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 Northern Oaks Living & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to discontinue or appropriately justify extended PRN lorazepam orders for three residents with dementia, anxiety, and other comorbidities. In each case, electronic physician orders showed PRN lorazepam initiated without an end date and remaining active well beyond 14 days, while MDS assessments did not reflect anti-anxiety medication use and physician progress notes lacked any documented rationale for continuation. Medication administration records showed that one resident received lorazepam on two occasions over two months, while the other two residents had no lorazepam doses administered despite active PRN orders. The DON stated that psychotropic PRN orders should not exceed 14 days and acknowledged responsibility for reviewing new orders daily, and the facility’s psychotropic drug use policy limited PRN psychotropic orders to 14 days unless the physician documented a rationale and specified duration.
Surveyors found that one medication cart contained expired Nitroglycerin and Ondansetron for two residents, as well as opened but undated insulin pens for two other residents. An RN and the DON reported that nurses are responsible for dating multiuse medications when opened, checking dates before administration, and removing expired drugs from the cart, but also acknowledged there was no specific policy on dating insulin or other multiuse dose medications, despite a general policy requiring removal and destruction of outdated medications.
Surveyors found that one medication cart contained two insulin pens without open dates and two expired medications (nitroglycerin and ondansetron) that had not been removed from stock. An RN and the DON both stated that multiuse medications should be dated when opened, checked before each administration, and that expired medications should be removed immediately, but also acknowledged that the facility lacked a specific policy on dating insulin and other multiuse dose medications.
A resident with neurocognitive disorder with Lewy bodies and generalized anxiety disorder received multiple PRN doses of lorazepam for anxiety and restlessness without documented informed consent from the resident or her POA. The care plan required education on risks, benefits, and side effects of antianxiety medication, and facility policy required completion of informed consent for new psychoactive medications. The order for lorazepam was entered by an RN after receiving it from hospice, and the MAR showed repeated administrations, but no consent form was found in the EMR or pending for upload. The DON, an LVN, and medical records staff all confirmed that lorazepam required consent and that none was on file, while the POA reported learning of the medication from hospice and did not recall facility staff explaining side effects.
A male resident with bowel and bladder incontinence and a history of urinary system conditions had a care plan directing staff to wash, rinse, and dry the perineum, consistent with the facility’s peri-care policy. During an observed incontinent brief change, one CNA removed a soiled brief, wiped the buttocks multiple times with the same wipe, and another CNA then applied a clean brief without cleansing the penis or peri-area. In interviews, the CNAs reported they did not recognize they were performing peri-care, believed genital cleansing occurred during showers, and did not perceive risk from omitting penile and peri-area cleaning, while the DON stated that the penis and peri-area must be cleaned with each episode of incontinent care and that she was responsible for CNA training.
A resident with a terminal neurocognitive disorder was on hospice services, but the facility failed to maintain required hospice documentation and coordinate care as outlined in the care plan and hospice contract. The resident’s chart and hospice binder lacked the Texas Medicaid Hospice Recipient Election/Cancellation form, Physician Certification of Terminal Illness, current interdisciplinary notes, and evidence of communication with the hospice provider, despite reports that hospice staff visited frequently and participated in care plan meetings. The DON could not identify a current hospice coordinator, while posted signage still listed a former ADON who was no longer employed, and the facility’s end-of-life policy did not specify a designated person or process for hospice collaboration and care planning.
The facility did not ensure that results of recent surveys and complaint investigations, including plans of correction, were posted in an accessible location for residents, families, and legal representatives. Surveyors found that only an older standard survey was available in the survey binder near the nurses' station, and multiple subsequent investigation findings were missing. The Administrator, who was responsible for maintaining the binder, reported he was unaware that investigation results needed to be included and confirmed that no policy on posting survey results was identified.
A resident with severe cognitive impairment and a history of repeated falls had a care plan listing a floor mat at bedside as a fall prevention intervention, but the mat was not in use and the care plan was not updated to reflect this. Staff interviews revealed confusion about care plan access and implementation, and the outdated intervention remained visible to CNAs in the electronic system, leading to inconsistencies between documented and actual care.
The facility failed to provide necessary assistance with ADLs for three residents, resulting in poor hygiene and body odor. A resident with chronic heart failure and dementia, another with diabetes and anemia, and a third with diabetes and heart disease were observed with poor hygiene due to missed showers. Staff interviews and shower logs confirmed the deficiency, with the DON acknowledging the issue.
