Vidor Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Vidor, Texas.
- Location
- 470 Moore Dr, Vidor, Texas 77662
- CMS Provider Number
- 676108
- Inspections on file
- 35
- Latest survey
- April 20, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Vidor Health & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that kitchen staff failed to properly clean and maintain a deep fryer, which contained food particles and blackish brown cooking oil, and staff acknowledged the fryer should have been cleaned earlier and that no new cooking oil had been obtained or reported to the DM. The facility’s written dietary policies required that work surfaces, utensils, and large equipment be thoroughly cleaned and sanitized after use, and that equipment be sanitized with appropriate chemical solutions, but the condition of the deep fryer and staff statements showed these procedures were not followed.
A resident with a regular diet order and medical conditions including high blood sugar and a weak heart did not receive the ordered breakfast sausage with his meal after requesting meat such as bacon or sausage. A dietary staff member prepared the breakfast tray without using the resident’s tray card and later acknowledged that this caused the omission of meat, while the DM confirmed that residents are expected to receive items listed on their tray cards, consistent with facility dietary policies.
A resident with anoxic brain injury and epilepsy was maintained on phenytoin after a dose reduction ordered for a previously high level, with subsequent lab monitoring showing a subtherapeutic phenytoin level of 5.6 ug/ml. Nursing staff notified the NP about the abnormal level and documented "no new orders," but there was no evidence of further assessment, timely repeat labs, dose adjustment, or escalation to the attending physician or medical director, despite the care plan requiring monitoring and follow-up of subtherapeutic labs. The resident continued on the same phenytoin dose, later developed altered mental status and severe pain, and was transferred to the hospital, where he was diagnosed with status epilepticus and a very low/undetectable Dilantin level. Interviews with facility staff and family confirmed that the low level was recognized but not acted upon beyond NP notification, and that the abnormal lab was not effectively addressed in accordance with professional standards and facility policy for abnormal lab notification.
A resident with severe cognitive impairment alleged sexual abuse by another resident, but a CNA who overheard the allegation failed to report it to the appropriate facility leadership or state agency as required. The incident was not reported or investigated until surveyors intervened, resulting in a delay in protective measures and investigation.
Two staff members, an activity aide and a dietary aide, were found preparing food without current Texas Food Handler's Licenses. Personnel files lacked evidence of valid certifications, and interviews with the DM and Administrator confirmed the absence of current food handler credentials and a facility policy to ensure compliance. The facility's infection control policy required valid food handler cards, but this was not followed for these staff.
Surveyors identified multiple deficiencies in kitchen operations, including improper food storage with unlabeled, undated, and expired items, unsanitary conditions such as standing water and ice build-up in coolers, and inadequate cleaning of pots and pans. Additionally, several staff members failed to fully contain their hair with hairnets while preparing food, despite having received training on proper hygiene practices. These failures were confirmed by the Dietary Manager, Administrator, and Maintenance Supervisor during interviews.
The facility did not notify physicians when two residents experienced significant changes in condition: one resident had consistently high blood glucose levels without physician consultation or adjustment of insulin orders, and another had multiple instances of low heart rate resulting in held medication doses without physician notification or documentation. Staff interviews and facility policy confirmed that physician notification was required in these situations.
The facility did not maintain water temperatures at or below 110°F at hand sinks and a shower room, exposing several residents who required assistance with bathing and personal hygiene to water that exceeded the facility's documented standard. Although no residents reported burns or discomfort, and staff were aware of monitoring procedures, the absence of a written policy and inconsistent temperature control resulted in water temperatures above the recommended range.
A resident with multiple respiratory conditions and severely impaired cognition was diagnosed with pneumonia and prescribed antibiotics, but the care plan was not updated to address the new diagnosis or treatment. The DON, responsible for care plan updates, did not revise the plan after the previous Infection Control Nurse left, resulting in the omission of pneumonia-specific interventions.
Expired over-the-counter medications, including antacids, laxatives, supplements, and vitamins, were found in the main medication storage room after their expiration dates. An LVN discovered 11 unopened bottles during an observation, and staff interviews revealed that the Medical Records Clerk was responsible for removing expired stock, with the Pharmacy Consultant as backup. The process for checking and organizing medications failed to prevent expired items from remaining in stock, and the most recent pharmacy review did not include the medication supply room.
Staff failed to accurately document and obtain daily vital signs for a resident with dementia, hypertension, and diabetes. Instead, identical vital sign readings were repeatedly entered into the MAR over several days, with staff and leadership confirming that actual assessments were not performed and previous values were copied or reused.
A wound care nurse failed to perform proper hand hygiene and change gloves during wound care for two residents with open wounds, resulting in contamination of clean fields and supplies. Despite being trained and aware of infection control protocols, the nurse did not follow required procedures, as confirmed by both the nurse and the DON. Facility policy mandates hand hygiene and glove changes during such care, but these were not adhered to during the observed incidents.
Surveyors found that the kitchen floors, including areas under the hand sink and behind the stove, had significant dust, grime, and food particle buildup. The Dietary Manager confirmed that deep cleaning had not yet been completed, and facility records showed that such cleaning should occur biweekly.
Two residents with significant physical and cognitive impairments did not receive scheduled bed baths as required by their care plans. Documentation and interviews confirmed that multiple scheduled baths were missed due to staffing shortages, despite both residents being unable to perform bathing independently and having no behaviors of care rejection that would prevent staff from providing assistance.
A resident with multiple chronic conditions did not receive her preferred breakfast sandwich with egg, bacon, and cheese as documented on her meal ticket, resulting in her not eating breakfast when her preferences were not met. The dietary manager confirmed the omission of the egg substitute, and the issue had occurred multiple times previously despite facility procedures to accommodate food preferences.
The facility failed to address grievances raised during residents' council meetings over three months. Complaints included staff using personal phones, untimely call light responses, and issues with food and bed making. Staff interviews revealed a lack of awareness and communication regarding grievance responsibilities, and residents reported dissatisfaction with the facility's handling of complaints.
