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 Lampstand Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses did not have a comprehensive care plan that included dates of injuries or goals and interventions for schizophrenia. The care plan lacked measurable objectives and timeframes, and staff confirmed these omissions, resulting in incomplete clinical documentation.
A resident with severe cognitive impairment and non-verbal status was administered medication by a med aide who did not inform the resident of the medication name or purpose, contrary to facility policy requiring explanation of medications during administration. Staff interviews confirmed the omission, noting the resident's inability to understand but acknowledging the lapse in procedure.
A resident with a history of TBI and high fall risk was left in an unsafe position by a CNA who attempted to reposition the resident alone, contrary to the care plan requiring two-person assistance. The resident was left with legs hanging off a raised bed and the call light out of reach, while the CNA left the room to seek help. Facility leadership confirmed that proper procedures were not followed and the resident was not safely supervised.
A resident with a seizure disorder and severe cognitive impairment did not receive two scheduled doses of Keppra due to lethargy and refusal, with staff failing to make additional administration attempts or notify the provider and responsible party as required. This resulted in the resident experiencing a seizure and hospital evaluation, with documentation and interviews confirming the missed doses and lack of appropriate notification.
A resident's legal representative requested that an LVN not provide care, but the LVN continued to care for the resident due to a lack of timely communication and updates to staff assignments. The resident, who was dependent on staff for mobility and ADLs and had multiple medical conditions, did not have their representative's wishes honored, as required by facility policy.
A bottle of Nystatin Topical Powder was found unattended and unsecured at the bedside of a resident with multiple medical conditions, despite facility policy prohibiting medications from being left in resident rooms. Staff interviews confirmed that no one was aware of the medication being left out, and all acknowledged that medications should be administered by licensed personnel and properly stored.
The facility did not provide all residents with notice of their rights, as required, with postings only available in one hallway and the resident rights document omitted from admission packets for several months. Interviews with multiple residents revealed they were unaware of their rights, and staff confirmed a lack of awareness and process to ensure this information was distributed.
Surveyors identified failures in food storage, labeling, and sanitation, including onions stored in water and leaking, undated and expired food items, improperly stored eggs, tea, and cake, and an ice machine with black slime. Dietary staff acknowledged not following protocols for labeling, dating, and cleaning, and were unaware of when the ice machine was last cleaned, contrary to facility policy.
Two medication aides failed to sanitize a blood pressure cuff between uses on multiple residents during medication administration, contrary to facility policy and infection control expectations. The aides acknowledged the oversight when questioned, and the DON confirmed that equipment should be cleaned between residents to prevent cross-contamination.
Essential kitchen equipment, including a coffee brewing system, oven, steam table, and heated delivery cart, were found to be nonfunctional or not maintaining proper temperatures. Staff interviews revealed these issues had persisted for months, with inconsistent reporting and follow-up, and maintenance logs lacked documentation for most equipment failures. Supervisory staff were not fully aware of the problems, and no facility policies for equipment maintenance were provided.
A dietary aide was allowed to work in the kitchen without completing required training, obtaining a food handler's certificate, or receiving proper supervision. Staff interviews and record reviews confirmed the aide had not been trained on key kitchen procedures, and facility leadership was unaware of the lack of training and oversight.
The facility failed to maintain proper hand hygiene during food preparation, as observed with a staff member who did not wash or sanitize her hands between tasks, leading to potential cross-contamination. The staff member handled food and kitchen utensils without gloves and touched various contaminated surfaces. Interviews with facility management confirmed the deficiency, and the facility's hand washing policy was not adhered to.
A resident with severe cognitive impairment and incontinence was found in a room with a strong urine odor and soiled sheets, indicating a failure to maintain a clean and comfortable environment. Staff interviews revealed a lack of awareness and action, as the assigned CNA did not recall the resident's condition, and another CNA noticed the issue but was unsure of responsibility. The facility's policy required immediate action to address such conditions, which was not followed.
