff failed to follow protocols for handling combative residents, resulting in the resident sustaining a small skin tear and bruising. The facility's policy required stopping care and notifying the charge nurse, but this was not adhered to, leading to the incident being reported to Health and Human Services.
A resident with dementia and severe cognitive impairment displayed combative behavior during a shower, but staff continued with the care, resulting in physical injuries. The care plan did not address the resident's behavior during showers, and staff failed to follow procedures to stop care and notify a charge nurse. The facility's policies for managing behaviors and care plans were not adequately followed, leading to a deficiency in care.
The facility failed to adhere to professional standards for food service safety, with multiple violations observed during a kitchen tour. Issues included improper food storage, unclean surfaces, expired food items, and staff not wearing hair restraints. Both the Dietary Manager and Administrator acknowledged these issues, which could place residents at risk for foodborne illness.
The facility failed to ensure chemicals were not accessible to residents and were not stored with resident toiletries in two common resident baths and one hall. Surveyors observed chemicals like Fabulosa and Mean Green Cleaner stored alongside resident items, and a housekeeping cart with accessible chemicals was left unattended. Staff interviews revealed a lack of adherence to proper chemical storage protocols and a need for staff education on safe practices.
The facility failed to maintain an infection control program as two CNAs did not follow proper hand hygiene protocols during incontinence care for two residents with severe cognitive impairment, increasing the risk of infection and cross-contamination.
The facility failed to address and resolve grievances for a resident with a history of depression and anxiety. The resident reported multiple issues, including a CNA not offering hydration and changing the resident's preferred shower time. Despite these complaints, the facility did not investigate or document the grievances properly, nor did they provide the resident with written decisions or follow-ups as required by their policy.
The facility failed to implement their abuse prevention policies, resulting in a resident being physically and verbally abused by a CNA. Despite being notified, the Administrator did not reassign the CNA to non-patient care duties, and staff members did not report the abuse, believing no action would be taken.
The facility failed to ensure a safe environment and adequate supervision for residents requiring mechanical lift transfers. Staff frequently transferred residents alone, leading to near-fall incidents due to improper use of the lift and sling. The administration and staff were unaware of the proper procedures and did not have clear policies or training in place.
Failure to Involve Residents and Representatives in Care Plan Development
Penalty
Summary
The facility failed to ensure that care plans were developed in consultation with residents and their representatives for four out of six residents reviewed. Specifically, there was no evidence that residents or their family members were invited to participate in care plan meetings. Documentation for care plan meetings was incomplete, lacking information on the date, time, attendees, and invitations for the meetings. Residents and their family members reported not being aware of or involved in care plan meetings, and some were unfamiliar with the concept of a care plan meeting altogether. For example, one resident with paraplegia and multiple medical conditions, who was cognitively intact, stated he had not been invited to a care plan meeting and was unaware of such meetings. His family member also confirmed not being involved or informed about care planning, despite recent acute health events. Another resident with moderate cognitive impairment and complex medical needs, as well as her family member, reported not being informed or involved in care plan meetings, with the family member expressing a desire to participate. Additional residents with moderate cognitive impairment and significant medical diagnoses, including those requiring oxygen therapy and those with Parkinson's disease, also indicated they had not participated in or been informed about care plan meetings. Staff interviews confirmed that care plan meetings were the responsibility of the MDS Coordinator, who stated that invitations were sent via mail or email but could not provide evidence of such communication. The facility's policy required that residents and their representatives be invited to care plan meetings at least quarterly, but there was no documentation to support that this occurred.
Failure to Provide Access and Information on Grievance Procedures
Penalty
Summary
The facility failed to provide residents and their representatives with information regarding their rights to file grievances, including the process for submitting grievances anonymously. During a Resident Council meeting, 12 out of 22 residents reported they did not have access to grievance forms, were unaware of the option to file grievances anonymously, and did not know where or how to submit an anonymous grievance. These residents, all of whom had resided in the facility for over six months, stated that grievance forms were only available by requesting them from the Activities Director (AD), and that the AD typically completed the forms during council meetings when complaints were voiced. The grievance procedure had not been discussed in Resident Council meetings. A review of the facility's grievance policy confirmed that anonymous grievances could be submitted in a locked box on hall 3. However, surveyor observation revealed that the box was labeled for payments and not for grievances, and grievance forms were not available in the hallways. The Director of Nursing (DON), who served as the Grievance Officer, stated that grievance forms were kept in her office and with the AD, and that staff typically completed the forms for residents. The DON also acknowledged there was no established procedure for residents to submit grievances anonymously and was unaware that the grievance process was not being discussed in Resident Council meetings.