The facility failed to provide palatable and attractive meals, serving cold and unappetizing food on disposable foam plates, contrary to policy. Staff used foam dishes to avoid using the dishwasher due to high kitchen temperatures, without informing management. Residents reported consistently cold meals, leading to potential decreased food intake.
A resident with multiple health conditions did not receive a scheduled shower, as required by her care plan, due to staff running out of time and failing to notify the charge nurse. The resident, at high risk for skin issues, reported not receiving a shower until three days later. The facility's policy highlights the importance of regular bathing for skin integrity and infection prevention.
A facility failed to ensure safe electrical outlet use in a resident's room, where a 6-outlet adapter powered multiple devices, risking circuit overload. The resident expressed concern about sparks, and the administrator was unaware of the non-compliance, attributing responsibility to the previous maintenance supervisor.
The facility failed to report abuse allegations in a timely manner, including a verbal abuse incident involving a resident and an LVN, and two separate incidents involving residents. The delays in reporting to the Abuse Coordinator and the State Agency could have placed residents at risk of continued abuse.
A facility failed to investigate and report a verbal abuse allegation involving a resident with Alzheimer's disease. A CNA reported that an LVN verbally abused the resident, but the incident was not communicated to the Administrator or the state promptly. The LVN continued working the next day, failing to protect the resident from potential further abuse. The delay in reporting and investigation placed residents at risk of undetected abuse.
A resident with severe cognitive impairment and specific care needs fell from the bed during a treatment due to inadequate supervision. The LVN, unaware of the requirement for two staff members for bed mobility, attempted the procedure alone, resulting in the resident sustaining injuries. The incident highlighted a failure in adhering to the care plan and facility policies.
The facility failed to designate a qualified infection preventionist with specialized training, as the current Infection Preventionist (LVN IC) had not completed the necessary training. The DON and Regional Compliance Nurse acknowledged the lack of training, which posed a risk to the facility's infection surveillance capabilities. The previous infection preventionist had completed the training but resigned months ago.
The facility failed to employ a qualified dietary manager, as the designated Dietary Supervisor did not have the necessary certification. Despite being appointed in June 2023, the Dietary Supervisor was still in school and expected to complete the certification by September 2024. This non-compliance was confirmed through interviews and record reviews.
The facility failed to provide a functioning call light system for residents in multiple halls, leading to the use of alternative methods like whistles and bells for calling assistance. Staff made frequent rounds to monitor residents, especially those with cognitive impairments, while the facility awaited repairs.
The facility failed to ensure proper storage and security of medications in two medication carts and one medication room, including expired medications and a non-affixed lock box for controlled drugs in the refrigerator. Staff interviews confirmed the lapses in following facility policies and procedures.
The facility failed to ensure that a dietary staff member had a current Food Handler's Certificate while working in the kitchen. This deficiency was confirmed through record review and interviews with the Administrator and Regional HR, who acknowledged the facility's responsibility to maintain such certificates to prevent foodborne illness.
The facility failed to maintain an infection prevention and control program. An LVN did not wash or sanitize her hands when entering a resident's room and between glove changes during medication administration. Additionally, two LVNs did not clean the glucometer device according to the required contact time of the disinfectant before and after use on three residents.
The facility failed to ensure resident privacy during incontinent care when two CNAs did not pull the privacy curtain, exposing a resident with severe cognitive impairment to her roommate. Both CNAs admitted to forgetting the procedure, despite being trained to provide privacy.
The facility failed to ensure comprehensive care plans were reviewed and revised for two residents. One resident's care plan did not address the need for a fire-resistant smoking apron, and another resident's care plan did not include the diagnosis related to an indwelling urinary catheter. These oversights were acknowledged by various staff members, including the MDS Nurse, SW, DON, and Administrator.
The facility failed to provide appropriate respiratory care for two residents. One resident received oxygen therapy without physician orders, and another received an incorrect oxygen dose. Both issues were confirmed by an LPN and the DON.
The facility failed to ensure proper medication administration for two residents. One resident did not have their g-tube placement checked before medication administration, and another received the wrong type of insulin. These deficiencies were observed and confirmed through interviews and record reviews.
Improper Cleaning and Maintenance of Deep Fryer and Cooking Oil
Penalty
Summary
Surveyors identified a deficiency in dietary services related to improper storage, preparation, and sanitation of cooking equipment in the kitchen. During an observation and interview, the deep fryer was noted to contain food particles and blackish brown cooking oil. A staff member (identified as [NAME] A) stated the deep fryer should have been cleaned the previous week and acknowledged that there was no new cooking oil available, further admitting he had not reported the need for cooking oil to the Dietary Manager (DM). The DM stated that the deep fryer should be kept clean to prevent foodborne illnesses. Review of the facility’s 2012 Dietary Services Policy & Procedure Manual showed requirements that work surfaces be kept neat and clean during preparation and service, that all utensils, pots, and pans be properly washed and sanitized after use, that all work areas be thoroughly cleaned and sanitized after use, and that large equipment be sanitized with a chemical sanitizing solution at least twice the minimum strength needed for immersion sanitizing. The observed condition of the deep fryer and the staff’s statements demonstrated noncompliance with these written policies. No specific residents or their medical histories were mentioned in the report, but the deficiency pertained to the kitchen that provides food and beverages to residents.
Failure to Follow Tray Card Resulting in Omission of Ordered Breakfast Protein
Penalty
Summary
The deficiency involves the facility’s failure to provide a nourishing, palatable, well‑balanced diet that met a resident’s daily nutritional and special dietary needs, including preferences, for one breakfast meal. Record review showed that the resident, who was admitted in April 2026 with diagnoses including high blood sugar, a weak heart, and uncontrollable worry, had a physician’s order for a regular diet. The resident reported in an interview that he did not receive any meat with his breakfast and had requested bacon or sausage. He stated this had happened before, though he could not recall how often or when, and said he had informed a staff member of his desire for meat but could not remember which staff member. In a separate interview, a dietary staff member stated that someone had requested meat for the resident that morning, but breakfast had already been put away. He acknowledged that he had prepared the resident’s breakfast tray without using the resident’s tray card and therefore did not provide meat. The Dietary Manager stated that residents should receive what is listed on their tray cards and provided the printed tray card for the resident, which indicated the resident was to receive breakfast sausage along with cereal, egg, and a biscuit. The facility’s Dietary Services Policy & Procedure Manual stated that diets are to be ordered and provided in accordance with the approved Diet Manual and that the department’s role is to serve attractive, appetizing, nourishing, high‑quality food to help keep residents healthy.
