Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Focused Care Of Waxahachie during CMS and state inspections, most recent first.
A resident with multiple medical conditions and mild cognitive impairment had Enhanced Barrier Precautions (EBP) signage posted on the room door requiring hand hygiene upon entry and exit. During observation, therapy staff assisting the resident back from therapy and the ADM entered and exited the room without performing hand hygiene, despite the posted EBP instructions. Interviews with an LVN, CNA, therapy staff, the DON, and the ADM confirmed they were regularly in-serviced on infection control and understood that EBP signage is used to prevent infection spread, and the facility’s infection control policy required EBP signage and adherence. The observed noncompliance with hand hygiene requirements for a resident under EBP led to the cited infection control deficiency.
A resident with dementia, major depressive disorder, restlessness, and impulsiveness had been assessed as high risk for elopement and care planned with a wander guard and diversionary interventions. On one occasion, video showed the resident alone at an exit door, manipulating the keypad and crash bar, then exiting the building while the door alarm and wander guard alarm activated. A staff member later approached the door, entered the alarm code, and walked away without opening the door or checking outside, contrary to facility expectations and staff training that alarms required visual verification for exiting residents. The resident traveled off the premises, crossed a street, and fell in a nearby area, and the facility only became aware of the elopement when notified by a passerby, demonstrating a failure to provide adequate supervision and to follow elopement procedures for a known high-risk resident.
A resident with dementia, anxiety disorder, heart failure, and total bowel/bladder incontinence, who was dependent on staff for toileting, received perineal care that did not follow facility infection control policies. During observed incontinent care, a CNA wiped the buttocks multiple times with the same wipe, discarded soiled wipes and a brief onto the floor, then applied a clean brief without changing gloves or performing hand hygiene before handling clean items. The CNA then picked up the soiled brief from the floor and bagged it. The CNA later acknowledged she had been checked off on perineal care only once since hire and that her actions did not follow the facility’s perineal care and handwashing policies, which require front-to-back cleansing, single-use wipe surfaces, proper disposal in designated containers, glove removal, and hand hygiene between contaminated and clean tasks.
A resident with multiple chronic conditions did not receive medications as ordered on several occasions, including incorrect dosing of an anti-seizure medication and possible omission of a neuropathy medication. Nursing staff failed to follow physician orders, relied on incorrect instructions, and did not report or document medication errors as required. Facility leadership was unaware of the errors until notified by surveyors, and policy procedures for medication administration and error reporting were not followed.
A resident with multiple medical conditions was found with ants on his body by an LVN, who performed an assessment and found no bites. The incident and assessment were not documented in the EMR, as the LVN was told by the ADON that documentation was unnecessary. The DON also assessed the resident but recorded findings only in a non-medical record book. Facility policy requires such events to be documented in the medical record, but no entry was made.
A resident with multiple serious diagnoses and moderate cognitive impairment was found with ants on his body by an LVN, who assessed for injury and reported the incident to the DON. Neither the LVN nor the DON documented the event or notified the resident's responsible party or hospice. The responsible party only learned of the incident during a routine visit the following day, and the facility's policy on resident rights was not provided when requested.
A resident who was fully dependent on staff for care was found lying in bed with soiled, stained linens and reported not having been showered for several days. Staff interviews revealed miscommunication and staff shortages led to the oversight, with CNAs unaware of the condition of the linens until the survey. Facility policy required linens to be changed as needed and soiled linens to be discarded, but this was not followed, resulting in the resident experiencing an unclean and uncomfortable environment.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet care needs.
Several residents with chronic medical and mental health conditions did not receive scheduled or resident-centered activities for an extended period due to the abrupt departure of the activity director and lack of staff coverage. Observations and interviews confirmed that no formal activities were provided, the activity calendar was outdated, and residents' interests and suggestions were not addressed, resulting in dissatisfaction and boredom.
A resident with dementia and significant hearing loss was inaccurately assessed in the MDS as having minimal hearing difficulty and no hearing aids, despite care plan notes and staff observations indicating otherwise. The MDS was completed remotely by an LVN who did not directly observe the resident, leading to discrepancies in documentation and care planning for the resident's hearing needs.
Two residents with mental health diagnoses did not receive accurate PASRR screenings, resulting in missed Level I and Level II assessments despite documented conditions such as major depressive disorder and bipolar disorder. Staff interviews revealed gaps in knowledge and inconsistent policy implementation, and facility records showed that required PASRR procedures were not followed.
A resident with hearing impairment did not have their use or refusal of hearing aids documented in their care plan, despite staff and resident reports of inconsistent use and communication challenges. The care plan only addressed general communication needs and omitted specific interventions related to hearing aids, contrary to facility policy.
Surveyors found multiple expired IV administration sets, a catheter stabilizer, and a central line dressing kit in a medication storage room. Staff interviews confirmed that nurses and medication aides were responsible for removing expired supplies, in accordance with facility policy, but these items had not been removed as required.