Failure to Complete Accurate PASRR Level I Assessments for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that all residents with mental illness diagnoses received accurate Pre-admission Screening and Resident Review (PASRR) Level I assessments, resulting in two residents not being properly identified for further PASRR Level II evaluation. Both residents had documented diagnoses of major depressive disorder and post-traumatic stress disorder (PTSD), with one also having dementia. Despite these diagnoses, their PASRR Level I forms incorrectly indicated that they did not have a mental illness. For one resident, medical records showed active diagnoses of depression and PTSD, moderate cognitive impairment, and ongoing treatment with Sertraline for depression. The care plan included interventions for mood problems related to depression, dementia, and PTSD. However, the PASRR Level I form for this resident was marked as negative for mental illness, and no PASRR Level II evaluation was conducted. The second resident also had active diagnoses of major depressive disorder and PTSD, was cognitively intact, and was prescribed Buspirone for anxiety. The care plan included referrals to mental health authorities and therapy. Despite these documented mental health conditions, the PASRR Level I form was marked negative for mental illness, and no PASRR Level II evaluation was completed. Interviews with facility staff confirmed the inaccuracies in the PASRR Level I assessments and the absence of a PASRR policy at the facility.
Failure to Maintain and Monitor Hot Food Holding Temperatures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during a lunch meal. Staff brought in hamburgers and tater tots from an outside source and placed them on the kitchen steam table. When temperatures were checked, the tater tots measured 129 degrees F, which is below the required holding temperature. The dietary manager acknowledged the low temperature and attempted to reheat the tater tots using the fryer. Despite this, staff proceeded to serve the tater tots from the dining room steam table without verifying the temperature of the food being served. Interviews with the dietary manager and another staff member revealed that food temperatures were not checked on the dining room steam table before serving, contrary to facility policy and staff training. Both staff members stated that food should be served at or above 140 degrees F, and acknowledged that the required temperature checks were not performed. The DON confirmed that maintaining proper food temperatures is necessary to prevent spoilage and ensure palatability, and that staff had been trained on these procedures. Facility policies reviewed also specified the required temperature range for hot food holding.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic medications were limited to 14 days unless the attending physician or prescribing practitioner documented the appropriateness of extending the order. A resident with severe cognitive impairment, anxiety disorder, Alzheimer's disease, diabetes, and major depressive disorder had multiple PRN orders for Lorazepam Oral Concentrate with indefinite end dates. These orders were not discontinued or reviewed for duration, and no documentation was provided to justify extending the PRN orders beyond 14 days. Interviews with the DON and QA Nurse confirmed that the PRN psychotropic medication orders lacked required stop dates and that staff were responsible for monitoring and auditing such orders. The QA Nurse acknowledged the oversight and indicated that the medication had not been discontinued because she was waiting for a response from the physician. The facility's policy required monthly reassessment of psychoactive medications, but this was not followed in the case of the resident.
Failure to Administer Metoclopramide as Ordered Before Meals
Penalty
Summary
A deficiency occurred when a resident with a history of gastroparesis, acute kidney failure, depression, anxiety, and hypertension did not receive her prescribed medication, metoclopramide, as ordered. The physician's order specified that metoclopramide 10 mg should be administered orally before meals. However, on the date in question, the medication was documented as given at 07:30 AM, but direct observation showed that the medication was actually administered at 08:45 AM, after the resident had already finished breakfast. The medication administration record, pharmacy label, and facility policy all indicated the medication should be given before meals and within one hour of the scheduled time. Interviews with the DON and the medication aide confirmed that the medication was not given at the correct time, with the aide stating she was unable to administer it before meals due to her medication pass schedule. The DON acknowledged that the medication was late and that all nursing staff had been trained on medication administration times. The facility's policy required medications to be given within one hour before or after the scheduled time, which was not followed in this instance.
