Legacy Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Cameron, Texas.
- Location
- 2202 N Travis Ave, Cameron, Texas 76520
- CMS Provider Number
- 676174
- Inspections on file
- 31
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation during CMS and state inspections, most recent first.
Kitchen staff failed to properly thaw, store, label, date, and discard food items, and surveyors observed trash cans without lids, expired and unlabeled foods in the refrigerator, freezer, and pantry, and raw chicken thawing improperly in the sink. Staff also failed to perform hand hygiene after glove removal and after handling raw chicken, a dishwasher wore no beard restraint, and an ADON fed a resident with severe cognitive impairment after touching contaminated surfaces and the resident’s food without washing or sanitizing hands.
Resident Council Meetings Not Held Monthly: The facility failed to ensure Resident Council met on a monthly basis for six confidential residents reviewed. Record review showed the council did not meet in two months, and residents stated they wanted to be invited to council and have monthly meetings but were not given a reason for the missed meetings. The Activity Director was unsure of the meeting requirement, and the Administrator stated the facility policy required monthly meetings and that the Activity Dept was responsible for ensuring they occurred.
Failure to provide individualized activity programming: Three residents with anxiety, depression, and dementia-related diagnoses did not receive group, in-room, or independent activities despite care plans and MDSs identifying activity preferences and the need for person-centered programming. Staff stated they had not asked the residents about preferences, no participation records showed activities were provided, and observations showed one resident repeatedly yelling in her room, one resident lying in bed requesting in-room interaction, and one resident agitated and yelling in the common area.
Unlocked Medication Carts Left Medications Accessible: Two medication carts were observed unlocked and unattended, with the locking mechanisms protruding outward while staff were nearby but not monitoring the carts. The ADON, RN Supervisor, and DON all stated medication carts should be locked when not in use, and the facility policy required medication compartments to be locked when not in use.
MDS Did Not Reflect Active Dialysis A resident with ESRD, CKD, DM, and heart disease had active dialysis on M/W/F, but the MDS did not document dialysis in Section O. The care plan included dialysis, yet the 802 Resident Matrix also did not list the resident for dialysis because it pulled from the MDS. The DON, corporate MDS nurse, and Administrator all stated they did not know why the dialysis information was missing.
Dirty, rough fingernails were observed on three residents who required ADL assistance. One resident had hemiplegia and intact cognition, another had severe cognitive impairment with dementia, and a third had dementia and diabetes; all required staff help with hygiene and grooming, and one required nursing nail care due to diabetes. Staff and the DON stated the residents did not refuse care, and the facility policy required nails to be clean, clipped, and filed smoothly.
A cook was hired and allowed to prepare meals without a current Texas food handler certificate, contrary to facility policy requiring food service staff to be trained and competent before handling or serving food. The cook believed a prior certificate was still active but had not confirmed its validity and had no certificate on file. The Dietary Manager did not verify the cook’s credential when she began overseeing the department and acknowledged the cook had been preparing meals without the required license. HR had scheduled a food handler class shortly after the cook’s hire but did not confirm attendance or completion and failed to ensure the certificate was obtained and filed, while the ADM stated the Dietary Manager and HR shared responsibility for verifying and filing the required credential.
A resident was not provided with hospice services, nor was assistance given to transfer the resident to a facility that could arrange for hospice care, resulting in a deficiency related to the provision of end-of-life services.
Three residents experienced misappropriation of their controlled medications when an ADON removed discontinued narcotics from a medication cart without proper documentation or following required procedures, resulting in missing doses for each resident. The ADON did not count or sign out the medications, and the narcotic logs showed discrepancies and unrecognized signatures. Staff interviews and record reviews confirmed that facility policies for handling and securing discontinued narcotics were not followed.
A resident experienced a significant weight loss of 10.98% in less than 60 days due to inadequate monitoring and intervention by the facility. Despite being at risk for weight loss, the resident's nutritional needs were not addressed, and staff were unaware of the severity of the situation. Communication gaps and a lack of timely evaluation by the dietitian contributed to the deficiency.
A facility's medication error rate was found to be 9.68%, exceeding the acceptable threshold of 5%. This involved two residents and one medication aide who failed to check vital signs before administering medications as per physician orders. The residents had severe cognitive impairments and conditions requiring specific medication parameters, which were not adhered to, leading to the deficiency.