A resident with chronic health conditions reported a grievance about delayed response to call lights, waiting over forty-five minutes for assistance. Despite the resident's clear communication, the grievance was not documented or investigated as per facility policy. The DON acknowledged the oversight, and the facility's grievance policy was not adhered to.
A resident with multiple sclerosis and dysphagia was not properly positioned during meals, leading to potential risks of choking and discomfort. Despite the resident's preference to sit up, he was observed lying in bed with the head slightly elevated while eating. Staff interviews confirmed the need for residents to be upright during meals to prevent choking, but the facility failed to consistently ensure this positioning.
A facility failed to maintain an effective infection control program, as staff did not consistently wear PPE or tie back long hair while providing care to a resident on enhanced barrier precautions. Video evidence and staff interviews confirmed these lapses, which increased the risk of cross-contamination and infection.
A resident with severe cognitive impairment and multiple medical conditions had their call light out of reach, contrary to their care plan. Observations confirmed the call light was under the bed, and staff interviews highlighted the importance of accessible call lights for resident safety. The facility lacked a specific call light policy.
A resident with cognitive impairment and blindness was unsafely discharged from an LTC facility and left unsupervised on a busy street. The facility failed to coordinate the discharge with the resident's family and did not wait for the completion of an appeal process. The resident's care plan indicated that discharge was not feasible due to dementia and elopement risk, yet the facility proceeded without ensuring a responsible party was present to receive the resident.
The facility failed to review and revise a resident's care plan within the required quarterly timeframe, missing the deadline by several weeks. The resident, with multiple diagnoses and moderate cognitive impairment, had his last care plan update in December 2023. Staff cited high admission rates and workload as reasons for the oversight.
Incomplete and Inaccurate Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex diagnoses, including traumatic brain injury, intellectual disability, schizophrenia, and seizures. The care plan did not include measurable objectives or timeframes to address the resident's medical, nursing, mental, and psychosocial needs as identified in the comprehensive assessment. Specifically, the care plan omitted the dates when the resident sustained bruises, such as a right lower leg bruise from swinging his leg over a chair and abdominal bruising from Lovenox injections. Additionally, there were no documented goals or interventions related to the resident's diagnosis of schizophrenia, despite the resident receiving medication for this condition. Record reviews and staff interviews confirmed these omissions. The resident was noted to have severe cognitive impairment, total dependence for mobility and transfers, and was non-communicative during observation. The facility's staff, including the Regional RN, ADO, and Administrator, acknowledged that the care plan and clinical records were incomplete and lacked necessary details to ensure continuity of care. The facility's documentation policy required complete and accurate records, but this was not followed in the resident's case.
Failure to Inform Resident of Medication During Administration
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate administering of medications to meet the needs of a resident with severe cognitive impairment. Specifically, a medication aide administered Keppra Oral Solution to a non-verbal male resident with a BIMS score of 00, indicating severe impairment, and diagnoses including convulsions, schizophrenia, and a history of traumatic brain injury. The resident's care plan noted impaired cognitive function, non-verbal communication, and a need for staff to monitor and document changes. During medication administration, video footage showed the medication aide entering the resident's room, greeting him, and giving him the medication without advising him of the name or purpose of the medication. The aide ensured the resident swallowed the medication but did not explain what was being administered, despite facility policy requiring staff to explain the administration procedure to residents and adhere to the six rights of medication administration, including explaining the medication to the resident. Interviews with facility staff, including the medication aide, DON, and ADM, confirmed that the resident was not advised of the medication being given. Staff acknowledged that the resident was not cognitively capable of understanding the information, but also recognized that not advising residents of their medications is not appropriate and does not align with facility policy. The deficiency was identified through observation, interview, and record review, and was limited to this resident among those reviewed for pharmacy services.
