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 Richland Hills Rehabilitation And Healthcare Cente during CMS and state inspections, most recent first.
A CNA transferred a resident with significant mobility limitations alone and without a mechanical lift, contrary to the resident's care plan and facility policy, which required two staff and a mechanical lift for transfers. The resident, who needed substantial assistance due to weakness and limited mobility, was not injured during the incident. The DON was unaware of the deviation from protocol until after the event.
Medication aides left two medication carts unlocked and unattended near the nurse's station, contrary to facility policy requiring all drugs and biologicals to be securely stored. Both aides acknowledged the carts were not locked, and the DON confirmed staff are expected to ensure carts are locked when unattended.
A nurse left empty medication packets containing a resident's identifiable information unattended on top of a medication cart in a hallway, making the information accessible to others. The resident had multiple complex medical conditions, and the nurse admitted to leaving the packets as a reminder to reorder medication, acknowledging this was a privacy violation. The DON confirmed staff are expected to secure all resident information.
Two residents requiring enhanced barrier precautions did not receive care using proper sterile or aseptic technique. An ADON contaminated sterile supplies during tracheostomy care, failed to maintain a sterile field, and did not perform hand hygiene between glove changes. During wound care for another resident, supplies were placed on contaminated surfaces, hand hygiene was not performed, and perineal care was incomplete. The ADON also lacked knowledge of infection control reporting and QAPI processes, and infection control in-services were not current.
The facility failed to follow the planned menu for a lunch meal by omitting dinner rolls, which were not delivered, and did not document or communicate a substitution. The Dietary Supervisor and another staff member acknowledged the oversight and its potential impact on residents' nutritional intake. Both had been previously in-serviced on menu adherence.
A malfunctioning warewasher in the facility's kitchen failed to dispense sanitizer, leaving dishes unsanitized from February 24 to February 26. Despite attempts to repair the machine, it continued to malfunction, prompting the use of paper and plastic utensils and a three-compartment sink with sanitizing solution. Staff were aware of the importance of proper sanitization to prevent bacterial contamination and illness among residents.
The facility failed to provide necessary wound care to three residents, leading to a risk of infection and delayed healing. A resident with severe cognitive impairment missed daily wound care, while another resident with cellulitis did not have updated wound care orders in the MAR, resulting in missed treatments. Additionally, a resident with osteomyelitis did not receive daily wound care as ordered. The responsible nurse admitted to not updating orders and failing to notify management, contributing to the deficiencies.
Two residents in a facility had undated and improperly maintained IV dressings, leading to a deficiency in care. One resident with pneumonia and infective endocarditis had a dirty midline catheter dressing, while another with osteomyelitis had a peeling dressing. Nursing staff failed to document dressing changes, increasing infection risk. The DON was unaware of these issues, and training records showed involved nurses missed relevant in-service training.
Two residents were found with unsecured medications at their bedsides, including nitroglycerin and various over-the-counter drugs, without proper orders or authorization. Staff interviews revealed a lack of awareness and enforcement of the facility's medication storage policy, posing a risk of overdose and unauthorized access.
A resident with multiple health conditions was improperly discharged from an LTC facility after attending a neurologist appointment. The resident arranged her own transportation and signed an AMA form, unaware of its implications. Upon returning, she was denied re-entry and sent to a hospital. The facility failed to provide a 30-day discharge notice and did not return her medications.
A facility failed to provide a resident with individualized in-room activities, as required by their care plan. The resident, with significant cognitive and psychological challenges, was often found in his room with only the television on, lacking engagement in activities. The Activities Director attempted one-on-one activities but did not document these efforts and lacked training for managing residents with intellectual and developmental disabilities. The facility's policy on activities was not effectively implemented, contributing to the resident's isolation and unmet needs.
A facility failed to apply a prescribed splint to a resident's left hand, leading to a deficiency in contracture management. The resident, with a history of dementia and joint stiffness, was observed without the splint on multiple occasions. Staff interviews revealed a lack of awareness and communication regarding the responsibility for applying the splint after the resident's discharge from therapy. The facility lacked a policy on range of motion or contracture management devices.
The facility failed to maintain accurate clinical records for two residents requiring wound care. A nurse documented care before performing it and did not provide the care due to workload, leading to missed treatments. Despite in-service training, the facility's policy did not address documentation, contributing to the deficiency.