The facility failed to ensure call lights were within reach for four residents, impacting their ability to receive timely assistance. Residents with various medical conditions reported their call lights were inaccessible, forcing them to wait for staff or yell for help. Staff interviews confirmed the responsibility to ensure call lights are accessible, yet observations showed a lapse in policy adherence.
The facility failed to update care plans for two residents, one of whom experienced unwitnessed falls, and another with nutritional and behavioral issues. Both residents were cognitively intact, but their care plans lacked necessary updates and interventions. The absence of a DON and overwhelming responsibilities of the ADON contributed to this deficiency.
A resident was administered several psychoactive medications without obtaining written consent, violating their right to be informed about treatment options and risks. The facility failed to provide necessary education and documentation, placing the resident at risk of not understanding the medications' side effects and purposes.
A resident with schizoaffective disorder did not receive Depakote from March 20 to April 10, despite MARs indicating administration. The facility lacked pharmacy delivery records for March, and insurance records showed no billing for that month. Staff believed the medication was given, but the resident's family reported behavioral issues during a home visit, suggesting a lapse in medication. The facility's policy on timely medication receipt and record-keeping was not followed, leading to a deficiency in pharmaceutical services.
The facility failed to ensure call lights were within reach for two residents, one with severe cognitive impairment and another with cerebral infarction. Observations showed call lights tied or placed out of reach, contrary to care plans and facility policy. Staff interviews confirmed the responsibility to ensure accessibility, which was not consistently practiced.
A resident's urinal was not emptied appropriately, leading to a failure in providing a clean and homelike environment. The resident, with multiple health conditions, reported that the urinal had contained urine since the morning. Staff interviews confirmed that it is the responsibility of direct care staff to empty urinals during care rounds, which should occur every two hours. The facility's policy emphasizes treating residents with dignity, including maintaining a clean environment.
Two residents with known histories of disputes were left unattended, resulting in one resident hitting the other with a cane, causing a head injury. Both residents had care plans indicating potential for aggression, but the facility failed to implement effective measures to prevent altercations, despite being aware of ongoing issues. The facility's policies and staff training were inadequate to ensure resident safety.
Two residents with a history of disputes and aggressive behavior were involved in a physical altercation due to the facility's failure to implement comprehensive care plans. Despite known issues, the care plans lacked measurable objectives and effective interventions, resulting in one resident hitting the other with a cane, causing a head injury.
A resident with a history of traumatic brain injury, depression, and heart failure was discharged from an LTC facility to a group home without sufficient preparation and documentation. The facility failed to provide a comprehensive discharge plan or communicate effectively with the ombudsman, leading to a deficiency in ensuring a safe and orderly transfer. The resident was initially deemed unable to care for himself at home, and the discharge process did not adhere to the facility's policies.
A resident with severe cognitive impairment sustained a tibial fracture when a CNA accidentally hit her leg on a table. The CNA did not report the incident, delaying the resident's assessment and treatment. The facility did not conduct a thorough investigation, and the CNA was moved to another hall at the family's request.
The facility failed to develop comprehensive care plans for three residents, resulting in incomplete or missing care plans. Interviews revealed that the facility had not had an MDS nurse for a few weeks, leading to confusion about responsibility for care plans and non-compliance with facility policy.
The facility failed to ensure proper storage of controlled substances when a refill of Hydrocodone for a resident was received by one LVN and handed to another, but was later discovered missing. The facility policy requiring two nurses to witness the storage of controlled substances was not followed, and the involved LVN was unaware of this policy.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene Requirements
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff consistently practiced hand hygiene in accordance with posted Enhanced Barrier Precautions (EBP) signage for a resident identified as requiring such precautions. The resident’s electronic medical record showed admission in March 2026 with a history of bipolar disorder, epilepsy, GERD without esophagitis, and adjustment disorder with anxiety, and a BIMS score of 12 indicating mild cognitive impairment. During observation, EBP signage was posted on the resident’s door, and the surveyor noted that the signage required hand hygiene before entering and when leaving the room. On the day of observation, the resident was assisted back from therapy, and the therapy personnel who accompanied the resident did not perform hand hygiene upon entering or exiting the resident’s room, despite the posted EBP sign. The Administrator (ADM) also entered the resident’s room without performing hand hygiene, only doing so after the surveyor stated they would perform hand hygiene because of the EBP requirements. The EBP sign specified that everyone must clean their hands before entering and when leaving the room, and that providers and staff must wear gloves and a gown for specified high-contact resident care activities, and not wear the same gown and gloves for more than one person. Multiple staff interviews, including with an LVN, a CNA, a therapy personnel (THP), the DON, and the ADM, confirmed that they had been regularly in-serviced on hand hygiene, infection control, and EBP, and that they understood that EBP signage was placed on resident doors to prevent infection and that not following the signage could result in spread of infection or cross-contamination. Staff described that room-ready personnel, central supply, the DON, nurses, and others were responsible for placing EBP signs and ensuring they were followed. The facility’s infection control policy stated that EBP is CDC guidance to reduce transmission of MDROs and required signage placement and maintenance of PPE in residents’ rooms, with assurance that all team members were aware of resident status and need for EBP during high-contact care. Despite this, the observed failure of therapy personnel and the ADM to perform required hand hygiene when entering and exiting the resident’s room constituted the cited infection control deficiency.