Failure to Provide Required Supervision and Safe Positioning During Resident Repositioning
Penalty
Summary
A deficiency occurred when a resident, a 37-year-old male with a history of unspecified convulsions, schizophrenia, weakness, and traumatic brain injury, was not provided the required level of care and supervision to prevent accidents. The resident was care planned as a high fall risk and required two staff members for all bed mobility and repositioning. Despite this, a CNA attempted to reposition the resident alone, resulting in the resident being left in a diagonal position on the bed with both legs hanging off the side up to the knees, the bed in a raised position, and the call light out of reach. Video evidence showed the CNA making several unsuccessful attempts to reposition the resident, who exhibited muscle rigidity and resistance to movement. The CNA then left the resident unattended in this unsafe position, stating, "I can't be doing this all day," and exited the room. The resident remained unsupervised with the bed elevated and his legs off the bed until the CNA returned with another staff member. The care plan and Kardex clearly indicated the need for two-person assistance for repositioning, which was not followed. Interviews with facility leadership, including the DON, Administrator, and Corporate Administrator, confirmed that the CNA should not have attempted to reposition the resident alone or left the resident in an unsafe position. The staff acknowledged that the resident was at high risk for falls and that the actions taken were not in accordance with the resident's care plan or facility policy. The deficiency was identified as past noncompliance, and the incident was self-reported by the facility after review of the video evidence.
Failure to Prevent Significant Medication Error for Seizure Disorder
Penalty
Summary
A deficiency occurred when a resident with a history of seizure disorder and traumatic brain injury did not receive two out of three scheduled doses of the anticonvulsant medication Keppra (Levetiracetam) as ordered. The medication was not administered on two occasions: once because the resident was lethargic and staff felt it was unsafe to administer, and once because the resident refused by keeping his mouth closed. Documentation shows that staff did not make multiple attempts to administer the medication, nor did they notify the provider or responsible party of the missed or refused doses, as required by facility policy. The resident was categorized as severely cognitively impaired and nonverbal, with a care plan indicating the need for seizure medication as ordered and monitoring for side effects and effectiveness. Despite this, staff did not follow up with additional attempts to administer the medication or escalate the issue to medical providers or the resident's representative. The lack of notification and follow-up led to the resident missing critical doses of his seizure medication. Subsequently, the resident experienced a seizure, which was documented by staff and confirmed by hospital records showing an undetectable Keppra level. Interviews with staff and medical providers confirmed that the missed doses and lack of notification were not in accordance with facility policy and expectations for care of residents with seizure disorders. The incident was self-reported by the facility, and staff interviews indicated knowledge of the policies, but these were not followed in this instance.
Failure to Honor Resident Representative's Refusal of Specific Caregiver
Penalty
Summary
The facility failed to ensure that a legal surrogate, designated as the resident's representative (RP), could exercise the resident's rights as provided by state law. Specifically, the RP instructed LVN F not to provide care to a resident after a verbal request was made through a camera in the resident's room. Despite this request, LVN F continued to provide care to the resident on the same day and was also assigned to the resident's hall the following day. The RP's request was not communicated to the appropriate facility staff in a timely manner, resulting in the continued assignment of LVN F to the resident. The resident involved was a 37-year-old male with diagnoses including unspecified convulsions, schizophrenia, weakness, and a history of traumatic brain injury. He was dependent on staff for all forms of mobility and required significant assistance with activities of daily living. The RP's request for LVN F to be removed from the resident's care was made verbally via the room camera, citing concerns related to social media. However, the facility's staff, including the ADON and administrative personnel, were not promptly informed of the restriction, and the staff assignment sheets continued to list LVN F as responsible for the resident's care. Interviews with facility staff revealed a lack of awareness regarding the restriction, and the list of staff not permitted to care for the resident was not available to all relevant personnel prior to the second day. The facility's policy states that the decisions of a resident representative must be treated as the decisions of the resident, but this was not followed in practice. As a result, the resident's right to have their care decisions made by their legal surrogate was not honored.