Failure to Follow Up on Subtherapeutic Phenytoin Level Leading to Status Epilepticus
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident’s choices, specifically related to management of an anti-seizure medication (phenytoin/Dilantin) and associated lab monitoring. The resident was an adult male with anoxic brain damage, epilepsy with status epilepticus, and severe cognitive impairment. His care plan identified a seizure disorder and directed staff to administer seizure medication as ordered, monitor and document side effects and effectiveness, monitor labs, report any subtherapeutic or toxic results to the physician, and obtain and follow up on lab/diagnostic work as ordered. The resident had an order for phenytoin, initially at 250 mg daily, with phenytoin levels to be checked every three months. After a critically high phenytoin level of 23.4, the physician decreased the dose from 250 mg to 200 mg daily and increased lab monitoring to every two months. A subsequent phenytoin lab result showed a level of 5.6 ug/ml, below the therapeutic range of 10.0–20.0 ug/ml. This low result was documented on the lab report and in the record, including a medication regimen review noting the low level and recommending a redraw and possible dose adjustment, with the physician checking a box agreeing with the recommendation. Progress notes indicated that the NP reviewed the resident’s BMP, CBC, and phenytoin labs and documented “no new orders” at that time. Despite the documented subtherapeutic phenytoin level of 5.6, there was no evidence in the record that nursing staff implemented additional assessments, obtained repeat labs in a timely manner, or followed up beyond notifying the NP. Interviews with the DON and nursing staff confirmed that the NP was contacted twice regarding the abnormal lab value and that no new orders were received, with no further escalation to the attending physician or medical director. The DON stated that the lab value was low but not critical and that it was beyond the nurse’s scope to question the NP’s response. The NP later stated she had missed the low level and that, given the resident’s seizure history and low level, she would normally have ordered a repeat lab and subsequent dose adjustment. The resident continued to receive 200 mg of phenytoin daily as documented on the MAR, and there was no documentation of seizure symptoms prior to his transfer to the hospital for screaming in severe pain, where he was diagnosed with status epilepticus and a subtherapeutic/undetectable Dilantin level. Interviews with family members indicated they were told by a hospital neurologist that the hospitalization and seizures were preventable and related to the decrease in medication and low phenytoin levels. The attending physician acknowledged that the first recheck level after the dose decrease was “5 something,” which he described as on the low side, and stated that the NP had missed the lab. He also stated he did not recall being notified of this specific lab value and that he would not “chase the numbers” in the absence of symptoms. Another physician interviewed stated that changes in phenytoin dosing or lab values should be followed by more frequent lab monitoring and that changes should not be based on old labs. The facility had a policy requiring physician notification of abnormal labs and documentation of such notifications and interventions, but there was no documentation that the low phenytoin level was escalated beyond the NP or that any clinical interventions or additional monitoring were implemented in response to the subtherapeutic result prior to the resident’s hospitalization. An Immediate Jeopardy (IJ) was identified related to this failure, based on the facility’s lack of follow-up after notifying the NP twice about the subtherapeutic phenytoin level and the absence of interventions or assessments in response to that abnormal lab value. The IJ was later removed, but the facility remained out of compliance at a lower severity level while it continued to monitor implementation and effectiveness of its corrective actions.
Removal Plan
- Transferred Resident #1 to the hospital for treatment of status epilepticus and subtherapeutic Dilantin level.
- Completed a 100% audit of anticonvulsant medications to ensure therapeutic lab values and communicated any abnormal findings to the attending physician.
- Notified the provider of an abnormal lab identified during the audit, awaited new orders, and monitored the resident for signs/symptoms of seizures.
- Provided 1:1 in-service to the DON and ADON by the Regional Compliance Nurse on provider notification of abnormal lab values, documentation of provider notification for changes in condition including abnormal labs, escalation process when the NP/attending does not address non-therapeutic labs, and abuse/neglect implications of failure to intervene on abnormal labs.
- Notified the Medical Director of the Immediate Jeopardy.
- Completed an ad hoc QAPI meeting with the interdisciplinary team including the Medical Director.
- Initiated facility-wide in-services for all charge nurses and ensured staff not present would not be permitted to work until in-serviced, new hires would be in-serviced during orientation, and agency staff would be in-serviced prior to working floor assignment, covering provider notification of abnormal labs, documentation of provider notification for changes in condition including abnormal labs, escalation process when the NP/attending does not address non-therapeutic labs, and abuse/neglect implications of failure to intervene on abnormal labs.
- Reviewed the facility-wide anticonvulsant audit, reviewed documentation of Resident #2’s follow-up to an abnormal lab, reviewed in-service documentation for the ADON/DON/all staff, and ensured any incomplete in-services would be completed before the staff member’s next shift.
- Conducted individual staff interviews across shifts/weekends/PRN to confirm staff understanding of training and reporting requirements for lab results including reporting to the DON, MD, and family.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required. Specifically, a resident with severe cognitive impairment and a history of dementia alleged that another resident touched her breast. This allegation was overheard by a CNA, who did not report the incident to the charge nurse, Administrator, or DON, despite having been trained to do so. The CNA admitted to overhearing the allegation one to two weeks prior but did not act, believing the resident was confused. The incident was not reported to the facility's abuse coordinator or to the state agency within the required timeframe. The deficiency was identified when a non-staff person relayed the resident's allegation to surveyors, prompting further investigation. Interviews confirmed that neither the Administrator nor the DON had been informed of the allegation until surveyor intervention. The facility's own policy required immediate reporting of abuse allegations, especially those involving serious bodily injury or abuse, within two hours. However, the required notifications and investigation were not initiated until the surveyors became involved. The residents involved both had severe cognitive impairment and were admitted to a secure unit due to elopement risk and dementia. The alleged perpetrator denied the incident, and the alleged victim was unable to provide specific details about when the event occurred or which staff were aware. The lack of timely reporting and investigation meant that no interventions were initiated to protect the resident or prevent further abuse until after the surveyor's discovery.