Failure to Supervise High-Risk Resident Resulting in Undetected Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent an elopement for a resident identified as an elopement risk. The resident was a 92-year-old male with diagnoses including major depressive disorder, restlessness and agitation, impulsiveness, and dementia, and had been assessed on admission as high risk for elopement. His care plan, initiated several months prior, identified him as an elopement risk/wanderer with impaired safety awareness and included interventions such as distraction with pleasant diversions, structured activities, reorientation strategies, and use of a wander guard bracelet to alert staff if he attempted to exit the facility. Despite these identified risks and interventions, the resident was able to access and exit through a secured door without staff intervention. On the day of the incident, facility video from a non-audio camera showed the resident standing alone in front of an exit door with his walker. The video reflected that he manipulated the keypad next to the exit door and pushed on the crash bar, which temporarily kept the door locked from the inside for 15 seconds. After this delay, he successfully opened the door and exited the building. The door closed behind him shortly thereafter. Approximately two minutes later, a facility staff member (FT) approached the same exit door, entered the alarm code on the keypad to turn off the alarm, and then walked away without opening the door or looking outside to determine whether a resident had exited. Following his exit, the resident traveled down a concrete ramp, across a grassy yard, and crossed a residential street with a posted speed limit of 30 mph, ultimately falling on the ground in an adjacent parking lot approximately 500 feet from the exit door. The facility was not alerted to his absence by its own staff or alarm response, but instead was notified by a passerby who observed the resident on the ground and came to the facility’s laundry room door to report that a resident was across the street. Staff interviews confirmed that the facility’s expectation and training were that when a door or wander guard alarm sounded, staff were to open the door, look outside, and ensure no resident had exited before turning off the alarm. The Administrator, DON, ADON, HOH, CNAs, and nursing staff all stated that staff were trained not to simply silence alarms, but the FT who responded to the alarm did not follow this process, allowing the resident’s elopement to go undetected until reported by the public. Interviews with multiple staff members, including the Administrator, DON, ADON, RN B, LVN A, HOH, and CNAs, consistently described that the resident had been identified as a wanderer and high elopement risk, and that staff were aware of the need to respond appropriately to door and wander guard alarms. The Administrator and DON both stated that all staff were expected to answer door alarms by going to the door, opening it, and looking outside for residents. The HOH and CNAs reported that housekeeping staff, including the FT, had been trained that if an alarm sounded, they were to look outside for a resident before turning the alarm off. Despite this, the FT’s response captured on video showed the alarm being silenced without checking outside, and the resident’s elopement was only discovered after he had left the premises, crossed a street, and fallen, demonstrating a failure to provide adequate supervision and to follow the facility’s elopement procedures for this high-risk resident.
Improper Perineal Care and Hand Hygiene During Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain proper infection prevention and control practices during incontinent perineal care for one resident. The resident was an elderly female with unspecified dementia, anxiety disorder, heart failure, moderate cognitive impairment (BIMS score of 9), and was always incontinent of bowel and bladder and dependent on staff for toileting hygiene. During an observed perineal care episode, CNA A unfastened the resident’s brief, had her roll toward another CNA, and wiped the resident’s buttocks using multiple passes with the same wipe. CNA A then threw the soiled wipes and the soiled brief onto the floor instead of into a designated container. Without changing gloves or performing hand hygiene, CNA A obtained and applied a clean brief, then picked up the soiled brief from the floor and placed it into a plastic bag provided by CNA B. CNA A later stated she had been checked off on perineal care only once in about a year of employment and acknowledged she should have cleaned the front perineal area first, wiped only once before changing the wipe surface, changed gloves, washed her hands between handling the soiled and clean briefs, and avoided placing the soiled brief on the floor. The facility’s written policies on perineal care and hand hygiene required front-to-back cleansing, not reusing the same side of disposable wipes, discarding disposable items into designated containers, removing gloves and discarding them appropriately, and performing hand hygiene before moving from a contaminated to a clean body site, which were not followed during this care episode.
Failure to Accurately Administer and Document Medications
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for a resident with multiple diagnoses, including type 2 diabetes, hyperlipidemia, COPD, hypertension, seizures, and cerebral infarction. On three separate occasions, medications were not administered as ordered: Lamotrigine was given in an incorrect dose on two occasions, and Pregabalin was not properly documented or possibly not administered on another occasion. Medication administration records (MAR) and controlled drug administration records (CDAR) showed discrepancies between what was signed off and what was actually given, with staff unable to confirm whether medications were administered as documented. Interviews with nursing staff revealed confusion and lack of adherence to proper medication administration procedures. One nurse followed handwritten instructions from a family member rather than the physician's order on the medication bottle and MAR, resulting in the resident receiving only half the prescribed dose of Lamotrigine. Another nurse signed off on the MAR for Pregabalin but could not confirm if the medication was actually given, and there was no corresponding entry on the CDAR. Staff also failed to report these medication errors to the Director of Nursing (DON) as required by facility policy. The facility's administration and medical director were unaware of the medication errors until informed by the surveyor. The facility's policy required staff to verify medication orders against the MAR and to report any medication errors immediately, but these procedures were not followed. Documentation and communication lapses contributed to the errors, and there was no evidence that the errors were identified or addressed by staff prior to the survey.