A facility failed to maintain an effective infection prevention and control program when an LVN did not adhere to Enhanced Barrier Precautions while administering medication to a resident with a gastronomy tube. Despite training and policy requirements, the LVN only wore gloves and failed to don a gown, posing a risk of infection transmission. Interviews confirmed the facility's policy required PPE for residents on EBP, particularly those with indwelling medical devices.
A resident in the facility was found without a call light, which is essential for requesting staff assistance. Despite the care plan's directive to keep the call light within reach, the resident had been without one for months, relying on her roommate's call light or walking to the nurse's station. Staff interviews revealed a lack of awareness about the missing call light, and the maintenance log showed no request for replacement, indicating a communication lapse.
A resident with severe cognitive impairments was subjected to involuntary seclusion by an ADON, who tilted the resident's wheelchair forward, causing him to fall onto his bed, and then removed the wheelchair from the room. This left the resident without means to call for help or reposition himself. The incident was witnessed by another resident and a CNA. The facility's policy on abuse prevention was violated, and the ADON was terminated.
Two residents in an LTC facility were observed with uncovered urinary catheter bags, compromising their dignity and privacy. One resident, with severe cognitive impairment, often removed the cover himself, while the other, who preferred the cover, found it missing. Staff interviews confirmed the expectation to cover catheter bags, but this was not consistently achieved.
Two residents in a shared room were found to lack a privacy curtain, compromising their right to personal privacy during care. Staff interviews revealed a lack of awareness and communication about the missing curtain, which was removed when the room was previously a private one. The facility's policy on resident rights, including personal privacy, was not followed, leading to this deficiency.
Failure to Follow Safe Transfer Procedures for Dependent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan and facility policy for transferring a resident who required extensive assistance due to general weakness, limited mobility, morbid obesity, and muscle conditions. The resident's care plan specified that transfers should be performed using a mechanical lift with the assistance of two staff members. However, on the date in question, the CNA was observed transferring the resident alone, without the use of a mechanical lift, by lifting her under the armpits from the bed to a wheelchair. The CNA admitted to not following the care plan or facility policy, stating he was in a rush to get the resident to therapy and that other staff were occupied at the time. The resident, who had intact cognition and required substantial assistance with activities of daily living, confirmed that transfers were usually performed with two staff and a mechanical lift, and reported no injury during the incident. The Director of Nursing (DON) was unaware of the incident until informed and confirmed that the facility policy required two staff and a mechanical lift for non-weight-bearing residents. The facility's policy also stated that two or more assistants must be used for all mechanical lift transfers.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were securely stored in accordance with professional standards and facility policy. On two separate occasions, medication carts were observed left unlocked and unattended in the hallway near the nurse's station. On one occasion, a medication aide (MA A) left her medication cart unlocked and unattended while she was across the hall at the nurse's station. When questioned, MA A initially believed the cart was locked but was able to open the drawer, confirming it was not secured. She later stated that she was distracted and thought she had locked the cart before leaving it. MA A acknowledged that the unlocked cart contained over-the-counter medications and recognized the risk of residents accessing or stealing medications. On another occasion, a different medication aide (MA D) left her medication cart unlocked and unattended near the nurse's station. When approached by the surveyor, MA D admitted that she knew the cart was not locked and acknowledged that it should have been secured. The facility's policy requires that all drugs and biologicals be stored in locked compartments and that medication carts be locked or attended by authorized personnel at all times. The Director of Nursing (DON) confirmed that the expectation is for staff to double-check that medication carts are locked when unattended and recognized the risk of residents accessing medications from an unlocked cart.
Unsecured Resident Medication Information Left Unattended
Penalty
Summary
The facility failed to safeguard resident-identifiable information by leaving empty medication packets containing sensitive information unattended on top of a medication cart in a hallway accessible to residents and staff. The unattended packets displayed the resident's name, medication details, and pharmacy address. The medication cart was left unsupervised for approximately two minutes, during which time other individuals could have accessed the information. A medication aide identified the unattended packets and secured them after being questioned by the investigator. The resident involved was a male with multiple complex medical conditions, including acute respiratory failure with hypoxia, heart attack, pneumonia, candidiasis, anoxic brain damage, cognitive communication deficit, tracheostomy, gastrostomy, and an indwelling urethral catheter. The nurse responsible for the medication cart admitted to leaving the packets unattended as a reminder to reorder medication and acknowledged this was a violation of privacy protocols. The Director of Nursing confirmed that staff were expected to secure all resident information and recognized the incident as a breach of policy.