Failure to Ensure Dietary Staff Maintained Required Food Handler Certification
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, one activity aide and one dietary aide were found to be preparing food in the kitchen without having a current Texas Food Handler's License. Observations confirmed that the activity aide was preparing shredded cheese at the prep table, and record reviews of both aides' personnel files showed no evidence of current or prior food handler certifications at the time of review. Interviews with the Dietary Manager and Administrator confirmed that these staff members did not have current food handler certifications and that there was no facility policy in place to ensure compliance with food handler certification requirements. The Administrator acknowledged the importance of food handler certification for all staff involved in food preparation to ensure adherence to best practices, proper sanitation, and prevention of cross-contamination. The activity aide also confirmed that her certification was expired at the time she was preparing food and recognized the risk this posed to residents. The facility's infection control policy required valid food handler cards for dietary associates, but this was not followed for the staff in question.
Multiple Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as evidenced by multiple observations in the kitchen. Food items in Icebox #1 were found to be unlabeled, undated, unsealed, and in some cases, expired. Specific items included cantaloupe slices and pudding in unmarked containers, undated tomatoes, an opened and exposed bag of broccoli, and sliced tomatoes with visible spoilage. Additionally, the dry pantry contained expired juice containers, dented cans stored with non-dented cans, an unsealed bag of vanilla wafers, and an expired jar of horseradish. The Dietary Manager (DM) confirmed these findings and acknowledged that expired or spoiled foods had not been removed as required by facility policy. The facility also failed to maintain sanitary conditions in food storage and preparation areas. Icebox #2 had standing water on the floor, with cases of milk cartons sitting in the water, and unpackaged food present. The milk box cooler exhibited a significant ice build-up and accumulation of food crumbs and debris along the wall and rubber gasket. The DM and Maintenance Supervisor confirmed these conditions, with the Maintenance Supervisor attributing the issues to a clogged drain and a dirty rubber seal. Additionally, the storage area for pots and pans contained multiple items with baked-on black and brown residue, indicating inadequate cleaning practices. Staff hygiene and use of hair restraints were also deficient. Observations revealed that Activity Aide B, Dietary Aide G, and another dietary staff member were working in the kitchen with hairnets that did not fully contain their hair, leaving portions of hair exposed around the face and nape. Staff interviews confirmed that they had received training on proper hair restraint use, but were unaware that their hair was not fully covered. The DM and Administrator both acknowledged the importance of proper hair restraint to prevent contamination, and the DM stated it was her responsibility to ensure compliance with these standards.
Failure to Notify Physician of Changes in Condition and Medication Holds
Penalty
Summary
The facility failed to consult with physicians regarding significant changes in condition for two residents. For one resident with diabetes and severe cognitive impairment, blood glucose levels were consistently elevated on multiple dates, as documented in the medication administration record. Despite these abnormal readings, there was no evidence that the physician was notified or that sliding scale insulin was considered or ordered. Nursing staff and the DON confirmed that physician notification should have occurred for these abnormal results, and that an order for sliding scale insulin was needed to manage the resident's blood glucose levels. For another resident with congestive heart failure and hypertension, the medication Digox was held on several occasions due to low heart rates, as per physician orders. However, there was no documentation that the physician was consulted about the repeated low heart rates or the pattern of the medication being withheld. Staff interviews confirmed that the physician should have been notified and that such notifications should be documented in the resident's medical record. Facility policy also required physician notification when a dose of medication was not given.
Failure to Maintain Safe Water Temperatures for Resident Use
Penalty
Summary
The facility failed to maintain safe water temperatures at or below 110 degrees Fahrenheit at hand sinks and a shower room used by several residents. During observations, the Maintenance Supervisor measured water temperatures ranging from 111.3 to 115 degrees at the hand sinks in the rooms of three residents and in the shower room between two halls. These temperatures exceeded the facility's stated standard for water temperature, which was documented as 100 to 110 degrees in the water temperature logs. The Maintenance Supervisor acknowledged that water temperatures had been fluctuating and that a plumber had provided an estimate for a new mixing valve, but the issue persisted at the time of the survey. The residents involved had varying degrees of cognitive function and required substantial or maximal assistance for bathing and personal hygiene. None of the residents reported having been burned or experiencing discomfort from the water temperature, and no burns or pressure wounds were documented in their medical records. Staff interviewed were aware of the need to monitor water temperatures to prevent burns and stated they routinely checked water temperatures when assisting residents with grooming or showering. Despite these precautions, the facility did not have a written policy regarding water temperature, and the Administrator relied on external resources for guidance. Water temperature logs from earlier in the month showed compliance, but logs from the days of the survey indicated temperatures above the acceptable range. The lack of a consistent and documented approach to monitoring and maintaining safe water temperatures led to the deficiency, as residents were exposed to water temperatures above the recommended maximum.
Failure to Update Care Plan for New Pneumonia Diagnosis
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's recent diagnosis of pneumonia. The resident, an elderly female with a history of pleural effusion, chronic obstructive pulmonary disease, and severely impaired cognition, was admitted with multiple respiratory conditions and was dependent on continuous oxygen therapy. Despite a physician's order for Doxycycline to treat pneumonia and documentation of the resident's ongoing respiratory symptoms, the care plan was not updated to include interventions specific to the new pneumonia diagnosis or the antibiotic treatment. Interviews with facility staff revealed that the Director of Nursing (DON) was responsible for updating care plans for new infections but had not done so for this resident following the resignation of the previous Infection Control Nurse. The DON acknowledged being aware of the pneumonia diagnosis and the antibiotic order but did not revise the care plan, believing existing respiratory care plans were sufficient. The administrator confirmed that the omission occurred during the transition between staff roles. The facility's policy requires comprehensive care plans with measurable objectives and timeframes for all identified needs, but this was not followed in this case.