The facility failed to maintain sanitary conditions in its kitchen and nourishment room, with unlabeled and undated food in the walk-in cooler, improperly stored scoops in bulk food bins, and expired items in the nourishment room refrigerator. Interviews with the DM, DON, and Administrator confirmed these practices could lead to foodborne illnesses, violating the facility's Food Safety and Sanitation Policy.
A facility failed to update a resident's care plan after an arterial status ulcer on the right great toe was resolved. The MDS Coordinator did not revise the care plan, which could lead to errors in care. The DON emphasized the importance of updating care plans to ensure proper resident care.
Two residents in an LTC facility did not receive necessary assistance with ADLs, leading to deficiencies in personal hygiene. A male resident with diabetes had dirty and rough fingernails despite requesting care, while a female resident with intact cognition was embarrassed by facial hair she could not remove. Staff interviews revealed a lack of awareness and communication regarding these residents' needs, highlighting systemic issues in the facility's care provision.
A resident identified as a fall risk did not have a fall mat placed beside her bed as required by her care plan. Despite being severely cognitively impaired and having a history of falls, the fall mat was found against a chest of drawers instead. Staff interviews confirmed the oversight, acknowledging the mat's necessity as per the resident's care plan and Kardex. The facility's fall protocol was not followed, leading to a deficiency in accident prevention measures.
Kitchen Food Safety and Hand Hygiene Failures
Penalty
Summary
The facility failed to properly store, prepare, and distribute food in the kitchen. During the initial kitchen tour on 02/10/2026, surveyors observed 3 trash cans without lids, large bins of sugar and flour in the food preparation area without discard or use-by dates, and multiple food items in the walk-in refrigerator and freezer that were unlabeled, undated, or missing discard dates. These included deli turkey, shredded cheese, sliced cheese, boiled eggs, an unknown product resembling icing, tortillas, enchilada sauce, coleslaw dressing, chicken, and a breaded item resembling biscuits. The dry pantry also contained expired cereal and dented cans of carrots. Surveyors also observed improper thawing and handling of food. On 02/10/2026, two large turkey breasts and a storage bag of ground beef were sitting in a sink thawing with no running water. On 02/11/2026, raw chicken was observed thawing in the sink without a container. The dietary aide stated she thought that was how meat was thawed, and the dietary manager later stated that raw chicken should have been placed in a container or thawed in the walk-in refrigerator. The dietary manager also stated that food labeling should include the received date and that cooked food is labeled with the received date, opened or prepared date, and discard date. The report also documented hand hygiene and hair restraint failures. A cook was observed not washing or sanitizing her hands after removing gloves and after handling raw chicken before touching another food item. A dishwasher with a beard of approximately 2 inches was observed without a beard restraint, despite stating he knew hair restraints should be worn in the kitchen. In addition, the ADON was observed touching a chair, the resident’s clothing, wheelchair, plate, spoon, napkin, and food while feeding a resident with severe cognitive impairment and without washing or sanitizing her hands. The resident had a BIMS score of 1, required staff assistance with eating, and had diagnoses including dementia, osteoporosis, and anxiety disorder.
Resident Council Meetings Not Held Monthly
Penalty
Summary
The facility failed to ensure residents had the right to organize and participate in Resident Council meetings for six of six confidential residents reviewed. Record review of Resident Council minutes from 09/2025 through 02/2026 showed the council did not meet during October 2025 and January 2026. During a confidential group interview, six residents stated they wanted to be invited to Resident Council and wanted meetings held once a month. They also stated they had not been having monthly Resident Council meetings and were not given a reason why the meetings were not held on a regular basis. During an interview on 02/11/2026, the Activity Director stated she was unsure how many times Resident Council was required to meet and said she would review the facility policy, but she did not complete the interview with the surveyor before exit. During an interview on 02/12/2026, the Administrator stated the facility policy required Resident Council to meet monthly and that this was his expectation. He stated the Resident Council President was not feeling well when the meeting was scheduled in January 2026, that the meeting could have been changed to another date, and that someone in the Activity Department could have informed residents of the change. He stated it was the Activity Director's responsibility to ensure Resident Council meets monthly.