Failure to Document Resident Assessment After Ants Found on Resident
Penalty
Summary
The facility failed to ensure accurate documentation in the medical record for a resident who was found with ants on his body while lying in bed. The resident, a 65-year-old man with diagnoses including hemiplegia, COPD, diabetes, sepsis, and dementia, was under hospice care. On the morning of the incident, an LVN discovered two ants on the resident—one on his forehead and one on his throat, with food deposits present on his gown and bed. The LVN performed a quick assessment and found no bites, then verbally reported the incident to the DON, but did not document the event or her assessment in the electronic medical record (EMR). The LVN stated she was instructed by the ADON not to document the incident, as there were no bites or harm, and no incident report was made. Further review revealed that the DON also assessed the resident and found no injuries, but documented his findings only in a Standards of Care book, which is not part of the official medical record. The ADM was aware of ants being found in the resident's room but was not informed that ants had been found on the resident himself. The facility's policy requires that all services, changes in condition, and incidents involving residents be documented in the medical record. However, no documentation of the incident or assessments was found in the resident's EMR, constituting a failure to maintain accurate and complete medical records as required.
Failure to Notify Responsible Party of Change in Resident Condition
Penalty
Summary
The facility failed to immediately notify a resident's responsible party (RP) of a significant change in the resident's condition when the resident was found with ants on his body while lying in bed. The resident, a 65-year-old man with diagnoses including hemiplegia, COPD, diabetes, sepsis, and dementia, was under hospice care and had moderate cognitive impairment. On the morning of the incident, an LVN observed ants on the resident's forehead and throat, with food present on his gown and bed. The LVN assessed the resident for bites, found none, and reported the incident to the DON, who stated he would handle it. Neither the LVN nor the DON documented the incident or notified the RP or hospice. The event was not recorded in the resident's progress notes, and the RP was not informed until the following day during a routine visit. Interviews confirmed that the DON performed an assessment but did not document it or notify the RP, and the ADM was only aware of ants in the room, not on the resident. The pest control logbook noted the presence of ants around the resident's bed, and pest control was scheduled. The resident's family member expressed concern about not being notified, especially given the resident's partial paralysis and inability to feel potential bites. The facility's policy on resident rights was requested but not provided.
Failure to Provide Clean Bed Linens and Maintain Resident Dignity
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living due to conditions including diabetes with nephropathy and incontinence, was found lying in bed with unclean linens. During observation and interview, the resident was noted to have unbrushed hair, clothing with food crumbs, and sheets with a urine odor and multiple large brown dried stains. The resident reported not having been showered in eight days and expressed feeling dirty and uncomfortable. Staff interviews revealed that certified nurse aides (CNAs) were responsible for changing bed linens, but due to miscommunication and staff shortages, the resident's sheets had not been changed as needed. The CNAs were unaware of the stained sheets until it was brought to their attention during the survey. Further interviews with staff, including a licensed vocational nurse (LVN) and the Director of Clinical Operation, confirmed that facility policy required sheets to be changed on shower days and as needed if soiled, and that stained or worn sheets should be discarded. The failure to provide clean bed linens in good condition resulted in the resident experiencing an uncomfortable and unclean environment, contrary to facility policy and the resident's right to a safe, clean, and homelike setting.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. No additional details about the specific residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing, resident-centered activity program designed to meet the interests and support the physical, mental, and psychosocial well-being of several residents. Specifically, from January 23, 2025, through February 12, 2025, scheduled activities were not provided as outlined on the activity calendar. Multiple residents, including those with diagnoses such as major depressive disorder, anxiety, diabetes, and pulmonary conditions, reported that activities had not been offered for approximately two weeks, and that the activity program had been inconsistent and unorganized even prior to this period. Observations confirmed that no formal activities were being conducted during the survey period, and the activity room was found unused, with only minimal materials available and an outdated activity calendar posted. Interviews with residents revealed dissatisfaction and boredom due to the lack of activities, with some expressing that their interests and suggestions for activities were ignored. Residents reported that previously enjoyed activities, such as pet therapy and church services, had ceased due to lack of scheduling and space allocation. The absence of an activity director, who left abruptly on January 22, 2025, was cited as a primary reason for the discontinuation of the activity program. Other staff members, including therapy staff and a hospitality aide, attempted to provide impromptu activities, but these were not scheduled or consistent, and staff were not formally trained or assigned to maintain the activity calendar. Facility staff interviews confirmed that the activity director position was vacant and that no one had been formally assigned to ensure the activity calendar was followed. The administrator acknowledged that activities had been missed and that the facility was in a rebuilding stage. The lack of activities was also discussed during a resident council meeting, where residents voiced complaints about the situation. The facility's own policies and job descriptions require a comprehensive activity program tailored to residents' interests and needs, but these requirements were not met during the period in question.