Expired Over-the-Counter Medications Found in Main Medication Storage Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals in the main medication storage room were labeled and stored in accordance with professional standards, specifically by allowing 11 unopened over-the-counter medication bottles to remain in stock past their expiration dates. During an observation, an LVN identified these expired medications, which included antacids, laxatives, supplements, and vitamins, all with expiration dates ranging from several months prior to the survey. The LVN explained that the process for organizing medications involved placing older stock in front, but acknowledged that expired items may have been overlooked or accessed out of order. Interviews with facility staff revealed that the Medical Records Clerk was responsible for ordering, stocking, and removing expired medications, with the Pharmacy Consultant serving as a backup. The DON confirmed this arrangement and stated that the expired medications were likely missed during routine checks. The Medical Records Clerk reported conducting monthly checks for expired medications, with the last check occurring the previous month, and noted that nurses were also expected to help identify and remove expired stock. The Pharmacy Consultant indicated that her inspections of the medication rooms were periodic and not comprehensive, with her most recent check of the medication carts occurring the previous month. The Executive Summary of the Consultant Pharmacist's Medication Regimen Review documented a medication cart audit but did not indicate a review of the medication supply room. Staff interviews consistently acknowledged the risk that expired medications could be administered to residents, potentially resulting in reduced effectiveness.
Failure to Accurately Document and Obtain Daily Vital Signs
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for one resident by not properly documenting daily vital signs as required by physician orders. Review of the resident's Medication Administration Record (MAR) for May 2025 revealed that staff repeatedly documented identical vital sign readings over consecutive days, rather than recording new measurements. Both the LVN and the DON confirmed during interviews that the vital signs were not being taken daily as ordered, and staff appeared to be copying previous entries or using an electronic record feature to repeat prior values instead of performing actual assessments. The resident involved had diagnoses including dementia, hypertension, and diabetes, and was severely cognitively impaired according to a recent assessment. Physician orders required daily vital signs to be obtained on the morning shift, and the care plan specified regular blood pressure monitoring. Despite these requirements, the MAR showed repeated, identical entries for vital signs over multiple days, indicating that staff did not follow proper procedures for assessment and documentation.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper wound care practices observed for two residents. For one resident, a 66-year-old male with diabetes, edema, kidney disease, and an arterial ulcer of the left great toe, the wound care nurse donned gloves and prepared a clean field but then contaminated the field by touching the resident's wound and subsequently retrieving clean supplies with the same gloves. The nurse placed used gauze and dirty gloves on the same surface as clean dressings and did not perform hand hygiene before donning new gloves and continuing care. For another resident, a female with a stage 4 pressure ulcer on the coccyx and a history of surgery, anxiety disorder, and kidney failure, the wound care nurse did not perform hand hygiene before starting care and failed to change gloves or wash hands at multiple points during the dressing change. The nurse removed a soiled dressing, handled clean supplies with contaminated gloves, and applied medication and a new dressing without appropriate hand hygiene or glove changes, thereby contaminating the clean field and supplies. Interviews with the wound care nurse confirmed awareness of the correct procedures, including the need for hand hygiene and glove changes, but acknowledged these steps were not followed during the observed care. The Director of Nursing, who also serves as the Infection Control Preventionist, stated that staff are expected to follow hand hygiene protocols and that training is provided during orientation and as needed. Facility policy also requires hand hygiene before and after dressing changes and after removing gloves.
Failure to Maintain Kitchen Floor Cleanliness
Penalty
Summary
Surveyors observed that the facility failed to maintain clean floors in the kitchen, specifically under the hand washing sink, juice area, and behind the stove. There was a buildup of dust, grime, and food particles along the floor under the hand sink area, which extended the length of the wall, and behind the stove, which extended approximately six inches from the baseboard. The Dietary Manager acknowledged that she had not yet had the opportunity to deep clean the floors and confirmed that the kitchen should not have grime or buildup to prevent contamination of food. The Administrator also stated a desire for the kitchen to be clean. Review of the facility's deep clean list indicated that cleaning under sinks and scrubbing floors with a floor machine should occur every two weeks.
Failure to Provide Scheduled Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing, to two residents who were unable to perform these tasks independently. One resident, a female with diagnoses including cardiomegaly, dementia with behavioral disturbance, morbid obesity, urogenital candidiasis, and rheumatoid arthritis, required substantial to maximal assistance for bathing and had no behaviors of care rejection. Her care plan specified a bed bath on Monday, Wednesday, and Friday with one staff assist. However, CNA flowsheets and resident interviews confirmed that scheduled bed baths were missed on multiple occasions, with only one bath documented over a one-week period. Staffing shortages were cited by CNAs as a reason for not completing all scheduled baths. Another resident, also a female with heart disease, dementia, morbid obesity, schizophrenia, and heart failure, required moderate assistance from two staff for bathing and was noted to be occasionally resistive to care. Her care plan included strategies for negotiating ADL times and re-approaching if she was initially resistive. Despite this, CNA documentation and resident interviews indicated that scheduled bed baths were not consistently provided, with only two baths given in a week and several missed on scheduled days. The DON acknowledged staffing challenges and the impact on the ability to provide scheduled baths, while the administrator confirmed the expectation that residents receive their scheduled hygiene care.