Failure to Follow Infection Control Protocol During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident. The CNA did not change contaminated gloves or perform hand hygiene before handling clean linen after cleaning the resident, despite being trained to do so. This lapse was observed during incontinence care, where the CNA transitioned from a dirty to a clean task without changing gloves or washing hands, contrary to facility policy and infection control guidelines. The resident involved was a cognitively intact female with a history of chronic respiratory failure with hypoxia, end stage renal disease, and type 2 diabetes, and was frequently incontinent of bowel and bladder. The resident's care plan required peri-care after each incontinent episode. The facility's hand-washing policy specified hand hygiene after contact with body fluids or potentially contaminated items, which was not followed in this instance.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement effective abuse policies and procedures, which resulted in the mishandling of an alleged abuse incident involving a resident. The resident, who had a history of dementia and was severely cognitively impaired, reported being hurt by a staff member, LVN C. Despite the resident's complaint of chest pain and the presence of lumps near her pacemaker, the facility did not document the incident or report it to the State Agency as required by their policies. The incident was not properly investigated or documented by the facility. The ADM, who was responsible for coordinating the abuse prevention program, did not report the incident to the State Agency, believing there was no allegation of abuse. The ADM and DON reviewed video footage and concluded that there was no evidence of abuse, but they did not follow the facility's policy to report all allegations of abuse. Additionally, the ADM did not respond to text messages from LVN D, who assessed the resident and reported her findings, including the resident's pain and swelling. Interviews with staff revealed inconsistencies in the handling of the incident. CNA A reported the incident to the ADM, but the ADM did not take further action to protect the resident or investigate the allegations thoroughly. The facility's failure to report the incident and protect the resident during the investigation process was a significant deficiency in their abuse prevention policies and procedures.
Failure to Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident and a Licensed Vocational Nurse (LVN) to the Health and Human Services Commission (HHSC) within the required timeframe. The incident involved a resident with dementia and a pacemaker, who was allegedly bumped by an LVN while the LVN was pushing a wheelchair. The resident complained of chest pain and was observed to have two lumps near her pacemaker, which were tender to touch. Despite these observations, the facility administrator did not report the incident to HHSC, as she did not believe it constituted abuse. The administrator, who was responsible for coordinating the facility's abuse prevention program, was informed of the incident by a Certified Nursing Assistant (CNA) but did not take immediate action to report it. The administrator reviewed video footage of the incident and concluded that there was no evidence of abuse, as the LVN did not intentionally bump the resident. The administrator also did not notify the resident's family or implement protective measures, as she believed there was no allegation of abuse. Interviews with staff revealed that the resident was upset and in pain following the incident, and a Licensed Vocational Nurse (LVN) assessed the resident and administered pain medication. However, the administrator did not respond to the LVN's text messages regarding the resident's condition. The facility's policies require that all suspected or alleged incidents of abuse be reported to the appropriate state agencies, but this was not done in this case, leading to a deficiency in the facility's handling of the situation.
Failure to Prevent Abuse During Resident Care
Penalty
Summary
The facility failed to ensure a safe environment free from abuse for a resident who was combative during care. The resident, who had severe cognitive impairment and a history of psychotic disorders, was subjected to care by a CNA and a nurse aide despite her resistance and combative behavior. The resident was known to exhibit physical and verbal behavioral symptoms, and her care plan indicated she was at high risk for side effects and physical injury due to psychotropic medications. On the day of the incident, the resident was agitated and refused to go to the shower, but the staff continued with the showering process, during which the resident was combative and attempted to hit and bite the staff. The staff involved, CNA A and NA B, did not follow the facility's protocol for handling combative residents, which required stopping care and notifying the charge nurse. Instead, they continued with the shower, restraining the resident's arms to complete the task. This resulted in the resident sustaining a small skin tear and bruising on her hands and forearms. The facility's policy emphasized preventing abuse and required staff to stop care when a resident becomes combative, but this was not adhered to in this case. Interviews with staff and family members revealed that the resident's family had requested to be notified if the resident became combative, but this was not done until after the shower was completed. The facility's failure to follow its own policies and the resident's care plan led to the incident, which was later reported to Health and Human Services. The staff involved were aware of the protocols but did not implement them, resulting in the resident's distress and physical harm.