Inaccurate MDS Assessment of Hearing Status and Hearing Aid Use
Penalty
Summary
The facility failed to ensure that a resident's Minimum Data Set (MDS) assessment accurately reflected the resident's hearing ability and use of hearing aids. The resident, an older adult male with diagnoses including dementia, major depressive disorder, and neuropathy, was documented in his quarterly MDS as having minimal hearing difficulty and no hearing aids or appliances. However, his care plan noted he was very hard of hearing and required special communication interventions, though hearing aids were not included in the care plan. During observation and interviews, the resident expressed that his hearing aids needed repair and that a family member would be taking them for servicing. The surveyor had to stand close, speak loudly, and repeat questions multiple times due to the resident's significant hearing impairment. Staff interviews revealed inconsistent knowledge and documentation regarding the resident's use of hearing aids. The LVN responsible for completing the MDS assessment did so remotely, relying solely on existing documentation without direct resident observation, and acknowledged that the MDS should have been coded differently if hearing aids were present and significant impairment existed. Further interviews with the DON and CNA confirmed the resident's hearing difficulties and inconsistent use of hearing aids, with the DON stating that the resident refused to wear them and the CNA noting frequent communication challenges. The CMDS indicated that the MDS nurse is responsible for assessment accuracy and that the process should include direct observation. Facility policy and federal regulations require that assessments accurately reflect the resident's status and involve direct observation and communication with staff and the resident.
Failure to Complete Accurate PASRR Screenings for Residents with Mental Illness
Penalty
Summary
The facility failed to provide accurate Pre-Admission Screening and Resident Review (PASRR) screenings for individuals with mental disorders, as evidenced by two residents who did not receive appropriate PASRR assessments. One resident was admitted with a diagnosis of Major Depressive Disorder and other neurological conditions, but did not have a new PASRR Level I or Level II screening completed after the mental illness diagnosis was made post-admission. The resident's care plan and medical records indicated active mental health diagnoses, yet the PASRR Level I screening documented no mental illness, and no further PASRR evaluation or services were initiated. Another resident was admitted with a negative PASRR Level I screening conducted by an acute care hospital, despite having diagnoses of bipolar disorder and depression, and was prescribed antipsychotic medication. The resident's care plan and MDS assessment reflected these mental health conditions, but the PASRR Level I screening failed to identify them, and no Level II screening was completed. Observations showed the resident with severe cognitive impairment and significant physical and mental health needs. Interviews with facility staff, including the DON, ADM, and Corporate MDS Coordinator, revealed a lack of awareness and understanding of PASRR requirements and policies. Staff acknowledged that PASRR screenings should be completed upon admission and after a change in condition, and that failure to do so could result in residents not receiving necessary assessments and services. Facility policy required timely and accurate PASRR completion, but audits and oversight were inconsistent, contributing to the deficiencies identified.
Care Plan Lacked Accurate Documentation of Hearing Aid Use
Penalty
Summary
The facility failed to ensure that the care plan for a resident with hearing impairment accurately reflected the resident's current status and needs. Specifically, the care plan did not address the resident's use or refusal of hearing aids, despite documentation and staff interviews indicating that the resident possessed hearing aids, sometimes wore them, and had difficulty using them. The care plan only noted that the resident was very hard of hearing and included general interventions for communication, but omitted any mention of hearing aid management or the resident's preferences and challenges regarding their use. Observations revealed that the resident's hearing aids were present in his room but not in use, and the resident reported that they needed repair and that a family member would be taking them for servicing. Staff interviews confirmed inconsistent use of the hearing aids and communication difficulties, with one CNA noting frequent need to repeat herself and questioning the resident's ability to read lips. The facility's policy required individualized, interdisciplinary care plans based on current needs, but this was not followed in the case of the resident's hearing aid use.