Failure to Provide Resident with Preferred Breakfast Items
Penalty
Summary
A deficiency occurred when the facility failed to provide food that accommodated a resident's stated preferences. Specifically, a resident with diagnoses including cardiomegaly, dementia with behavioral disturbance, morbid obesity, urogenital candidiasis, and rheumatoid arthritis, who was on a regular diet, did not receive a breakfast sandwich with egg, bacon, and cheese as requested and documented on her meal ticket. During breakfast service, the resident received a sandwich without egg, which she reported had happened one to two times per week previously. The resident stated that when her breakfast was not prepared as requested, she would not eat breakfast. The dietary manager confirmed that the omission was due to forgetting the egg substitute, which was used in place of real eggs due to supply issues. The resident's care plan included offering the diet as ordered and updating food preferences as needed. The facility's meal service policy required dietary staff to interview residents about food preferences upon admission and periodically thereafter, and to serve breakfast to order. Despite these procedures, the resident's preferences were not consistently met.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances over a three-month period. During this time, grievances voiced during residents' council meetings were not thoroughly investigated or addressed. Specific complaints included staff using personal phones while providing care, call lights not being answered timely, lack of fresh water and evening snacks, untimely bed making, food not matching meal tickets, cold food, incorrect meals, and irregular provision of clean bedsheets. Despite these issues being raised in meetings, no grievances were documented or addressed in the facility's records for the months reviewed. Interviews with staff revealed a lack of awareness and communication regarding the grievance process. The Social Worker (SW) was unaware of any unaddressed grievances and did not know she was responsible for writing up or addressing grievances from the residents' council meetings. Similarly, the Activity Director did not document grievances from the meetings and only emailed the minutes to the Administrator, without informing the SW. The Administrator admitted to not reviewing the residents' council minutes to ensure complaints were addressed, attributing the oversight to the SW being new and possibly unaware of her responsibilities. Residents expressed dissatisfaction with the facility's handling of grievances, stating that complaints were not addressed and that issues such as cold and unappetizing food, particularly on weekends, persisted. The facility's grievance policy mandates that residents have the right to voice grievances without fear of reprisal and that the facility must make prompt efforts to resolve them. However, the facility did not adhere to this policy, as evidenced by the lack of documented grievances and unresolved complaints from the residents' council meetings.
Deficiency in Food Palatability and Presentation
Penalty
Summary
The facility failed to provide palatable and attractive food for residents, as evidenced by observations, interviews, and record reviews. Over a period from December 19, 2024, to February 8, 2025, meals were consistently served cold and unappetizing, often on disposable foam plates and bowls, contrary to the facility's policy. Photos and interviews revealed meals such as cold grilled cheese sandwiches, flavorless tuna on unbuttered bread, and cold, unseasoned meat, all served in disposable foam containers. These meals were described as lacking flavor and being served at inappropriate temperatures, which could lead to decreased food intake and potential weight loss among residents. Interviews with staff and residents confirmed the issues with meal temperatures and presentation. Dietary staff admitted to using disposable foam dishes to avoid using the dishwasher due to high kitchen temperatures, without informing management of the air conditioning issues. Residents consistently reported that food served on disposable foam was always cold. The facility's policy stated that meals should be served on regular dining plates and bowls with warmer covers to maintain proper temperatures, but this was not adhered to, leading to the deficiencies noted in the report.
Failure to Provide Scheduled Bathing Services
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received necessary services to maintain good hygiene. Specifically, the resident did not receive a scheduled shower or bath on February 7, 2025, as per her care plan, which required assistance from one staff member. The resident, who had multiple diagnoses including cardiomegaly, dementia, morbid obesity, and rheumatoid arthritis, was at high risk for skin issues due to her impaired mobility and co-morbid conditions. The resident reported not receiving a shower until February 10, 2025, and expressed concern about her skin breaking out due to missed showers. Interviews with staff revealed that the CNA responsible for the resident's care on February 7, 2025, ran out of time and did not complete the shower, failing to notify the charge nurse or the Director of Nursing (DON). The subsequent shift also did not complete the shower, and the charge nurse was not informed. The DON confirmed that it was the facility's expectation for residents to receive showers as scheduled and acknowledged the risk of skin breakdown and infections when showers are missed. The facility's policy emphasized the importance of regular bathing for maintaining skin integrity and preventing infections.
Improper Use of Electrical Outlets in Resident Room
Penalty
Summary
The facility failed to ensure the safe use of electrical outlets in a resident's room, leading to a potential risk of overloading the electrical circuit. Observations revealed that a duplex outlet was equipped with a 6-outlet adapter to power multiple devices, including an electric bed, mini refrigerator, television, cell phone charger, oxygen humidifier, and fans connected through extension cords. The resident expressed concern about the potential for sparks but had not witnessed any. The facility's administrator was unaware of the non-compliance with regulations and indicated that the previous maintenance supervisor was responsible for ensuring electrical safety. The new maintenance supervisor, hired recently, was expected to address these issues.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to report a verbal abuse allegation immediately to the Abuse Coordinator. A CNA alleged witnessing an LVN verbally abusing a resident, but the incident was not reported to the Administrator, who was the Abuse Coordinator, until the following day. The CNA reported the incident to two ADONs, who did not immediately inform the Administrator. This delay in reporting resulted in the LVN continuing to work until the next day, potentially placing residents at risk of continued abuse. In another incident, the facility failed to report an allegation of abuse to the State Agency within the required 2-hour timeframe. A resident was reported to have hit another resident with a soft plastic urinal, but the incident was not reported to the state until 12 hours later. The delay in reporting such incidents could lead to residents being at risk of further harm or abuse. Additionally, the facility did not report a verbal abuse allegation involving another resident within the required timeframe. A CNA was reported to have spoken rudely to a resident, but the incident was not reported to the state until more than 16 hours later. These failures in timely reporting of abuse allegations highlight significant lapses in the facility's procedures for handling and reporting such incidents, potentially compromising resident safety.
Removal Plan
- Resident #1 was assessed for emotional distress by the DON. A trauma informed care assessment was completed by the DON. No additional emotional distress was noted.
- LVN B was terminated and ADON D resigned. Both are no longer employed at the facility.
- The Administrator, DON, and ADON C were in-serviced 1:1 by the Area Director of Operations and Regional Compliance Nurse on following topics: Abuse and Neglect, reporting immediately to the abuse coordinator, suspension of alleged perpetrators, reporting to HHS, investigation delegation, and notification procedures if the Administrator is unavailable.
- The medical director was informed of the immediate jeopardy citation by DON.
- An ADHOC QAPI meeting was held to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal.
- All staff will be in-serviced on abuse and neglect, reporting procedures, and the role of the abuse coordinator. Staff not present will not assume duties until in-serviced. PRN staff will be in-serviced prior to assignments. New hires will be in-serviced on hire date. Agency staff will be in-serviced prior to assignment. Completion date.