A facility failed to implement a comprehensive care plan for a resident with malnutrition and severe cognitive impairment. The care plan required house shakes with every meal, but observations showed the resident did not receive a shake. Staff interviews revealed discrepancies between care plans and physician orders, and the facility's policy emphasized the need for specific care plans, which was not met in this case.
A resident's Quarterly MDS assessment was inaccurately coded to show anticoagulant medication use, despite the resident only being prescribed antiplatelet medications like clopidogrel bisulfate and aspirin. The MDS coordinator acknowledged the error, and the DON confirmed the expectation for accurate assessments, although the facility lacked a specific policy for assessment accuracy.
The facility failed to update comprehensive care plans for two residents in a timely manner. One resident's care plan was not revised to remove a discontinued medication, and another resident's care plan did not include hospice services promptly. Staff interviews revealed uncertainty about the time frame for updating care plans, despite acknowledging the need for accurate and resident-specific plans.
Failure to Discontinue or Justify Extended PRN Lorazepam Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from chemical restraints and that PRN psychotropic medications were managed according to regulatory and facility policy requirements. For one resident, a female with anxiety, dementia, and respiratory failure, the electronic physician orders showed a PRN lorazepam 0.5 mg tablet to be given every three hours as needed for anxiety/restlessness, starting in mid-October with no end date. Her discharge MDS assessment did not reflect the use of anti-anxiety medications, and physician progress notes from November through January contained no documented rationale for the continued provision of lorazepam or risperidone. The MAR showed lorazepam was administered once in December and once in January, and there was no documentation that the PRN order had been discontinued after 14 days or that a rationale for continuation had been entered. Another resident, a female with Alzheimer’s disease, cognitive communication deficit, and depression, also had an electronic physician order for PRN lorazepam 0.5 mg every three hours as needed for anxiety, starting in early July with no end date. Her quarterly MDS assessment did not indicate that she was receiving anti-anxiety medications, and physician progress notes from November through January did not contain a documented rationale for the continued PRN lorazepam order. Review of her MAR for December and January showed that no doses of lorazepam were administered during those months, yet the PRN order remained active beyond 14 days without an end date or documented justification. A third resident, a male with dementia, anxiety, and a history of cerebral infarction, had two active PRN lorazepam orders: 0.5 mg every two hours as needed and 1 mg (two 0.5 mg tablets) every two hours as needed for anxiety, agitation, or restlessness, both starting in early October with no end date. His quarterly MDS assessment did not show that he was receiving anti-anxiety medications, and physician progress notes from November through January lacked any documented rationale for the continued PRN lorazepam orders. MAR reviews for December and January showed no lorazepam doses administered. During an interview, the DON acknowledged that psychotropic PRN orders, including anti-anxiety medications, should not be scheduled for more than 14 days without appropriate documentation, and the facility’s psychotropic drug use policy specified that PRN psychotropic orders are limited to 14 days unless the physician documents a rationale and duration in the medical record.
Expired and Undated Medications Found on Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to expired and undated medications on one of three medication carts reviewed (the Hall 200/300 cart). During an observation, the cart was found to contain a bottle of Nitroglycerin for Resident #15 with an expiration date of 12/22/2025 and a box of Ondansetron for Resident #33 with an expiration date of 12/07/2025, both of which remained on the cart past their expiration dates. The same cart also contained a Novolin 70/30 FlexPen for Resident #2 and a Lantus FlexPen for Resident #69 that had been opened but were not dated, contrary to expected practice for multiuse vials and pens. In interviews, RN-E stated that all multiuse vials should be dated when opened, that nurses are responsible for dating medications at first use and checking dates prior to administration, and that expired medications should be removed from the cart during routine checks. The DON similarly stated that all multiuse dose medications, including insulin, should be dated when opened by the nurse and checked each time before administration, and that expired medications should be removed from the cart immediately. She also acknowledged that the facility did not have a policy specifically addressing the dating of insulin or other multiuse dose medications, although the existing “Medication Access and Storage” policy required outdated, contaminated, or deteriorated medications to be immediately removed from stock, disposed of according to destruction procedures, and reordered from the pharmacy.