Failure to Maintain Infection Control Practices for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for two residents who required enhanced barrier precautions due to their medical conditions. For one resident with a tracheostomy and a history of candidiasis, the ADON, who also served as the infection preventionist, did not follow sterile technique during tracheostomy care. The ADON contaminated sterile supplies by handling them with clean, non-sterile gloves, failed to maintain a sterile field, and did not perform hand hygiene between glove changes. Additionally, the ADON improperly removed personal protective equipment, further compromising infection control protocols. Another resident, who had osteomyelitis and a sacral pressure ulcer, did not receive wound care using aseptic technique. During wound care, the ADON placed supplies on a contaminated surface, touched sterile items to soiled materials, and failed to perform hand hygiene between glove changes. The resident was left on a soiled incontinence brief during the procedure, and perineal care was incomplete, with the same gloves used for wound care and handling bed covers after contact with feces. The ADON also failed to use a procedure-in-progress sign and did not follow facility guidelines for privacy and supply handling during treatments. Interviews revealed that the ADON, who was responsible for infection control training and oversight, lacked knowledge of state reporting requirements for communicable diseases and was unfamiliar with the facility's QAPI process. Documentation showed that infection control in-services had not been conducted recently, and no immunizations were administered in the previous month. These failures in infection control practices and program oversight placed all residents at risk for the spread of infections.
Failure to Follow Menu and Document Substitutions
Penalty
Summary
The facility failed to adhere to the planned menu for the lunch meal on February 26, 2025, by omitting the dinner roll with margarine for all diet types. This oversight was observed during a review of the kitchen's steam table, which included chicken fried steak, peas with onions, mashed potatoes, and gravy, but no dinner rolls. The Dietary Supervisor admitted to not serving the dinner rolls because they were not delivered by the truck the previous day and acknowledged forgetting to make a substitution. The Dietary Supervisor also failed to inform the residents of the change or post the information within the facility. An interview with another staff member revealed that they were aware of the missing dinner rolls and the potential impact on residents' nutritional intake, as the rolls were part of the dietician-approved menu. The staff member admitted to not reporting the substitution to the Dietary Supervisor or recording it in the substitution logbook. The facility's policy requires that any changes to the menu be documented and communicated, which was not followed in this instance. Both the Dietary Supervisor and the staff member had been in-serviced on following menus in December 2024.
Warewasher Malfunction Leads to Unsanitized Dishes
Penalty
Summary
The facility failed to prepare foods according to established food preparation practices and safety techniques, as evidenced by the malfunctioning warewasher (dish machine) that did not dispense sanitizer. This issue persisted from the afternoon meal on February 24, 2025, through the afternoon meal on February 26, 2025, leaving dishes unsanitized and potentially placing residents at risk of infection. Observations revealed that the warewasher was not dispensing sanitizer, and test strips confirmed the absence of sanitizer in the machine. Despite attempts to repair the warewasher, it continued to malfunction, and the facility resorted to using paper and plastic utensils and the three-compartment sink with sanitizing solution as a temporary measure. Interviews with the Dietary Supervisor and staff indicated that the warewasher was initially repaired on February 25, 2025, but malfunctioned again shortly after. The Dietary Supervisor and staff were aware of the importance of maintaining proper chlorine levels to prevent bacterial contamination and illness among residents. The facility's Sanitation in Dietary policy, dated October 2007, emphasized maintaining a clean and sanitary food service area. However, the warewasher's failure to function properly and the subsequent lack of sanitization of dishes highlighted a deficiency in adhering to these standards.
Failure to Provide Prescribed Wound Care
Penalty
Summary
The facility failed to provide necessary wound care treatment to three residents, leading to a risk of infection and delayed healing. Resident #25, a female with severe cognitive impairment and peripheral vascular disease, did not receive her prescribed daily wound care on 02/25/25. The observation on 02/26/25 revealed that the dressing on her right ankle was dated 02/24/25, indicating a missed treatment. LVN A, responsible for wound care, acknowledged the oversight and did not notify management or the oncoming nurse about the missed care. Resident #30, a male with intact cognition and a diagnosis of cellulitis, did not have his wound care orders updated in the Medication Administration Record (MAR) after being seen by the Wound Care Physician on 02/17/25. The orders were to cleanse and dress the wound on his left fourth toe three times a week, but the MAR still reflected outdated orders from 02/10/25. LVN A admitted to forgetting to update the orders, resulting in the resident not receiving the prescribed treatment, which could lead to infection and delayed healing. Resident #107, a male with intact cognition and acute hematogenous osteomyelitis, also did not receive daily wound care as ordered. His wound dressing was last changed on 02/24/25, and he expressed concern about potential infection due to missed care. LVN A confirmed that she did not complete the wound care on 02/25/25 and failed to inform management or the oncoming nurse. The Director of Nursing (DON) stated that physician orders should be updated the same day they are received, and it is the responsibility of all nurses to ensure wound care is provided as prescribed.