Failure to Provide Individualized Activity Programming
Penalty
Summary
The facility failed to provide an ongoing activity program that supported residents’ choices of activities, including facility-sponsored group activities, individual activities, and independent activities, for 3 of 8 residents reviewed for activities. Resident #41, Resident #50, and Resident #69 did not receive activities during January and February 2026, despite care plans and assessments reflecting activity preferences and the need for individualized programming. Resident #41 had diagnoses including anxiety disorder, depression, dementia with behavioral disturbance, and chronic pain syndrome. Her baseline care plan stated she preferred to attend activities of her choice and should be encouraged to attend different activities. However, activity participation records showed she had not been provided any activity by activity staff in her room or in a group since admission. During observations, she was repeatedly seen in her room in a wheelchair yelling for help, pulling on her hearing aids, and not responding appropriately to questions about her needs or preferences. The Activity Director stated she had not asked Resident #41 about her activity preferences, had not asked the resident or family what activities she enjoyed, and had not provided any type of activity item or activity program. Resident #50 had diagnoses including major depressive disorder, anxiety disorder, and unspecified dementia with behavioral disturbance. His MDS reflected a BIMS score of 7, indicating severely impaired cognition, and his care plan stated he preferred activities of his choice and should be encouraged to attend different activities. During observation, he was lying in bed with the television off and stated he did not enjoy group activities and would prefer someone to come to his room to talk with him and maybe play cards. The Activity Director stated she had not asked Resident #50 about his activity preferences and that there were no participation records showing he received any activities in January or February 2026. Resident #69 had diagnoses including anxiety disorder, unspecified dementia with behavioral disturbance, and type 2 diabetes mellitus with kidney complication. His MDS reflected a BIMS score of 9, indicating moderately impaired cognition, and his assessment identified several activities as very important to him, including reading, listening to music, being around pets, keeping up with the news, going outside, and participating in religious services. His care plan directed staff to encourage different activities, remind him of upcoming activities, and review his preferences. However, he was observed in the common area yelling, attempting to remove his clothes, trying to stand from a recliner, and continuing to yell and display agitation over multiple observations. The Activity Director stated he was not aware of him attending group activities during January and February 2026, that he did not receive in-room activities, and that no activity item was provided to divert his attention from yelling and removing his clothes in the public area.
Unlocked Medication Carts Left Medications Accessible
Penalty
Summary
The facility failed to keep medication carts locked and medications secured in 2 of 5 medication carts reviewed. On 02/10/2026 at 9:00 a.m., Medication Cart #1 was observed with the locking mechanism protruding outward, indicating it was unlocked, while it was partially in the hallway on 200 hall and partially behind the nurse’s desk on South Wing. The ADON was seated at the nurse’s desk with her back turned to the cart and stated she did not realize it was unlocked. She stated medication carts were to be locked except when a nurse was obtaining medications and reported that Medication Cart #1 contained all types of physician-prescribed medications except narcotics. On 02/11/2026 at 9:45 a.m., Medication Cart #2 was also observed unlocked, with the locking mechanism protruding outward, between the nurse’s desk on South Hall and the medication room. RN Supervisor E was about 50 feet away in a foyer and could not view the cart from where he was standing. He stated the cart was to always be locked except when dispensing medications. The DON stated on 02/12/2026 that all medication carts were expected to be locked when not in use and that residents, other staff, and visitors would have access to medications in an unlocked cart. Facility policy stated medications were to be stored in a safe, secure, and orderly manner and that compartments containing medications are locked when not in use.