Unsecured Medication Found at Resident Bedside
Penalty
Summary
A bottle of Nystatin Topical Powder was found unattended and unsecured at the bedside of a female resident with diabetes mellitus Type 2, mild cognitive impairment, pituitary gland disorder, and obesity. The resident had an order for Nystatin Powder to be applied topically for a yeast rash, and her care plan included medication administration as an intervention for pressure ulcer prevention. The medication was observed on the resident's bedside table during a survey, and the resident stated she had an order for medications to be left at her bedside. Multiple staff interviews, including those with the LVN, ADON, RN, and DON, revealed that none were aware of the medication being left at the bedside, and all confirmed that facility policy did not allow medications to be left in residents' rooms. The facility's Medication Administration Procedures required all medications to be administered by licensed personnel, and there was no policy permitting bedside medications. The presence of the medication at the bedside was not in accordance with professional principles or facility policy, and staff acknowledged the responsibility to ensure medications are properly stored and not left accessible in resident rooms.
Failure to Provide Notice of Resident Rights to All Residents
Penalty
Summary
The facility failed to provide residents with a notice of their rights, rules, services, and charges during their stay, as required. Information regarding residents' rights was only posted in one hallway (Hallway 4), making it inaccessible to residents in other areas of the facility. Additionally, the resident rights document was not included in admission packets since November 2023, despite the facility's policy requiring that this information be provided both orally and in writing to residents or their representatives upon admission and during their stay. Interviews with multiple residents from different hallways revealed that none were aware of their rights, had not been given a document listing their rights, and had not seen any postings about resident rights, ombudsman information, or complaint procedures. Residents expressed that knowing their rights was important and would help them understand what they could expect from the facility. Cognitive assessments indicated that at least one resident had intact cognition, while others had moderate cognitive impairment, yet all were unaware of their rights due to the lack of communication and documentation provided by the facility. Staff interviews confirmed that the staff member responsible for admissions was unaware that the resident rights document needed to be included in the admission packet and had never included it since starting in the role. The administrator also acknowledged that the postings were not accessible to all residents and that there was no process in place to ensure residents received all required information. Observations during a facility tour corroborated that resident rights postings were only present in one hallway, further limiting access to this essential information.
Deficient Food Storage, Labeling, and Sanitation Practices in Dietary Services
Penalty
Summary
Surveyors observed multiple failures in the facility's food storage, preparation, and sanitation practices. In the dry storage room, a 50-pound bag of yellow onions was found sitting in water and leaking, while undated red onions were sprouting greens. A large can was present without a label or date, and a box of potatoes was found with an expired date. Cold eggs were left sitting on the stove top in a pan with a spatula, and a pitcher of tea and a pan of cake were left in a food warmer that was turned off. The tea and cake were not refrigerated as required. Additionally, the inside of the ice machine had an unknown black slime by the internal dispenser, indicating improper cleaning. Interviews with dietary staff revealed a lack of adherence to food safety protocols, including failure to label and date food, dispose of expired or questionable items, and properly clean the ice machine. Staff admitted to not removing cans without labels or dates and not knowing when the ice machine was last cleaned. The new temporary dietary manager and other staff confirmed that these practices did not align with facility policy or the Texas Food Code. Record review of facility policies confirmed the requirements for food labeling, dating, and ice machine cleaning, which were not followed.
Failure to Sanitize Blood Pressure Cuff Between Residents During Medication Pass
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two medication aides not sanitizing a blood pressure cuff between residents during medication administration. Specifically, one medication aide used the same blood pressure monitor on two residents consecutively without cleaning it in between, despite being trained to do so. The aide acknowledged the lapse when interviewed and subsequently cleaned the equipment after being prompted. The residents involved had various medical conditions, including anemia, chronic viral hepatitis C, hypertension, congestive heart failure, and atrial fibrillation, with cognitive assessments ranging from intact to moderate impairment. A similar incident occurred with another medication aide, who also failed to sanitize the blood pressure monitor between two residents during medication pass. This aide admitted forgetting to clean the equipment due to focusing on the medication pass. The Director of Nursing confirmed that the facility's expectation and policy require blood pressure cuffs to be cleaned between residents to prevent cross-contamination. The facility's infection control policy specifies that non-invasive resident care equipment should be cleaned between uses, and documentation of cleaning should be maintained.