Deficiency in Dementia Care for a Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, leading to a deficiency in care. The resident, who had severe cognitive impairment and a history of psychotic disorders, displayed combative behavior during a shower. Despite the resident's resistance and agitation, staff continued with the shower, resulting in physical injuries such as a skin tear and bruising. The resident's care plan was not updated to address her combative behavior during showers, and staff did not follow procedures to stop care when the resident became combative. The incident involved a resident who was admitted with diagnoses including Alzheimer's disease and unspecified psychosis. The resident had a history of aggressive behavior, which was documented in her care plan. However, the care plan lacked specific interventions for managing her behavior during showers. On the day of the incident, the resident was combative, swinging her arms and attempting to hit staff. Despite this, the staff proceeded with the shower, and the resident sustained injuries, including a skin tear and swelling in her fingers. Interviews with staff revealed that they were aware of the resident's combative behavior but did not follow the facility's policy to stop care and notify a charge nurse. The staff involved did not use the call light to request assistance, and the resident's family member, who had requested to be notified in such situations, was not called until after the shower was completed. The facility's policies and procedures for managing behaviors and care plans were not adequately followed, contributing to the deficiency in care.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen tour, surveyors observed multiple violations, including gummy buildup on the fryer, cooked breakfast food stored on top of raw bacon in a stained box, rusted and soiled surfaces, and wet drinking glasses stacked improperly. Additionally, containers of juice and shakes were stored in undrained ice, and dented cans of food were found in the storage area. Expired food items, such as cottage cheese labeled 'Best by 4/29/24,' were also found in the walk-in refrigerator, which had rusted racks and a soiled floor with food debris. The upright dicer had dried food on the blades, and a rear kitchen table had a rusty lower shelf where food equipment was stored. Staff were observed entering the kitchen without hair restraints, handling food items improperly, and storing health shakes in undrained ice. The Dietary Manager admitted to being aware of some of these practices, such as storing cooked food on top of raw food and the use of undrained ice for drinks, but stated that the department was short-staffed and that she tried to do daily rounds. The Administrator was not aware of the issue with containers of cooked foods stored directly on top of containers of raw foods and believed that staff could go by the wall without hair restraints. Both the Dietary Manager and Administrator acknowledged that these issues could place residents at risk for foodborne illness. Record reviews revealed that an in-service training was conducted on 4/11/24, covering topics such as wearing hairnets, cleaning schedules, labeling and dating food items, and cleaning up spills immediately. However, the Dietary Manager admitted that the dietary issues occurred due to staff not knowing or being aware of proper procedures. The facility's current policy on sanitation and food handling outlined the responsibilities of the Food Service Director, but the observed deficiencies indicated a lack of adherence to these procedures, potentially compromising the safety and well-being of the residents.
Improper Chemical Storage in Resident Areas
Penalty
Summary
The facility failed to ensure that chemicals were not accessible to residents and were not stored with resident toiletries and personal items in two of four common resident baths and one of four halls. On multiple occasions, surveyors observed chemicals such as Fabulosa, Mean Green Super Strength Cleaner and Degreaser, Diversity Crew Clean Toilet Bowl Cleaner, and aerosol cans stored alongside resident use items like toilet tissue, hair conditioner, and body wash. These chemicals were found in unlocked cabinets in the 200 and 400 hall baths, posing a risk of chemical exposure to residents. Additionally, a housekeeping cart with accessible chemicals was left unattended in hall 400, further increasing the risk of resident exposure to hazardous substances. Housekeeper A admitted to leaving the cart unattended and acknowledged the potential harm to residents if they came into contact with the chemicals. CNA B also confirmed that cleaners were typically stored on the bottom shelf of the cabinet, mixed with resident toiletries, which could lead to accidental misuse. Interviews with LVN A, the Housekeeping Supervisor, the DON, and the Administrator revealed a lack of adherence to proper chemical storage protocols and a need for staff education on safe chemical storage practices. The facility's policy on storage areas emphasized the importance of maintaining a clean and safe environment, but the observed practices did not align with these guidelines. The report highlights the potential for resident harm due to the improper storage of chemicals and the need for improved oversight and staff training to prevent such incidents in the future.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases. Specifically, two CNAs did not follow proper hand hygiene protocols during incontinence care for two residents. CNA C did not wash her hands or use alcohol-based hand sanitizer before donning clean gloves after removing dirty gloves while providing incontinence care for a resident with severe cognitive impairment and a history of urinary and bowel incontinence. Similarly, CNA D did not wash her hands or use alcohol-based hand sanitizer between glove changes while providing incontinence care for another resident with severe cognitive impairment and an indwelling catheter, increasing the risk of infection and cross-contamination. During the observations, CNA C and CNA D were seen removing dirty briefs, cleaning the residents' peri areas, and changing gloves without performing hand hygiene. CNA D acknowledged that she was trained to wash her hands before and after resident care, after handling soiled items, and between glove changes, but failed to do so during the observed care. The ADM and DON confirmed that staff are trained on hand hygiene upon hire, annually, and as needed, and that improper handwashing could lead to the spread of infection. However, they were not aware of the specific instances of non-compliance observed during the survey. The facility's policies on infection prevention and control, as well as handwashing guidelines, emphasize the importance of hand hygiene, including the use of alcohol-based hand rubs and soap and water. The CDC guidelines also recommend using an alcohol-based hand sanitizer immediately after glove removal. Despite these policies and training, the observed failures in hand hygiene practices by CNA C and CNA D indicate a lapse in adherence to infection control protocols, potentially putting residents at risk for infection and cross-contamination.