MDS Did Not Reflect Resident’s Active Dialysis
Penalty
Summary
The facility failed to ensure Resident #64’s MDS accurately reflected his status by not documenting active dialysis in Section O on the resident’s latest MDS assessments. Resident #64 was a cognitively intact male with diagnoses including hypertensive heart disease and chronic kidney disease with heart failure, stage 5 chronic kidney disease/end stage renal disease, type II diabetes mellitus with diabetic chronic kidney disease, and acute osteomyelitis of the left ankle and foot. His care plan dated 2/10/2026 included a focus area for dialysis on Monday, Wednesday, and Friday, and the resident stated he was receiving dialysis at admission and continued to attend dialysis on those days. Record review also showed the facility’s 802 Resident Matrix dated 2/10/2026 did not list Resident #64 for dialysis. The DON stated the corporate MDS nurse was responsible for updating the MDS and that the MDS should reflect current, correct resident information, but she did not know why dialysis was missing. The corporate MDS nurse stated she updates the MDS, typically verifies dialysis by reviewing the MAR and chart, and acknowledged she did not have a better answer for why dialysis was not included. The Administrator stated he did not know why the resident was not listed on the 802 or why dialysis was not documented on the MDS.
Dirty, Rough Fingernails Not Addressed for Residents Needing ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who required assistance with activities of daily living received nail care that kept their fingernails clean and free of rough edges. During observation on 02/10/2026, Resident #10, Resident #50, and Resident #69 were each found with blackish/brownish substance underneath fingernails and with rough edges on their nails. Resident #10 was observed lying in bed with rough edges on the right hand fingernails and blackish/brownish substance under the middle and fore fingernails. Resident #50 was observed lying in bed with blackish/brownish substance under fingernails on both hands and rough edges on the right hand fingernails. Resident #69 was observed sitting in a recliner in the common area with blackish/brownish substance under fingernails on the left hand and rough edges on those nails. Record review showed that Resident #10 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, cerebral infarction, and lymphedema. His MDS reflected intact cognition with a BIMS score of 15, no refusal of care, and substantial to maximal assistance needed for personal hygiene and other ADLs. His care plan included assistance with hygiene and grooming tasks and bathing. Resident #50 had diagnoses including major depressive disorder, anxiety disorder, and unspecified dementia with behavioral disturbance. His MDS reflected a BIMS score of 7, no refusal of care, and supervision or touching assistance needed for personal hygiene, showers, and transfers. His revised care plan stated he required staff assistance for all ADLs, including hygiene, grooming, bathing, and adjusting clothing. Resident #69 had diagnoses including anxiety disorder, unspecified dementia with behavioral disturbance, and type 2 diabetes mellitus with other diabetic kidney complication. His MDS reflected a BIMS score of 9, no refusal of care, and supervision or touching assistance needed for personal hygiene, toileting hygiene, and oral hygiene, with partial to moderate assistance needed for showers, dressing, and shower transfers. His care plan stated he required assistance with personal hygiene. Interviews with the DON, charge nurse, and CNAs showed that CNAs were responsible for nail care for residents without diabetes, while nurses were responsible for residents with diabetes. Staff stated the residents did not refuse nail care, and the facility policy stated fingernails should be clean, clipped, and filed smoothly as part of bath care.
Cook Worked Without Required Food Handler Certification
Penalty
Summary
The facility failed to ensure sufficient qualified dietary staff by allowing a cook to work without a current Texas food handler certificate. Record review showed that the cook was hired as a cook on 11/25/2025, and there was no food handler certificate in her personnel file. The cook reported she began working at the end of November 2025 as a cook and believed her prior food service certificate was still active, but she could not recall when it expired and had not verified its status. She acknowledged it was expected that she have an active food handler license while preparing food. Interviews with facility staff revealed multiple missed checks related to the cook’s required credential. The Dietary Manager, who returned to the facility on 01/26/2026, stated she was unaware the cook did not have a food handler license and that the cook had been preparing meals in the kitchen; she acknowledged it was her responsibility to verify the license and that the cook should have had it before preparing food. The HR staff stated the cook’s orientation occurred on 11/26/2025 and that a food handler class had been scheduled shortly after hire, but she did not know why the cook did not attend and had failed to verify course completion or obtain the certificate. The Administrator stated the Dietary Manager was responsible for ensuring the cook had the license and HR was responsible for filing it. The facility’s “Preventing Foodborne Illness Food Handling Policy and Procedure” stated that all employees who handle, prepare, or serve food must be trained in safe food handling and demonstrate competency prior to working with or serving food to residents.
Failure to Arrange Hospice Services
Penalty
Summary
The facility failed to arrange for the provision of hospice services for a resident or assist the resident in transferring to a facility that would provide such services. This deficiency indicates that the necessary steps were not taken to ensure the resident received appropriate hospice care as required.