Failure to Properly Date and Remove Expired Medications From Medication Cart
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication labeling and storage practices on one of three medication carts (Hall 200/300). During an observation, the cart contained a Novolin 70/30 FlexPen for Resident #2 and a Lantus FlexPen for Resident #69 that were not labeled with an open date, despite being multiuse insulin pens. The same cart also contained a bottle of nitroglycerin for Resident #15 with an expiration date of 12/22/2025 and a box of ondansetron with an expiration date of 12/07/2025, both of which remained on the cart past their expiration dates. The facility’s written policy on Medication Access and Storage stated that outdated, contaminated, or deteriorated medications are to be immediately removed from stock, disposed of according to destruction procedures, and reordered from the pharmacy. In interviews, RN-E stated that all multiuse vials should be dated when opened, that it was the nurse’s responsibility to date medications upon opening and to check dates prior to administration, and that expired medications should be removed from the cart, which should be routinely checked for expired medications. RN-E acknowledged that not putting an open date on multiuse medications could result in residents receiving expired medications. The DON similarly stated that all multiuse vials should be dated when opened by the nurse who first uses them and checked each time they are administered, and that expired medications should be removed from the cart immediately. The DON also confirmed that the pharmacy conducted random cart checks but emphasized that nurses were ultimately responsible for ensuring medications requiring dating were dated, and she acknowledged that the facility did not have a policy specifically addressing the dating of insulin or other multiuse dose medications.
Failure to Obtain Informed Consent for Lorazepam Prior to Administration
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document informed consent for an antianxiety medication prior to administration for one resident. The resident was an elderly female with neurocognitive disorder with Lewy bodies and generalized anxiety disorder, admitted and later readmitted with a documented POA. A significant change MDS showed no BIMS score and documented physical, verbal, and other behavioral symptoms. Her care plan dated 1/12/2026 identified use of antianxiety medication related to anxiety disorder, with interventions including educating the resident and family about the risks, benefits, and side effects of the antianxiety drug and administering lorazepam while monitoring for specific side effects. A physician order dated 1/10/2026 directed lorazepam intensol oral concentrate 2 mg/mL, 0.5 mL by mouth every 2 hours as needed for anxiety and restlessness, entered by RN A. The MAR for January 2026 showed the resident received lorazepam multiple times on 1/13, 1/14, 1/19, 1/20, and 1/21. Review of the electronic medical record on 1/21/2026 revealed no evidence that the resident or her representative had consented to lorazepam. The resident’s POA reported being notified of the medication by hospice staff and did not recall facility staff explaining side effects, only knowing from her own understanding that lorazepam would cause drowsiness because it was for anxiety. Interviews with facility staff confirmed that the facility’s process required nurses to obtain informed consent for psychoactive medications prior to administration and that lorazepam required such consent. The DON stated she expected the charge nurse to obtain consent when entering the order and verified that no consent was present in the electronic record or in the basket where documents awaited upload. An LVN stated nurses were responsible for obtaining consents at the time orders were taken, that lorazepam required consent, and that she was unaware no consent existed for this resident. The medical records staff reported having no pending paperwork for the resident. RN A stated she received the lorazepam order from the hospice nurse, entered it into the record, told the hospice nurse to speak with the family because it was the middle of the night, and began the consent paperwork for day shift to obtain signatures, but did not know where that paperwork was if it was not in the record. Facility residents’ rights postings and facility policy required informed consent for psychoactive medications, including completion of a Verification of Informed Consent form upon initiation of new psychoactive medications, which was not documented for this resident’s lorazepam use.
Failure to Provide Proper Perineal Care During Incontinent Brief Change
Penalty
Summary
A resident with a history of urinary system surgery, obstructive and reflux uropathy, and ureteral calculi was admitted with bowel and bladder incontinence related to Alzheimer's disease. The admission MDS documented that the resident was always incontinent of bladder and frequently incontinent of bowel, and the care plan directed staff to wash, rinse, and dry the perineum. The facility’s perineal care policy stated that peri-care is to cleanse the perineum, eliminate odor, and prevent irritation or infection, with procedures emphasizing proper cleansing technique. During an observed incontinent brief change, one CNA removed the resident’s soiled brief, dropped it on the floor, and wiped the resident’s entire buttocks multiple times with the same wipe. The CNA then stepped away to get new gloves, and a second CNA sanitized her hands, donned gloves, and applied a clean brief without performing any peri-care or cleansing of the penis or genital area. In a subsequent interview, both CNAs stated they did not realize they were performing peri-care, believed the penis was usually cleaned during showers, and did not see any risk or negative outcomes from not cleaning the penis or peri-area. The DON stated that the penis and peri-area must be cleaned every time incontinent care is performed and that failure to provide proper incontinent care could lead to urinary tract infections, and also stated she was responsible for ensuring CNAs were trained properly but did not provide an explanation of when or how staff were trained.