Failure to Maintain Safe and Functional Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, as observed and confirmed through staff interviews and record review. Multiple pieces of equipment, including the coffee brewing system, the left side of the double oven, one well on the steam table, and a mobile heated delivery cart, were found to be nonfunctional or not maintaining proper temperatures. Observations revealed the heated delivery cart was only reaching 75 degrees, the coffee pot displayed a heating element malfunction error, the left well of the steam table was not working, and the left side of the oven was not heating. Staff interviews indicated that these issues had been ongoing for several months. Dietary staff reported that the warmer and steam table had been working intermittently or not at all, and that the coffee pot had been out of service for over a week. Maintenance staff were aware of some of the issues but had not completed repairs, citing reasons such as waiting for outside companies or believing the problems were electrical rather than equipment-related. Communication lapses were evident, with some staff unsure of who was responsible for reporting or following up on repairs, and maintenance requests were not consistently documented or tracked. The administrator and other supervisory staff were not fully aware of the extent or duration of the equipment failures until recently. Maintenance logs only documented the coffee pot issue, with no records available for the other broken equipment. No facility policies regarding equipment maintenance were provided for review. The lack of timely repair and inadequate documentation contributed to the ongoing deficiency in maintaining safe and functional kitchen equipment.
Failure to Ensure Dietary Staff Training and Competency
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. One dietary aide (DA B) was hired and began working in the kitchen without having completed mandatory online training, receiving training from facility management, or obtaining a food handler's certificate. Record review of DA B's employee file showed only her application and background check, with no documentation of training or certification. Interviews revealed that DA B was not trained on essential kitchen procedures, such as using the dishwasher, understanding appropriate temperatures, or proper food labeling and storage. She expressed uncertainty about her duties and concern about making mistakes due to lack of training. Other staff interviews confirmed that DA B had not received the required training or oversight before working independently in the kitchen. The traveling dietary manager and other facility leaders were unaware of DA B's lack of training and certification. The HR representative acknowledged that no further training was coordinated after DA B was hired, and the administrator assumed that traveling dietary managers were providing necessary training. No facility policies on training new dietary employees were provided, and there was no evidence of competency checks or supervision by a dietary manager prior to DA B working alone in the kitchen.
Failure in Hand Hygiene During Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene, during food preparation in the kitchen. During an observation, [NAME] C, a staff member, was seen preparing food without wearing gloves and failed to wash or sanitize her hands between tasks. She touched various surfaces, including her clothes and a utility cart, which were considered contaminated, and then proceeded to handle food and kitchen utensils without proper hand hygiene. This lack of hand hygiene was observed over a period of approximately 30 minutes, during which [NAME] C did not wash her hands until prompted by the Dietary Manager. Interviews with the Director of Operations and the Dietary Manager confirmed the observations, acknowledging that [NAME] C did not follow expected hand hygiene practices, which could lead to cross-contamination of food. [NAME] C admitted to not washing or sanitizing her hands between tasks and recognized the potential risk of contaminating food, which could result in foodborne illness for residents. The facility's hand washing policy, dated 2012, emphasized the importance of proper hand hygiene, yet the in-service training records requested were not provided at the time of the survey exit.