Failure to Prevent Misappropriation of Controlled Medications
Penalty
Summary
The facility failed to protect three residents from the misappropriation of their controlled medications. One resident, who was cognitively intact and being discharged, had her Hydrocodone-Acetaminophen medication removed from the medication cart by the ADON without proper documentation or following established procedures. The ADON did not count the medication upon removal, did not sign it out, and placed it in a locked drawer in her office instead of the designated discontinued medication storage. The medication count was later found to be off by 10 tablets, and the narcotic log contained three entries with an unrecognizable signature after the last documented administration. During an audit prompted by this incident, the facility discovered that two additional residents had missing discontinued narcotics: one had 120 ml of hydromorphone liquid unaccounted for, and another had 56 tablets of Hydrocodone-Acetaminophen missing. The facility's investigation determined that the ADON was the last in the chain of custody for at least one of the missing medications and had not followed the facility's narcotic policies and procedures. The charge nurse who released the medication to the ADON did so without ensuring proper procedures were followed, despite feeling uncomfortable with the situation. Interviews with staff confirmed that the ADON did not follow the required process for handling discontinued medications, and that the facility's policy required two nurses to sign for narcotics and for discontinued medications to be placed in secure storage. The ADON admitted to removing the medication and not following procedure, but denied taking any of the medication. The facility's review of narcotic logs and interviews with the DON and other nurses corroborated the discrepancies and the failure to adhere to established protocols for controlled substances.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, as evidenced by a significant weight loss of 10.98% in less than 60 days. The resident, a female with multiple health conditions including Type 2 Diabetes Mellitus, ulcerative colitis, and end-stage renal disease, experienced a severe weight loss without appropriate interventions being implemented. Despite being at risk for weight loss due to dialysis, the resident's care plan did not adequately address her nutritional needs, and there was a lack of timely evaluation and intervention by the dietitian. Observations and interviews revealed that the resident had a decreased appetite and poor intake following an injury sustained in October 2024, which was not adequately addressed by the facility staff. The resident's breakfast tray was observed untouched, and staff interviews indicated a lack of awareness and action regarding the resident's weight loss. The Licensed Vocational Nurse (LVN) and Dietary Manager (DM) were unaware of any new nutrition interventions, and the Director of Nursing (DON) and Registered Dietitian (RD) had not evaluated the resident for weight loss or made any new recommendations. The facility's failure to monitor and address the resident's nutritional status was further compounded by communication gaps among staff. The DON stated that weight loss should be discussed daily, yet the resident's significant weight loss had not been flagged. The RD admitted to not being aware of the weight loss due to a failure in updating the weight records. This lack of coordination and timely intervention placed the resident at risk for further health decline, as her nutritional needs were not being met adequately.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed rate of 9.68% during a survey. This deficiency involved two residents and one medication aide (MA D) who did not adhere to physician orders requiring vital sign checks before administering medications. Specifically, MA D did not check the vital signs of Resident #39 and Resident #63 before administering their prescribed medications, which included Lisinopril, Metoprolol Tartrate, and Midodrine HCL. Resident #39, a female with severe cognitive impairment, essential hypertension, and tachycardia, had physician orders for Lisinopril and Metoprolol Tartrate that required holding the medication if blood pressure or pulse fell below specified parameters. However, MA D administered these medications without documenting or checking the resident's vital signs, as required by the orders. Similarly, Resident #63, also with severe cognitive impairment and a history of traumatic subarachnoid hemorrhage, had an order for Midodrine HCL that required holding the medication if blood pressure exceeded a certain threshold. MA D again failed to check the resident's blood pressure before administration. The medication aide, MA D, stated that the medication administration record (MAR) did not indicate the need for vital sign checks, which led to the oversight. The Director of Nursing (DON) confirmed that staff should check vital signs for residents with specific medication parameters and acknowledged the potential for negative outcomes if these checks are not performed. The facility's policy on medication regimen review did not address the need for vital sign parameters in medication administration.