Failure to Coordinate and Document Hospice Services for a Terminally Ill Resident
Penalty
Summary
The deficiency involves the facility’s failure to collaborate with a hospice provider and coordinate hospice care planning and documentation for a resident receiving hospice services. The resident was an elderly female with a diagnosis of neurocognitive disorder with Lewy bodies and a documented terminal prognosis, with a significant change MDS indicating a condition that may result in a life expectancy of less than six months. Her care plan identified that she was on hospice services and outlined both facility and hospice responsibilities, including hospice RN, aide, social worker, chaplain, physician, and volunteer visits, as well as expectations for communication and care plan meetings. Record review showed that although there was a physician order to admit the resident to hospice care, the resident’s electronic chart did not contain required hospice documentation. Specifically, there was no Texas Medicaid Hospice Recipient Election/Cancellation form, no Physician Certification of Terminal Illness form, no current interdisciplinary notes, and no evidence of communication between the facility and the hospice provider in the resident’s record. Review of the hospice binder behind the nurses’ station revealed only an out-of-hospital DNR form for the resident, with no other hospice documentation present. Interviews further demonstrated a lack of clear coordination and designated responsibility for hospice communication. The resident’s POA reported that hospice staff were frequently present, had notified her of a change in condition, and had participated in a care plan meeting with facility staff, but this activity was not reflected in the facility’s documentation. The DON acknowledged that the hospice binder for the resident lacked key hospice documents and stated that hospice was at the facility daily for the resident, and that charge nurses could communicate with hospice, but did not identify a designated hospice coordinator. A posting in the hallway still listed a former ADON, whose employment had ended months earlier, as the hospice coordinator, and the DON did not identify a replacement. Review of the hospice contract showed that hospice was to make specific forms and interdisciplinary documentation available to the facility, and review of the facility’s end-of-life care policy showed no designated person or process for hospice collaboration and care coordination.
Failure to Post Recent Survey and Investigation Results for Resident and Family Access
Penalty
Summary
The facility failed to post the results of the most recent surveys and investigations, including plans of correction, in a location readily accessible to residents, family members, and legal representatives. During an observation, surveyors found that the only available information was a survey binder in a bin labeled "survey binder" near the first hall to the right of the nurses' station, with a sign indicating its location. Review of this binder showed it contained only the last standard recertification survey dated 10/29/2024 and did not include any subsequent investigation findings. In an interview, the Administrator stated he was responsible for updating the survey binder but was unaware that investigation findings, along with their plans of correction, also needed to be included. He confirmed that the last survey results placed in the binder were from the 10/29/2024 standard survey and acknowledged that investigation findings from 1/26/2025, 3/07/2025, 5/25/2025, 8/01/2025, 10/16/2025, 11/07/2025, and 1/15/2026 were not posted. He reported that no one had requested these investigation findings and that mock surveys conducted by administrators from sister facilities had not identified the omission. The Administrator also stated he did not know if the facility had a policy regarding survey result posting, and no such policy was provided at exit conference.