Failure to Document and Change IV Dressings
Penalty
Summary
The facility failed to ensure the proper administration and documentation of intravenous (IV) fluids for two residents, leading to a deficiency in care. Resident #56, a female with pneumonia and infective endocarditis, had a midline catheter inserted, but the dressing was not dated or initialed, which is against professional standards. Observations revealed that the dressing was dirty, and interviews with the nursing staff indicated a lack of awareness and training regarding the importance of dating the dressing to prevent infection. Similarly, Resident #107, a male with acute osteomyelitis, had a midline catheter with a dressing that was peeling off and not dated. The resident reported that the dressing had not been changed since leaving the hospital. Interviews with the nursing staff revealed that the dressing was supposed to be changed every seven days, but the staff failed to document the date and initials on the dressing, which could lead to infection due to the lack of knowledge about when the dressing was last changed. The Director of Nursing (DON) acknowledged the expectation for staff to change dressings every seven days and to follow physician orders. However, the DON was unaware of the lack of dating on the dressings for both residents. The facility's training records showed that the involved nurses did not attend the in-service training on PICC line dressings, contributing to the oversight. The absence of proper documentation and adherence to protocols placed the residents at risk for infection.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications and biologicals were securely stored, as evidenced by the presence of medications at the bedside of two residents. Resident #40, a cognitively intact female with a diagnosis of atherosclerosis, was found with a bottle of nitroglycerin 0.4 mg tablets on her bedside table. She admitted to using the tablets for chest pain, although there was no physician's order for this medication. The staff, including LVN A and the DON, were unaware of the presence of these medications in her room, which were supposed to be locked up, indicating a lapse in monitoring and securing medications. Similarly, Resident #15, a cognitively intact male with heart failure and lung cancer, had multiple medications, including a stool softener, Clear Eyes, heartburn relief tablets, allergy relief capsules, Linzess, and acetaminophen, stored at his bedside. None of these medications were prescribed or ordered for him, and the label on the Linzess prescription was peeled off, obscuring the intended recipient. Observations over several days confirmed the continued presence of these medications, and staff interviews revealed a lack of awareness and enforcement of the facility's policy on medication storage. The facility's policy mandates that all drugs and biologicals be stored in locked compartments, accessible only to authorized personnel. However, the observations and interviews with staff, including CNAs and LVNs, highlighted a failure to adhere to this policy. The DON acknowledged the risk of overdose and the responsibility of all staff to monitor and report unauthorized medications in residents' rooms. Despite a previous in-service training on this issue, the staff did not consistently enforce the policy, leading to the identified deficiencies.
Improper Discharge of Resident After Neurologist Appointment
Penalty
Summary
The facility failed to allow a resident to remain in the facility and improperly discharged her after she attended a neurologist appointment. The resident, who had a history of diabetes mellitus, anxiety disorder, chronic obstructive pulmonary disease, and cognitive communication deficit, was not permitted to return to the facility following her appointment. The facility had the resident sign an Against Medical Advice (AMA) form before she left, which was created by the Director of Nursing (DON). The resident's care plan did not include any goals or interventions related to this situation. The resident had arranged her own transportation to the appointment, despite the facility's lack of knowledge about it. The Assistant Director of Nursing (ADON) and other staff members attempted to persuade the resident to reschedule the appointment so that proper transportation could be arranged, but the resident insisted on going. The ADON explained that leaving for the appointment without a plan to return would be considered leaving AMA. The resident signed the AMA form and left for her appointment. Upon her return, she was met by police and was not allowed back into the facility. The facility called EMS, and the resident was taken to a hospital for evaluation. Interviews with the resident, her responsible party (RP), and facility staff revealed that the resident was not aware of the implications of signing the AMA form and was upset about not being allowed back into the facility. The facility's policy required residents to inform the facility of appointments in advance so that arrangements could be made for assistance. However, the resident's RP and the resident herself were not informed of this policy. The facility's actions resulted in the resident being discharged without a proper 30-day discharge notice, and her medications were not returned to her or her RP.