Expired Medical Supplies Found in Medication Storage Room
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored properly in one of two medication storage rooms, specifically the room located by Hall 300. During an observation, multiple expired IV administration sets, a catheter stabilizer, and a central line dressing kit were found in the medication storage room. The expired items included eight Zyno IV administration sets expired since March 2023, seven Zyno IV administration sets expired since June 2022, one Stat lock PICC PLUS Catheter stabilizer expired since April 2023, and one Central Line Dressing Kit expired since February 2021. Interviews with staff, including two LVNs, the DON, and the ADM, confirmed that the facility's policy required expired medical supplies to be removed from medication rooms and discarded. Staff acknowledged their responsibility for checking and removing expired supplies, emphasizing the importance of this process to prevent the use of ineffective or potentially harmful items. A review of the facility's policy also reflected that outdated medications are to be immediately removed from inventory and destroyed.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights were within reach for four residents, leading to a deficiency in accommodating the needs and preferences of these residents. On the specified date, observations and interviews revealed that the call lights for Residents #2, #3, #4, and #5 were not accessible, which could potentially affect their ability to receive timely assistance with activities of daily living. This issue was identified during a review of resident rights, focusing on the reasonable accommodation of each resident's needs. Resident #2, a cognitively intact female with multiple diagnoses including acute cystitis and major depressive disorder, reported that her call light was often on the floor or out of reach, forcing her to yell or wait for staff assistance. Similarly, Resident #3, also cognitively intact and diagnosed with anxiety disorder and multiple sclerosis, stated that her call light was out of reach and requested a clip to keep it accessible. Resident #4, with moderate cognitive impairment and several health issues, and Resident #5, a cognitively intact male with schizoaffective disorder, both reported their call lights were out of reach, leaving them unable to call for help when needed. Interviews with staff, including a CNA, RN, and the ADM, confirmed that it was the responsibility of all staff members to ensure call lights were within reach. The facility's policy on answering call lights emphasized the importance of timely responses to residents' needs, yet the observations indicated a failure to adhere to this policy. This deficiency highlights a significant lapse in ensuring residents' needs are met promptly and effectively.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental and psychosocial needs. For one resident, the care plan was not updated to reflect two unwitnessed falls out of bed, which occurred on specific dates. This resident was cognitively intact, as indicated by a BIMS score of 15, and had diagnoses including unspecified fall, type 2 diabetes, and primary hypertension. Despite being care planned for falls, the care plan did not document these incidents, indicating a lack of timely updates to address the resident's changing condition. Another resident's care plan was not updated to include interventions for nutritional impairment, behavior problems, and resistance to care, despite these issues being identified. This resident, also cognitively intact with a BIMS score of 15, had diagnoses including schizoaffective disorder, hyperlipidemia, and lack of coordination. The care plan, dated after the issues were identified, left the area for interventions blank, showing a failure to document necessary actions to address the resident's needs. Interviews with facility staff revealed that the absence of a Director of Nursing (DON) and the overwhelming responsibilities of the Assistant Director of Nursing (ADON) contributed to the failure to update care plans, potentially impacting the residents' receipt of appropriate interventions.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that residents were informed in advance about the risks and benefits of proposed care, treatment alternatives, and options, specifically regarding psychoactive medications. This deficiency was identified for one resident who was administered several psychoactive medications without obtaining written consent. The medications included Risperdal, Paroxetine, Depakote, Nudexta, Quetiapine, and Lorazepam. The resident, who was his own responsible party, had a history of schizoaffective disorder and traumatic brain injury, and was cognitively intact as per his BIMS score. The review of the resident's medical records revealed that consent forms for these medications were either missing or obtained well after the medications had been administered. For instance, the consent for Depakote was signed months after the medication was first administered, and no consent forms were found for other medications like Risperidone and Quetiapine. Interviews with facility staff, including the ADON and Medical Director, indicated a lack of awareness and adherence to the requirement for obtaining informed consent for psychoactive medications. The facility's failure to provide informed consent placed residents at risk of not understanding the potential side effects and purposes of the medications they were receiving. Interviews with the resident's family member and facility staff highlighted concerns about the lack of communication and education regarding the medications. The facility's policy on resident rights emphasized the importance of self-determination and being informed about medical conditions and treatments, yet a specific policy on psychoactive medication consent was not provided during the survey.
Failure to Maintain Adequate Supply of Depakote
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident, resulting in a lack of Depakote medication from March 20, 2024, to April 10, 2024. The resident, a male with schizoaffective disorder, traumatic brain injury, prostate cancer, ataxia, and gout, was supposed to receive Depakote twice daily as a mood stabilizer. Despite the medication administration records (MARs) indicating that the medication was given, there was no evidence of a pharmacy delivery for March 2024, and insurance records confirmed no billing for Depakote during that month. Interviews with facility staff, including the Director of Nursing (DON), Assistant Director of Nursing (ADON), and medication aides, revealed that they believed the medication was administered as recorded. However, the DON acknowledged a gap in the pharmacy delivery records for March 2024, and the family member (FM) of the resident reported that the resident experienced escalating behaviors during a home visit, suggesting a lapse in medication administration. The facility's social worker noted in a progress note that the resident was placed back on his medication, indicating a possible interruption in the medication regimen. The facility's policy on ordering and receiving medications requires timely receipt and accurate record-keeping, which was not adhered to in this case. The lack of documentation and pharmacy receipts for March 2024, combined with the resident's behavioral changes, suggests a failure to maintain an adequate supply of Depakote, potentially impacting the resident's health and well-being. Despite staff assertions of medication administration, the absence of delivery records and insurance billing indicates a deficiency in pharmaceutical services provided to the resident.