Failure to Maintain a Clean and Comfortable Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, leading to a deficiency in care. The resident, an elderly male with severe cognitive impairment and multiple diagnoses including Parkinson's disease and dementia, was found in a room with a strong urine odor and soiled sheets. Observations revealed that the sheets were partially wet and partially dried with urine, and the odor was particularly strong near the resident. The resident, who required substantial assistance with activities of daily living and was always incontinent of bowel and bladder, did not respond to questions or conversations during the observation. Interviews with staff members revealed a lack of awareness and action regarding the resident's condition. A CNA not assigned to the resident's care noticed the urine odor and soiled sheets but was unsure of who was responsible for the resident. Another CNA, who was assigned to the resident, did not recall the condition of the room or the resident's sheets during her rounds. The Director of Nurses stated that staff were expected to make rounds every two hours and change any soiled sheets immediately, but this protocol was not followed in this instance. The facility's policy on resident rights emphasized the importance of maintaining a safe, clean, and comfortable environment, which was not upheld in this case.
Failure to Document and Investigate Resident Grievance
Penalty
Summary
The facility failed to ensure prompt documentation and investigation of a grievance reported by a resident regarding delayed response to call lights. The resident, a male with chronic obstructive pulmonary disease, polyneuropathy, and morbid obesity, reported using the call light for assistance after a bowel movement and waiting at least forty-five minutes for staff to respond. Despite the resident's intact cognition and ability to communicate his needs, his grievance was not documented by the Director of Nurses as required by the facility's policy. The Director of Nurses acknowledged receiving the grievance from the resident and stated that she intended to document and investigate it on the same day. However, the grievance was not recorded in the facility's grievance records. The Director of Operations confirmed that grievances should be documented immediately and investigated promptly, with the Director of Nurses responsible for grievances related to call lights. The facility's policy outlines specific steps for documenting and investigating grievances, which were not followed in this instance.
Resident Not Properly Positioned During Meals
Penalty
Summary
The facility failed to ensure that a resident who was unable to perform activities of daily living received the necessary services to maintain functional abilities. Specifically, the facility did not place a resident in a safe and comfortable position while eating, which placed the resident at risk of discomfort and choking/aspiration. The resident, a male with a history of multiple sclerosis, dysphagia, and cognitive communication deficit, was observed lying in bed with the head slightly elevated while eating breakfast. Despite the resident's preference to sit up while eating, he was seen struggling to lift his head and see his food. Interviews with staff and the resident's responsible party confirmed concerns about the resident's positioning during meals. The staff acknowledged that residents should be in an upright position to prevent choking and aid digestion. The Assistant Director of Nursing noted that the resident's position in the video was unsafe, and the Administrator admitted the resident did not look comfortable. Despite this, the Administrator and Administrator in Training mentioned the importance of respecting the resident's wishes, even though the resident expressed difficulty eating while lying down.
Infection Control Deficiencies in PPE Use and Hair Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to enhanced barrier precautions (EBP) for a resident with specific care needs. A video observation revealed a staff member in the resident's room handling linens and the resident's diaper without wearing the required personal protective equipment (PPE), such as gowns and gloves. Interviews with various staff members, including a CNA, LVN, MA, and the ADON, confirmed that they were aware of the EBP requirements, which include wearing PPE during high-contact activities to prevent infection transmission. However, the staff did not consistently follow these protocols, as noted in the video and corroborated by the resident's statement that staff did not always wear gowns during care. Additionally, another video observation showed a housekeeping supervisor and a CNA providing care without gowns, despite the resident being on EBP. The housekeeping supervisor's long hair was not tied back, and it came into contact with dirty linens and the floor, posing a risk of cross-contamination. Interviews with the RN, ADON, and the ADM confirmed that long hair should be tied back to prevent infection risks. The facility's policy on dress code and grooming also required employees providing direct care to keep their hair pulled back, which was not adhered to in this instance.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for residents who require assistance with activities of daily living. This deficiency was identified during observations on a specific date when the call light for a resident with severe cognitive impairment and multiple medical conditions, including cerebral infarction and dysphagia, was found underneath the bed and out of reach. The resident's care plan specifically included the need for a safe environment with a working and reachable call light due to their dependency on staff for various activities of daily living. Interviews with facility staff, including a CNA and the DON, confirmed that call lights should always be within reach to allow residents to call for assistance. The CNA acknowledged that if a call light is not accessible, residents might attempt to get help on their own, potentially leading to falls. The DON emphasized the importance of CNAs ensuring call lights are in place during rounds. The ADM stated that rounds should be conducted at least every two hours, and staff should ensure residents are comfortable and have their call lights within reach. However, it was noted that the facility did not have a specific call light policy in place.