Failure to Provide Individualized In-Room Activities
Penalty
Summary
The facility failed to provide an ongoing program of in-room activities tailored to the needs of a resident with significant cognitive and psychological challenges. The resident, a male with diagnoses including anxiety disorder, depression, schizophrenia, profound intellectual disabilities, and cognitive communication deficit, was not provided with individualized in-room activities for a minimum of fifteen minutes three times per week as required. Observations revealed that the resident was often found in his room with only the television on, and there was no evidence of activity sheets or other types of activities available to him. Interviews with the Activities Director and other staff indicated a lack of consistent engagement with the resident. The Activities Director, who had been employed for about a month, attempted one-on-one activities with the resident approximately twice per week but did not document these attempts. The Director also admitted to not being trained on managing residents with intellectual and developmental disabilities (IDD) and did not explore alternative activity options or document the resident's participation. The Director of Nursing (DON) and Social Services Staff acknowledged that the resident's needs were not being met, contributing to his isolation and frequent yelling. The facility's Activities Program policy mandates daily social, recreational, or rehabilitative activities tailored to residents' preferences, needs, and abilities. However, the policy was not effectively implemented for this resident, as evidenced by the lack of documented activities and the resident's continued isolation. The Administrator was unaware of the frequency of activities provided to the resident and did not recognize the impact of missing socialization on the resident's well-being.
Failure to Apply Prescribed Splint for Contracture Management
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decline. Specifically, the facility did not apply a prescribed splint to the resident's left hand on multiple occasions, as observed on two consecutive days. The resident, who had a history of unspecified dementia, stiffness in multiple joints, and muscle weakness, was observed without the contracture management device in place, with the splint found on the floor or on a chair next to the bed. Interviews with staff revealed a lack of awareness and communication regarding the responsibility for applying the splint after the resident was discharged from occupational therapy. The Director of Rehabilitation acknowledged that the order for the splint was not updated after the resident's discharge from therapy, leading to a lapse in care. The Director of Nursing and other staff were unaware of the resident's need for the splint, indicating a breakdown in communication and order management. The absence of a policy regarding range of motion or contracture management devices further contributed to the deficiency, as the facility could not provide documentation outlining procedures for restorative care.
Failure to Accurately Document Wound Care
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for two residents who required wound care. Resident #25, a female with severely impaired cognition and a diagnosis of Peripheral Vascular Disease, had a physician's order for daily wound care on a skin tear. However, the treatment administration record indicated that wound care was documented as provided on a day it was not actually performed. Similarly, Resident #107, a male with intact cognition and a diagnosis of acute hematogenous osteomyelitis, had a physician's order for daily wound care on a surgical wound. His treatment administration record also showed wound care marked as provided on a day it was not performed. Interviews revealed that the wound care nurse, LVN A, documented the provision of care before actually performing it and subsequently did not provide the care due to workload. LVN A admitted to not notifying the oncoming nurse about the missed care, acknowledging that this could lead to infections and missed treatments. The Director of Nursing (DON) confirmed that staff are expected to document care accurately after it is provided, and acknowledged the risk of care not being provided if documentation is inaccurate. Despite in-service training on documentation, the facility's policy did not address charting and documentation, contributing to the deficiency.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN B, who did not adhere to Enhanced Barrier Precautions (EBP) while administering medication to a resident with a gastronomy tube. The resident, who had cerebral palsy and dysphagia following a cerebral infarction, was on EBP due to the presence of an indwelling medical device. Despite the requirement to don a gown and gloves for high-contact care activities, LVN B only wore gloves and failed to put on a gown before providing care, which was observed during a medication administration session. Interviews with LVN B and the Director of Nursing (DON) confirmed that the facility's policy required the use of personal protective equipment (PPE) for residents on EBP, particularly those with indwelling medical devices like feeding tubes. LVN B acknowledged the training received on EBP and the potential risk of contamination from not using PPE properly. The facility's infection prevention policy, revised in March 2024, clearly outlined the need for gown and gloves during high-contact activities to prevent the transmission of multidrug-resistant organisms (MDROs). Despite this, the failure to adhere to these precautions was noted, posing a risk of infection transmission within the facility.