Failure to Update and Revise Care Plan Interventions for Fall Prevention
Penalty
Summary
The facility failed to periodically review and revise the care plan for a resident with a history of dementia, muscle weakness, unsteady gait, and repeated falls. The resident's care plan included an intervention for a floor mat at bedside to prevent falls, but this intervention was not updated or removed when it was no longer in use. Observations on multiple occasions confirmed that no floor mat was present at the resident's bedside, despite it being listed in the care plan and visible to CNAs in their electronic charting system. Interviews with staff revealed confusion and lack of clarity regarding the implementation and updating of care plan interventions. CNAs reported not seeing a floor mat in use and were unsure how to access or interpret care plans, often relying on charge nurses for direction. The MDS coordinator and DON acknowledged that the floor mat intervention remained on the care plan due to it being added by a previous nurse years prior, and that it was not part of the current plan of care. However, the intervention was still listed in the system accessed by direct care staff, leading to inconsistencies between documented care plans and actual care provided. The facility's policies required the interdisciplinary team to review and revise care plans after each assessment and following falls, but the care plan for this resident was not appropriately updated to reflect current interventions. The lack of timely revision and removal of outdated interventions from the care plan resulted in discrepancies between the care plan and the care actually provided, as well as confusion among staff regarding which interventions should be implemented.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, resulting in poor hygiene and body odor. Resident #1, a female with chronic heart failure, hypertension, and dementia, was observed with an odor and messy hair. Her care plan required supervision and assistance with bathing three times a week, but her shower log indicated she only received showers on two occasions over a two-week period. Resident #2, a male with diabetes mellitus, anemia, and muscle weakness, also reported not receiving showers and was observed with an odor, dry flaky skin, and long fingernails. His care plan similarly required assistance with bathing three times a week, but his shower log showed no showers during the same period. Resident #3, a male with type 2 diabetes, heart disease, and a pressure ulcer, required two staff members for bathing assistance. He was observed with an odor, dry flaky skin, and wearing the same clothing from the previous day. His shower log also indicated no showers during the two-week period. Interviews with staff, including a nursing assistant and the Director of Nursing (DON), confirmed that the shower logs were marked as not applicable, indicating the residents did not receive showers. The DON acknowledged the issue and noted that missing showers could lead to poor hygiene and skin breakdown.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive and person-centered care plan for a resident, identified as Resident #60, who was diagnosed with malnutrition and severe cognitive impairment. The care plan was supposed to include the provision of house shakes with every meal, as per the resident's physician orders. However, during an observation, it was noted that the resident did not receive a house shake with her meal, despite the meal ticket indicating that a shake should be served. Interviews with facility staff, including the Director of Nursing (DON) and the MDS coordinator, revealed discrepancies between the resident's care plan and physician orders. The DON acknowledged the difference and stated that the care plan and orders were updated after consulting with the dietician and physician. However, the care plan still lacked specificity, as it did not clearly state the requirement for a house shake with every meal, instead referring to the orders. The MDS coordinator believed that care plans should reflect what the staff were doing for the resident, but also mentioned that care plans did not have a significant impact on resident care due to other documentation available. The facility's policy on comprehensive person-centered care planning emphasized the need for measurable objectives and timeframes to meet residents' needs. Despite this, the care plan for Resident #60 was not specific enough to ensure the resident's nutritional needs were met, as evidenced by the absence of a house shake during meal observations. The staff relied on verbal communication and meal tickets to inform nurse aides of care plan changes, which may have contributed to the oversight.
Inaccurate Medication Assessment for a Resident
Penalty
Summary
The facility failed to accurately assess the medication status of a resident, identified as Resident #19, during a Quarterly MDS assessment. The assessment incorrectly indicated that the resident was receiving anticoagulant medication, despite the absence of any such medication in the resident's physician orders. Instead, the resident was prescribed clopidogrel bisulfate and aspirin, which are antiplatelet medications, not anticoagulants. This error was identified through a review of the resident's electronic face sheet and physician orders, which showed no evidence of anticoagulant prescriptions. Interviews with the MDS coordinator and the Director of Nursing (DON) revealed that the MDS coordinator was responsible for the assessments and acknowledged the mistake in coding. The coordinator admitted to mistakenly coding the assessment and stated that she monitors the accuracy of MDS assessments. The DON confirmed the expectation for accurate and timely MDS assessments and recognized the error in medication classification. The facility did not have a specific policy for assessment accuracy but was expected to follow the RAI manual guidelines.
Deficiency in Comprehensive Care Plan Updates
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were reviewed and revised by a team of qualified persons after each assessment. For one resident, the care plan was not updated to remove a medication that was no longer ordered, despite the medication having been discontinued several months prior. This oversight occurred within 7 days of the completion of the resident's comprehensive assessment, which indicated moderate cognitive impairment and the presence of an indwelling catheter. For another resident, the facility did not include hospice services in the comprehensive care plan within 7 days of the completion of the resident's comprehensive assessment. This resident had severe cognitive impairment and had been admitted to hospice care for a terminal diagnosis of malignant melanoma. The care plan was not updated to reflect the hospice services until several days after the resident's admission to hospice care. Interviews with facility staff revealed a lack of clarity regarding the specific time frame for updating care plans, although it was acknowledged that hospice services should be included in the care plans.
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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 Abilene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Coronado | 1.1 mi | — | 28 | 0 |
| Hendrick Skilled Nursing Facility | 1.1 mi | — | 1 | 0 |
| Silver Spring | 2.7 mi | — | 2 | 0 |
| The Oaks At Radford Hills Healthcare Center | 2.9 mi | — | 12 | 0 |
| Willowcreek Rehab And Nursing | 3.5 mi | — | 1 | 0 |
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