Failure to Investigate and Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse involving a resident with Alzheimer's disease, anxiety, and heart failure. The incident occurred when a CNA reported that an LVN verbally abused the resident after finding her on the floor. The CNA reported the incident to two ADONs, but the allegation was not immediately communicated to the Administrator or the state as required. The resident, who was cognitively impaired with a BIMS score of 5, did not recall the incident when interviewed. The facility's records did not document the fall or any concerns on the day of the incident, and no incident report was completed. The LVN involved continued to work at the facility the following day, which failed to protect the resident from potential further abuse. The Administrator was not informed of the incident until the day after it occurred, delaying the investigation and reporting process. The ADONs did not ensure the allegation was reported to the Administrator, leading to a delay in suspending the LVN and initiating a thorough investigation. This failure placed residents at risk of undetected abuse and compromised their feelings of safety and well-being.
Removal Plan
- Resident #1 was assessed for emotional distress by the DON. A trauma informed care assessment was completed by the DON. No additional emotional distress was noted.
- LVN B was terminated and ADON D resigned. Both are no longer employed at the facility.
- The Administrator, DON, and ADON C were in-serviced 1:1 by the Area Director of Operations and Regional Compliance Nurse on following topics: Abuse and Neglect, reporting immediately to the abuse coordinator, suspension of alleged perpetrators, reporting to HHS, thorough investigation, delegation of responsibilities, and notification procedures if the Administrator is unavailable.
- The medical director was informed of the immediate jeopardy citation by DON.
- An ADHOC QAPI meeting was held to include the interdisciplinary team and medical director to discuss the immediate jeopardy citation and plan of removal.
- All staff will be in-serviced on abuse and neglect, reporting procedures, and suspension of alleged perpetrators. All staff not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to the start of their assignment.
Failure to Provide Adequate Supervision and Safe Environment
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to an accident. The resident, who had severe cognitive impairment and required two staff members for bed mobility, fell from the bed during a pressure ulcer treatment. The incident occurred when an LVN attempted to perform the treatment alone, without the required assistance, resulting in the resident sustaining a skin tear and bruises. The resident, who had a history of high blood pressure, kidney disease, stroke, and morbid obesity, was admitted to the facility with specific care needs documented in her care plan and Kardex. Despite these documented needs, the LVN proceeded with the treatment without assistance, citing an inability to find help. This action was contrary to the facility's policy and the resident's care plan, which clearly indicated the necessity of two staff members for bed mobility. Interviews with staff revealed that the LVN was not adequately oriented to the Kardex system, which led to the misunderstanding of the resident's care requirements. The incident was witnessed, and the resident was assessed for injuries before being sent to the hospital. The facility's failure to provide the necessary supervision and adhere to the care plan placed the resident at risk of harm, as evidenced by the injuries sustained during the fall.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified infection preventionist with specialized training in infection prevention and control. The designated Infection Preventionist (LVN IC) had not completed the necessary specialized training, which was acknowledged by both the Director of Nursing (DON) and the Regional Compliance Nurse. The LVN IC, who was also serving as the Assistant Director of Nursing (ADON), admitted to not having completed the specialized training and expressed concerns about the potential risk this posed to the facility's infection surveillance capabilities. The DON, who was new to the facility, also confirmed that she had not completed the specialized training and was unsure if the LVN IC had done so. Interviews revealed that the previous infection preventionist, LVN E, had completed the specialized training but had resigned from the role two to three months prior. The facility's infection control policy required the Infection Preventionist, DON, and Administrator to complete a CDC training course for infection control and prevention, which had not been fulfilled. The Regional Compliance Nurse acknowledged the importance of having a certified individual responsible for the infection control program and noted that both the DON and LVN IC had only started the training recently.
Failure to Employ Qualified Dietary Manager
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, the facility did not designate a person to serve as the dietary manager who met the required qualifications. The designated Dietary Supervisor did not have a dietary manager's certification or any other qualifying credentials from 06/14/23 to 04/10/24. This deficiency was identified through interviews and record reviews, which revealed that the Dietary Supervisor was still in school and expected to complete the certified Dietary Manager course by September 2024. Despite being appointed as Dietary Supervisor on 06/14/23, she had not yet completed the necessary certification at the time of the survey. During interviews, the Dietary Supervisor confirmed that she had not completed the dietary manager classes and was working in the role until she became certified. The Administrator acknowledged that her expectation was for the Dietary Manager to be certified to oversee dietary services, monitor staff's dietary certifications, and ensure diets were followed. The Regional HR also confirmed that the Dietary Supervisor was not a certified dietary manager. The facility's policy for the Dietary Manager was requested but not provided prior to the exit. The Texas Food Establishment Rules require at least one employee with supervisory and management responsibility to be a certified food protection manager, which the facility failed to comply with.
Facility Fails to Provide Functioning Call Light System
Penalty
Summary
The facility failed to provide a functioning call light system for residents in Halls 100, 200, 300, 500, and 600 from 04/05/24 to 04/10/24. During this period, residents were using alternative methods such as whistles, bells, and maracas to call for assistance. Staff members were observed responding to these alternative call tools and making frequent rounds to monitor residents, especially those with cognitive impairments. The lack of a functioning call light system was confirmed through multiple observations and interviews with staff and the Administrator, who acknowledged the issue and mentioned that the facility was in the process of obtaining bids to repair or replace the system. The Administrator stated that the call lights went out on a Friday, and the facility had implemented temporary measures such as extra staffing and frequent monitoring to ensure residents' needs were met. Despite these efforts, the call light system remained non-functional throughout the survey period. The Administrator also mentioned that the regional office had decided to repair the old call light system, with repairs scheduled to be completed by the following Tuesday. However, there was no existing policy on call lights available at the time of the survey.