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call lights for two residents were within reach, which is a violation of resident rights. Resident #1, a male with severe cognitive impairment and multiple diagnoses including sepsis and major depressive disorder, was observed multiple times throughout the day with his call light tied to his nightstand and out of reach. His care plan specifically included an intervention to ensure the call light was within reach and answered promptly, yet this was not adhered to. Due to his severe cognitive impairment, Resident #1 was unable to communicate this issue himself. Resident #2, a male with a cerebral infarction and hypertension, was cognitively intact but dependent on assistance for various activities of daily living. His call light was also observed out of reach, laid on top of his nightstand. During an interview, Resident #2 mentioned that his call light clip was broken, and he had to wait for staff rounds or call out for help. Interviews with staff, including a CNA and the DON, confirmed that ensuring call lights are within reach is a shared responsibility, yet this was not consistently practiced. The facility's policy on answering call lights emphasizes the importance of accessibility, which was not followed in these instances.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, specifically in the management of the resident's urinal. The resident, who has a history of osteomyelitis, unspecified dementia, major depressive disorder, Type 2 diabetes mellitus with foot ulcer, and muscle weakness, was observed to have a urinal with yellowish liquid, presumed to be urine, on two separate occasions on the same day. The resident reported that the urinal had contained urine since the morning and expressed that only a few staff members consistently emptied it as required. Interviews with staff, including a CNA and the DON, revealed that it is the responsibility of direct care staff to ensure urinals are emptied appropriately during care rounds, which should occur at least every two hours. The CNA and DON acknowledged that failing to empty the urinal could lead to unpleasant odors and potential infection control issues. The facility's Resident Rights policy emphasizes treating residents with kindness, respect, and dignity, which includes maintaining a clean and homelike environment.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from physical, mental, and verbal abuse, resulting in a significant altercation. Both residents had a known history of disputes, including verbal and attempted physical altercations. On one occasion, they were left unattended in the same room, leading to one resident hitting the other on the head with a cane, causing a 2 cm laceration that required hospital treatment. This incident highlighted the facility's failure to implement effective measures to prevent such interactions despite being aware of the ongoing issues between the two residents. Resident #1, a male with a history of traumatic brain injury, depression, and heart failure, had a care plan indicating potential for verbal and physical aggression. Despite this, his care plan did not list the use of a cane or wheelchair, which he was observed using. Resident #1 had a history of aggressive behavior towards Resident #2, including verbal threats and physical altercations. The facility's interventions, such as behavior plans and monitoring, were insufficient to prevent further incidents. Resident #2, also with a traumatic brain injury and schizoaffective disorder, exhibited behavior problems, including yelling and racial slurs. His care plan included interventions to manage his behavior, but these were not effectively implemented. The facility's failure to separate the residents and monitor their interactions led to repeated altercations, culminating in the serious incident on 10/09/2024. The facility's policies and staff training were inadequate to prevent the abuse and ensure the safety of both residents.
Removal Plan
- Resident #1 was placed on 1:1 and remained 1:1 until discharge.
- Resident #2 was placed on 1:1 until cleared by Psychology Nurse Practitioner.
- Administrator and Director of Nursing were in-serviced by Regional President of Operations to include keeping resident within eyesight at all times and maintaining resident safety.
- Staff members assigned to 1:1 will be in-serviced by Director of Nursing and/or designee on responsibilities to include keeping resident within eyesight at all times and maintaining resident safety.
- Safe Surveys were conducted by administrative nurses/designee with alert and oriented residents to determine if there were any residents who did not feel safe in the facility.
- Verification of completion was done by the Administrator.
- For non-alert and non-oriented residents, all nurses have been educated to monitor for changes in behavior and skin during weekly skin assessments for non-verbal signs and symptoms of abuse.
- The Director of Nursing and/or designee began educating all staff on the facility's Abuse and Neglect policy.
- The Director of Nursing and/or designee began educating all clinical staff on following resident #2 plan of care.
- Involvement of Medical Director and Quality Assurance Ad HOC QA meeting held with the medical director to review all aspects of Immediate Jeopardy and Initial Plan of removal.
- QA meetings are held on a monthly basis and all allegations, incidents, and accidents will be reviewed during the QA meeting.
Failure to Implement Effective Care Plans Leads to Resident Altercation
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which resulted in an incident of physical aggression. The care plans did not include measurable objectives and timetables to address the residents' medical, nursing, and mental and psychosocial needs. This deficiency was identified during a review of the care plans and progress notes for the residents involved, who had a known history of disputes and aggressive behavior towards each other. Resident #1, a male with a history of traumatic brain injury, depression, and heart failure, had a care plan that acknowledged his potential for verbal and physical aggression. Despite this, the interventions in place were not effective in preventing altercations with Resident #2. The progress notes revealed multiple incidents where Resident #1 exhibited aggressive behavior towards Resident #2, including threats and physical altercations. The care plan failed to adequately address these behaviors or provide effective strategies to prevent further incidents. Resident #2, who also had a history of schizoaffective disorder and traumatic brain injury, exhibited behavior problems such as yelling and using racial slurs. His care plan included interventions to manage his behavior, but these were insufficient to prevent conflicts with Resident #1. The progress notes documented several altercations between the two residents, culminating in an incident where Resident #1 hit Resident #2 with a cane, resulting in a head injury. The facility's failure to implement effective care plans for both residents placed them at risk of harm and did not ensure their safety.