Resident Lacks Call Light for Assistance
Penalty
Summary
The facility failed to ensure that a working call system was available for Resident #29, which is necessary for residents to call for staff assistance. During an observation, it was noted that Resident #29 did not have a call light in her room, and she confirmed that she had been without one for months. Despite the care plan indicating that the call light should be within reach, Resident #29 had to rely on her roommate's call light or walk to the nurse's station when she needed assistance. Interviews with staff, including a CNA, LVN, Maintenance Supervisor, DON, and the Administrator, revealed that they were unaware of the missing call light and acknowledged the importance of having one within reach for all residents. The facility's maintenance request log showed no record of a request to replace Resident #29's call light, indicating a lapse in communication and follow-up. The facility's policy mandates that call devices be placed within reach and any defects be reported immediately. However, this protocol was not followed, as evidenced by the lack of a call light for Resident #29 and the absence of a maintenance request. This deficiency highlights a failure in ensuring that all residents have access to a means of communication with nursing staff, as required by the facility's policy.
Involuntary Seclusion and Abuse by ADON
Penalty
Summary
The facility failed to protect a resident from involuntary seclusion and potential abuse by an Assistant Director of Nursing (ADON). The incident involved a resident with severe cognitive impairments and a history of stroke, who required assistance with activities of daily living (ADLs) and partial assistance with transfers. The ADON was witnessed taking the resident into his room, tilting his wheelchair forward, causing him to fall onto his bed, and then removing the wheelchair from the room while closing the door. This action left the resident without means to call for help or reposition himself comfortably, as he could not find his call light and no staff responded to his calls for assistance. The incident was corroborated by another resident who witnessed the event and a Certified Nursing Assistant (CNA) who saw the ADON exiting the room with the wheelchair. The Director of Nursing (DON) was involved in gathering staff statements but did not provide a comprehensive investigation report. The facility's policy on abuse prevention clearly states that residents have the right to be free from abuse, neglect, and involuntary seclusion, which was violated in this case. The ADON was terminated, but further interviews with the ADON, the Administrator, and the CNA were unsuccessful.
Failure to Maintain Resident Dignity by Not Covering Catheter Bags
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents by not covering their urinary catheter bags with privacy bags. Resident #3, a male with severe cognitive impairment and multiple diagnoses including dementia and anxiety disorder, was observed with his catheter bag uncovered while on the facility patio. Despite being aware of the issue, as documented in his care plan, staff reported that Resident #3 often removed the privacy bag himself, preferring to see the urine. Staff were expected to remind him to keep the bag covered, but this was not consistently achieved. Resident #4, a male with paraplegia and major depressive disorder, was also observed with his catheter bag uncovered inside the facility. Unlike Resident #3, Resident #4 expressed a preference for his catheter bag to be covered, indicating that staff usually did so but had not on this occasion. The facility's policy on resident rights emphasizes the importance of maintaining dignity and privacy, which was not upheld in these instances. Interviews with various staff members, including the ADON, Clinical Resources Coordinator, and CNAs, confirmed that catheter bags should be covered to ensure residents' dignity. Staff acknowledged the ongoing challenge with Resident #3's resistance to keeping the cover on and the oversight with Resident #4. The facility's policy and staff interviews highlight the expectation that all catheter bags should be covered to maintain resident dignity, which was not consistently met in these cases.
Privacy Curtain Missing in Shared Room
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of personal space for two residents, as there was no privacy curtain in their shared room. This deficiency was observed during a survey, where it was noted that the curtain separating the beds was missing, compromising the residents' right to privacy during personal care. The absence of the curtain was acknowledged by both residents, who expressed a preference for having it in place to maintain their privacy. Interviews with staff revealed a lack of awareness and communication regarding the missing privacy curtain. The Assistant Director of Nursing (ADON) admitted that the room had previously been a private room, and the curtain was removed at that time. The Clinical Resources Coordinator and the Administrator both emphasized the importance of having privacy curtains to ensure residents' rights to privacy. However, the Maintenance Director was not aware of the issue being logged, and the Certified Nursing Assistants (CNAs) had not noticed the missing curtain until the survey. The facility's policy on resident rights, which includes the right to personal privacy, was not adhered to in this instance. The lack of a privacy curtain between the beds of the two residents resulted in a failure to provide the necessary accommodations for their privacy needs. This oversight highlights a gap in communication and procedure adherence among the facility's staff, leading to the deficiency noted in the survey.
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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 Fort Worth
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Richland Hills | 0.5 mi | — | 6 | 0 |
| Glenview Wellness & Rehabilitation | 1.7 mi | — | 7 | 0 |
| Life Care Center Of Haltom | 2.1 mi | — | 15 | 0 |
| Avir At North Richland Hills | 3.1 mi | — | 5 | 0 |
| North Pointe Nursing And Rehabilitation | 3.9 mi | — | 1 | 1 |
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