Failure to Address and Resolve Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances in accordance with its policy for one resident. The resident, who was cognitively intact and had a history of major depressive disorder and anxiety, reported multiple grievances from February 2024 to April 2024. These grievances included issues such as a CNA not offering hydration, leaving the hall unattended, using the wrong lifting technique on the resident's roommate, and changing the resident's preferred shower time. Despite these complaints, the facility did not investigate or document the grievances properly, nor did they provide the resident with written decisions or follow-ups as required by their policy. The resident expressed feelings of neglect and frustration, stating that the staff made it difficult to live at the facility and that their concerns were not being addressed. The resident had communicated these issues to the administrator multiple times, both verbally and through text messages, but did not receive any formal acknowledgment or resolution. The administrator admitted to not following the formal grievance process, citing a personal relationship with the resident as the reason for handling the complaints informally. Interviews with the CNA and other staff members revealed a lack of awareness and communication regarding the resident's grievances. The CNA stated that they were unaware of any issues related to hydration and had not been addressed about the incidents. The administrator and DON also demonstrated a lack of understanding of the facility's grievance policy and failed to ensure that grievances were documented, investigated, and resolved promptly. This failure to follow the grievance policy had the potential to cause residents to feel helpless and diminish their quality of life.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. A confidential staff member knowingly failed to report allegations of abuse regarding a resident to the abuse coordinator after the resident reported that a CNA physically and verbally abused them. The resident stated that the CNA hit them on the head with a closed fist and called them derogatory names. Despite the resident's report, the staff member did not report the incident, believing that the facility administration would not take any action. The Administrator was notified by an HHSC worker about the abuse allegations but failed to reassign the CNA to duties that did not involve patient care. The CNA continued to work their entire shift, and the Administrator only instructed the CNA to avoid the resident who made the allegations. The Administrator admitted to being unaware of the specific requirements of the facility's abuse policy and stated that they would deal with the abuse allegation after the HHSC staff left the facility. Interviews with other staff members revealed that they were aware of the CNA's behavior but did not report it, either because they believed no action would be taken or because they were unsure of the reporting process. The Director of Nursing also stated that they had not received any complaints about the CNA and were unaware of any concerns from the resident. The facility's policies on reporting abuse, protecting residents during investigations, and reassigning staff accused of abuse were not followed, leading to a failure to protect the resident from further harm.
Failure to Ensure Safe Mechanical Lift Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and adequate supervision for residents requiring mechanical lift transfers. Observations, interviews, and record reviews revealed that staff frequently transferred residents alone using a mechanical lift, which required two people for safety. This practice was confirmed by multiple confidential interviews and by the residents themselves, who reported near-fall incidents due to improper use of the lift and sling. Resident #2, a male with Parkinson's disease and seizure disorder, reported that staff often transferred him alone using the mechanical lift, and he nearly fell out of the lift two months prior due to a loose sling strap. Similarly, Resident #3, a female with Parkinson's disease and anxiety, confirmed that staff sometimes transferred her alone, and she had almost fallen out of the lift because the sling strap was not secured properly. Observations of staff using the lift revealed that they did not examine the sling prior to operation nor did they lock the wheels during the transfer. Interviews with the facility's administration and staff indicated a lack of awareness and inconsistent practices regarding the use of the mechanical lift. The Administrator (ADM) and Director of Nursing (DON) were unaware that staff were using the lift alone and did not have clear policies or training in place to ensure the use of two staff members for safety. The MDS Coordinator acknowledged that two staff should be used for safety but admitted that staff were not trained accordingly. The facility's policy and the Hoyer lift manual both emphasized the need for proper assessment and the potential requirement for two staff members during transfers, which was not consistently followed in practice.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