Inadequate Discharge Preparation and Documentation
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a resident's discharge to a group home, which compromised the safety and orderliness of the transfer. The resident, a male with a history of diffuse traumatic brain injury, depression, and heart failure, was discharged without sufficient documentation of preparation. The resident was his own responsible party and had a BIMS score indicating intact cognition. Despite this, the facility did not provide evidence of a comprehensive discharge plan or orientation to ensure the resident's needs would be met at the new location. The resident's care plan initially indicated that discharge was not feasible due to his inability to ambulate and care for himself at home. However, on the day of discharge, the facility's social worker noted that the resident was upset and not receptive to discussions about his feelings and placement. The resident was eventually accepted by a group home after being declined by several skilled nursing facilities due to aggressive behavior. The discharge process lacked proper communication with the ombudsman, who was unaware of the discharge and did not receive a discharge letter, which is required for a 7-day discharge notice. The facility's discharge policy mandates that residents be prepared in advance for discharge, with a post-discharge plan developed and reviewed with the resident or their family. However, the facility did not adhere to these procedures, as evidenced by the lack of a documented discharge summary and post-discharge plan. The medical director approved the discharge but did not enter the order until two days later. The facility's failure to follow its own discharge policy and communicate effectively with the ombudsman and other involved parties led to a deficiency in ensuring a safe and orderly discharge for the resident.
Failure to Prevent Accident and Ensure Adequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for a resident, resulting in a tibial fracture. The resident, who had severe cognitive impairment and was dependent on staff for daily activities, was injured when a CNA accidentally hit her leg on a table while pushing her up to the dining table. The CNA did not report the incident to the nursing staff, and the resident later complained of knee pain, which led to the discovery of the fracture and subsequent hospitalization. Interviews with staff revealed that the CNA did not realize the severity of the impact and did not inform the nurse, which delayed the resident's assessment and treatment. The facility did not conduct a thorough investigation of the incident, as they believed it was unintentional. The CNA was moved to another hall at the family's request due to a previous fall incident involving the same staff member. The facility's policies on abuse/neglect and incident reporting were not followed, as the incident was not properly investigated or reported to the Executive Director of Operations (EDO).
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, which included measurable objectives and timetables to meet their medical, nursing, and mental and psychosocial needs. Specifically, Resident #3's care plan was entirely blank, Resident #4's care plan was incomplete with only one intervention for vaccine status, and Resident #5's care plan was incomplete with only two interventions for code status and alertness. This deficiency was identified through observation, interview, and record review, and it placed residents at risk of not having their individualized needs met in a timely manner, potentially leading to injury or a decline in physical well-being. Interviews with the ADON, DON, and AD revealed that the facility had not had an MDS nurse for a few weeks, and there was confusion about who was responsible for completing the care plans. The ADON and DON acknowledged the incomplete and missing care plans and admitted that this was not sufficient to provide proper care. The AD stated that care plans from February were either late, delayed, or not done, and the MDS nurse at the time had given notice in mid-February and possibly neglected her duties. The facility policy required an individualized interdisciplinary plan of care to be developed within 21 days of admission, which was not adhered to in these cases.
Failure to Properly Store Controlled Substances
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored and inaccessible to unauthorized staff and residents. Specifically, a refill of Hydrocodone, 10-325 milligrams, quantity of 75, for an 83-year-old male resident with diagnoses including senile degeneration of the brain, hypertension, dementia, shoulder pain, and a history of falls, was received from the pharmacy by LVN A and handed to LVN B. The medication was discovered missing two days later. An investigation revealed that LVN A handed the medications to LVN B, but it was unclear if LVN B properly stored the narcotics as required by facility policy, which mandates that two nurses witness the placement of controlled substances in the secure compartment of the medication cart. LVN A admitted she was unaware of this policy, and LVN B did not provide a written statement and was suspended pending the investigation's outcome. The Director of Nursing (DON) and Assistant Director (AD) confirmed that the medications were last in the possession of LVN B, who initially denied receiving the meds and later claimed to have handed them off to another staff member. The facility's incident report indicated that the hydrocodone was discovered missing on 3/6/2024, and the facility policy on receiving controlled substances was not followed. The DON and AD were not aware of the requirement for two nurses to witness the storage of controlled substances, highlighting a gap in staff training and adherence to facility policies. The resident did not miss any medication doses and reported no pain during the incident period.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 226 citations issued within 25 miles in the last 12 months — including the 10 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Waxahachie
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legend Oaks Healthcare And Rehabilitation - Waxaha | 2.8 mi | — | 9 | 0 |
| Pleasant Manor Healthcare Rehabilitation | 3.3 mi | — | 11 | 0 |
| Midtowne Meadows Health & Rehab | 8.9 mi | — | 0 | 0 |
| Midlothian Healthcare Center | 9.1 mi | — | 2 | 0 |
| Red Oak Health And Rehabilitation Center | 9.8 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Focused Care Of Waxahachie.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.