Unsafe Discharge of Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide and document an effective discharge planning process for a resident, leading to an unsafe discharge. The resident, who was blind and moderately cognitively impaired, was discharged from the facility and left unsupervised on the front porch of a home located on a busy street. The resident was at risk for elopement and had a history of elopement, making the situation particularly dangerous. The facility did not ensure that a responsible party was present to receive the resident, and the discharge occurred despite an ongoing appeal process. The resident's care plan indicated that discharge was not feasible due to the resident's dementia, inability to care for himself, and risk of elopement. Despite this, the facility proceeded with the discharge, citing ongoing behaviors as the reason. The facility attempted to find alternative placements, including a behavioral psychiatric hospital, but these efforts were unsuccessful. The decision to discharge the resident to the family was made without confirmation from the family, and the resident was left unattended, leading to a situation where the resident was confused and at risk of harm. Interviews with facility staff revealed that the discharge process was not coordinated with the resident's responsible parties, and the facility did not wait for the appeal process to be completed. The staff left the resident's medications and aftercare instructions on the porch, and the resident was left sitting outside with his belongings. The facility's actions were not in compliance with their discharge policy, which requires coordination with family representatives and ensuring a safe discharge environment.
Failure to Review and Revise Care Plan Quarterly
Penalty
Summary
The facility failed to review and revise the care plan for one resident, identified as Resident #1, within the required quarterly timeframe. Resident #1's care plan was last reviewed and revised on 12/29/23, but the next quarterly review, due by 03/29/24, was not completed. This oversight was discovered during a record review and interviews conducted on 04/25/24. Resident #1, a male with multiple diagnoses including unspecified dementia, major depressive disorder, and chronic obstructive pulmonary disease, had a moderate cognitive impairment with a BIMS score of 8 and required varying levels of assistance with daily activities. The failure to update his care plan could potentially impact his health, safety, and well-being, as his care needs may not be adequately met in a timely manner. Interviews with the facility staff, including two MDS Coordinators and the Director of Nursing (DON), revealed that the care plans were supposed to be reviewed and revised quarterly, as well as during significant changes in the resident's condition or as needed. Both MDS Coordinators and the DON acknowledged the importance of timely care plan reviews to ensure residents' needs are met. However, they were unaware that Resident #1's care plan had not been updated since December 2023. The MDS Coordinators cited high admission rates and workload as reasons for the oversight, with one coordinator mentioning that she had not been working full-time until after the missed deadline. The facility's policy on Comprehensive Care Planning mandates that care plans be reviewed and revised after each admission, quarterly, annually, and during significant changes in the resident's condition. Despite this policy, the facility failed to adhere to the required schedule for Resident #1, leading to a lapse in the care planning process. The DON mentioned that corporate oversight and training were in place, but it was unclear when the last in-service training for the MDS Coordinators occurred. This deficiency highlights a gap in the facility's adherence to its own care planning procedures, potentially affecting the quality of care provided to residents.
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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.
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Nursing homes near Bryan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Joseph Manor | 0.2 mi | — | 5 | 0 |
| Crestview Retirement Community | 0.4 mi | — | 0 | 0 |
| Legacy Nursing And Rehabilitation | 0.7 mi | — | 5 | 0 |
| Five Points Nursing & Rehabilitation Of College St | 5.7 mi | — | 5 | 1 |
| Fortress Nursing And Rehabilitation | 6.5 mi | — | 3 | 0 |
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