Sanitation Deficiencies in Kitchen and Nourishment Room
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen and nourishment room, as observed during a survey. In the kitchen, food and beverages stored in the walk-in cooler were not labeled or dated, including salad dressing, juice, and milk. Additionally, scoops were improperly stored in containers of sugar, flour, and thickener powder, which could lead to contamination. In the nourishment room refrigerator on the 100 hallway, expired yogurt and an unlabeled bag with a brown substance were found, indicating a lack of proper food management. Interviews with the Dietary Manager (DM), Director of Nursing (DON), and Administrator revealed that the facility's staff did not adhere to the policy of labeling and dating foods, and improperly stored scoops in bulk food bins. The DM and DON acknowledged that these practices could expose residents to foodborne illnesses. The facility's Food Safety and Sanitation Policy requires that all time and temperature control for safety (TCS) leftovers be labeled, covered, and dated, and used within 72 hours. The FDA Food Code 2022 also specifies that scoops should be stored in a clean, protected location.
Failure to Update Resident Care Plan for Resolved Ulcer
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a history of hemiplegia, hemiparesis following a cerebral infarction, and an unstageable pressure ulcer. The resident's care plan did not reflect a revision of care for his current skin condition and wound care, specifically regarding an arterial status ulcer on his right great toe. Although the ulcer was resolved, the care plan was not updated to reflect this change, which could lead to errors in care and wound tracking. Observations and interviews revealed that the MDS Coordinator, responsible for updating care plans, did not update the resident's care plan after the ulcer healed. The Director of Nursing (DON) stated that staff are expected to update care plans with any changes to resident care, and failure to do so could result in residents not receiving proper care. The facility's policy requires that each resident's care plan remain current and inform staff of the resident's needs, strengths, goals, and approaches, and be reviewed quarterly and as needed.
Deficiencies in ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance for activities of daily living (ADLs) to two residents, leading to deficiencies in personal hygiene and grooming. Resident #34, a male with type 2 diabetes, diabetic polyneuropathy, and peripheral vascular disease, required staff assistance for all ADLs. Despite this, observations on two consecutive days revealed that his fingernails were dirty and had rough edges. Resident #34 reported that he had requested nail care from staff but resorted to biting his nails due to lack of assistance, which he feared could lead to infection due to his diabetic condition. Resident #75, a female with intact cognition, required assistance with personal hygiene and grooming tasks. Observations showed that she had noticeable facial hair, which she found embarrassing. Despite requesting assistance from staff to remove the hair, she did not receive the help she needed, leading to feelings of humiliation and a reluctance to socialize. Interviews with staff revealed a lack of awareness regarding her requests for facial hair removal, indicating a breakdown in communication and care provision. Interviews with nursing staff and CNAs highlighted a systemic issue in the facility's approach to ADL care, particularly for residents with specific medical conditions like diabetes. The facility's policy required nurses to handle nail care for diabetic residents, but there was a failure to ensure this was consistently done. Additionally, the staff's lack of awareness of residents' requests and needs for grooming assistance contributed to the deficiencies observed. The facility's policy on nail care was not effectively implemented, leading to potential risks for the residents involved.
Failure to Implement Fall Prevention Measures for a Resident
Penalty
Summary
The facility failed to ensure that a fall mat was placed beside the bed of Resident #61, who was identified as a fall risk. This oversight was observed on 11/13/2024, when the fall mat was found against the chest of drawers instead of beside the resident's bed. Resident #61, a female with severe cognitive impairment and a history of falls, required supervision and assistance with transfers. Her care plan included the use of a low bed and a fall mat as interventions to prevent falls. Interviews with staff, including RN A, CNA B, and CNA C, confirmed that Resident #61 was a fall risk and required a fall mat beside her bed. The staff acknowledged that the fall mat was part of the resident's care plan and Kardex, which they referred to for guidance on the care needed. Despite this, the fall mat was not in place, posing a risk of injury if the resident attempted to get out of bed unassisted. The Director of Nurses also confirmed that the fall mat was a necessary intervention for Resident #61 and that it was the responsibility of the nurse supervisor to ensure all fall devices were in place. The facility's policy on fall protocol emphasized the importance of identifying residents at risk for falls and implementing preventative strategies, including the use of fall mats. However, the failure to adhere to this protocol resulted in a deficiency in providing adequate supervision and assistance devices to prevent accidents for Resident #61.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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