Improper Storage and Security of Medications
Penalty
Summary
The facility failed to ensure proper storage and security of drugs and biologicals in two medication carts and one medication room. Specifically, the Hall 6 Nurse Cart contained an opened Insulin Glargine kwik pen with an open date of 03/08/24, two cards of expired Acetaminophen with codeine, two opened inhalers of Trelegy without open dates, and an opened bottle of fluticasone nasal spray without an open date. Additionally, the MA cart had a card of expired escitalopram. The facility also failed to provide a separately locked, permanently affixed compartment for controlled drugs in the refrigerator of the medication room, which contained a removable locked metal box for controlled medications that had not been affixed since a new refrigerator was installed three months prior. Interviews with staff, including an LVN, MA, and the DON, confirmed that expired medications should be removed from the carts to prevent administration to residents and potential drug diversion. The LVN acknowledged that insulin should be used within 28 days of opening, and inhalers and nasal sprays should have open dates to ensure timely disposal. The DON and Administrator confirmed that the lock box in the refrigerator should be permanently affixed to prevent drug diversion. The facility's policies and procedures for medication storage and controlled substances were not followed, leading to the observed deficiencies.
Failure to Ensure Dietary Staff Had Required Food Handler's Certificate
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Specifically, Dietary Staff G did not have a current Food Handler's Certificate while working in the facility's kitchen from April 8, 2024, to April 10, 2024. This deficiency was identified through record review and interviews. The Administrator confirmed that Dietary Staff G's certificate was not found, and the Regional HR acknowledged that the facility was responsible for ensuring all dietary staff had the necessary certificates to prevent foodborne illness. The Texas Food Establishment Rules require that food handler training certificates be maintained on the premises, effective since September 1, 2016. The facility's policy on food handler certificates was requested but not provided prior to the survey exit.
Infection Control Deficiencies in Hand Hygiene and Glucometer Cleaning
Penalty
Summary
The facility failed to ensure an infection prevention and control program was maintained for four residents. Specifically, LVN C did not wash or sanitize her hands when entering Resident #31's room and between glove changes during medication administration via g-tube. LVN C acknowledged that she should have washed her hands upon entering the room and sanitized her hands between glove changes. Additionally, LVNs J and K did not clean the glucometer device according to the required contact time of the disinfectant before and after use on Residents #72, #7, and #82. Both LVNs acknowledged that the disinfectant wipes required a 1-minute contact time, which they did not adhere to. The facility's Glucometer policy and procedure indicated that the meter should be cleaned with a germicidal and allowed to air dry between patient testings.
Failure to Ensure Resident Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure resident rights for personal privacy for one resident. During an observation, two CNAs provided incontinent care to a resident without pulling the privacy curtain between the resident and her roommate. The resident, who had severe cognitive impairment and was dependent on staff for toileting hygiene, was exposed during the care procedure. The CNAs admitted to forgetting to pull the privacy curtain, despite being trained to do so. The Director of Nursing confirmed that the expectation was for all nursing staff to provide privacy when exposing residents' private areas. The facility's policy on resident rights emphasized the importance of treating residents with respect and dignity, including ensuring personal privacy. The failure to pull the privacy curtain during the care procedure was a clear violation of this policy.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to ensure that each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for two residents. For one resident, the care plan did not accurately address the need for a fire-resistant smoking apron despite multiple assessments indicating its necessity. This oversight was acknowledged by various staff members, including the LVN, MDS Nurse, SW, DON, and Administrator, who all admitted that the requirement for the fire-resistant smoking apron was overlooked in the care plan updates. The risk identified was that staff might be unaware of the need for the apron, potentially leading to safety hazards during smoking activities. For another resident, the care plan failed to address the diagnosis of benign prostatic hyperplasia and urinary retention related to his indwelling urinary catheter. Although the resident had an indwelling catheter and no cognitive impairment, the care plan did not include the necessary diagnosis, which was also acknowledged as an oversight by the MDS Nurse, DON, and Administrator. The risk identified was that staff might not be aware of the reason for the catheter, which could affect the quality of care provided. The facility's policies on comprehensive care plans and smoking safety were not followed, leading to these deficiencies. The interdisciplinary team, including the MDS Nurse, SW, ADON, and DON, were responsible for ensuring care plans were accurate and updated, but failed to do so in these instances. The Administrator confirmed that the care plans should be accurate and updated appropriately, but acknowledged that the care plans for these residents had not been reviewed properly.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure that two residents who needed respiratory care were provided such care consistent with professional standards of practice and their comprehensive person-centered care plans. Resident #14, who had multiple sclerosis and neoplasm of the meninges and was on hospice services, was observed receiving oxygen therapy without any physician orders. Despite receiving oxygen for several months, there were no orders documented for the administration of oxygen, and the care plans did not reflect the oxygen therapy. LVN A confirmed that the resident had been receiving oxygen without orders and acknowledged that it was the nurse's responsibility to ensure orders were in place and to check the oxygen settings every shift. Similarly, Resident #41, who had heart failure and emphysema, was ordered oxygen at 2L nasal cannula continuously but was observed receiving oxygen at 3L nasal cannula on multiple occasions. LVN A confirmed that the resident's oxygen was set incorrectly and should have been at 2L as ordered. The DON acknowledged that Resident #14 should have had orders for oxygen and that Resident #41 should have received the correct dose of oxygen. The facility's Oxygen Administration policy indicated that oxygen therapy should be administered as ordered by the physician, but this was not followed in these cases.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to ensure proper pharmaceutical services for two residents. For Resident #31, a male with a gastrostomy tube, the Licensed Vocational Nurse (LVN) did not check the placement of the g-tube before administering medications. The LVN claimed to have checked the placement earlier in the day, but this did not align with the facility's policy, which requires checking the placement before each medication administration. This oversight was observed during a medication administration session and confirmed through interviews and record reviews. For Resident #72, a female with type 2 diabetes mellitus, the facility failed to administer the correct type of insulin as per physician orders. The LVN administered Humulin N instead of the prescribed regular insulin. The Director of Nursing (DON) confirmed that the resident should have received regular insulin and was unaware of why the pharmacy sent Humulin N. The discrepancy was discovered during an observation and subsequent interviews with the LVN and DON, who later contacted the pharmacy consultant to clarify the issue.
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.
