Treemont Healthcare And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Dallas, Texas.
- Location
- 5550 Harvest Hill Rd, Dallas, Texas 75230
- CMS Provider Number
- 455823
- Inspections on file
- 43
- Latest survey
- March 17, 2026
- Citations (last 12 mo.)
- 26 (2 serious)
Citation history
Health deficiencies cited at Treemont Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, and significant physical limitations was assessed as high risk for elopement, but this risk was not incorporated into the care plan and staff did not notify the DON of the elevated score. During a night shift, a door alarm sounded and an RN checked the door but did not go outside around the building before returning to complete a head count, at which point the resident was found to be missing. Around the same time, a CNA from another floor encountered the resident outside but mistook him for a homeless person and did not intervene. The resident ultimately eloped off the premises and was located by police near a main road and transported to a hospital, where no injuries were found.
A resident with a history of stroke, hemiplegia, dementia, and psychiatric conditions was admitted, then sent to the hospital the next day for evaluation of possible aspiration related to a G-tube. Documentation showed an unplanned discharge to a short-term hospital, and the resident was not allowed to return. Interviews with the DON, ADON, BOM, and Marketer/Admissions revealed the resident had been clinically but not financially approved, was admitted by confusion while management was absent, and was not funded or fully identified. Staff acknowledged that transportation had been arranged for another individual and that, once the error was recognized, the resident was not readmitted after hospitalization, contrary to the facility’s written discharge planning policy regarding residents returning from the hospital.
A resident with moderate cognitive impairment and multiple medical conditions exited the facility unsupervised by observing and using a door code after a delivery person, without staff presence in the hallway or at the entrance. The resident was later found at a family member's residence in a stressed and medically compromised state, having walked a significant distance before being located and taken to the hospital.
Three CNAs provided resident care while their certifications were expired, as confirmed by registry and timecard reviews. Staff interviews indicated that both HR and the CNAs were responsible for monitoring certification status, but lapses occurred, and a policy for registry verification was not provided when requested.
A resident with multiple comorbidities, including end stage renal disease and chronic heart failure, experienced shortness of breath during transport to dialysis, resulting in a missed appointment. Facility staff did not immediately notify the physician or complete required documentation of the change in condition, despite facility policy and direct instructions from the ADON. Both the physician and NP confirmed they were not informed of the event at the time.
A facility's second-floor storage room was found unlocked and disorganized, containing broken and hazardous equipment. Staff interviews revealed confusion about key access and security protocols. The Administrator confirmed the expectation for storage rooms to remain locked to prevent unauthorized access and potential harm.
The facility failed to store and handle food according to professional standards, risking food-borne illness. Observations revealed expired and improperly stored food items, such as unrefrigerated Teriyaki Sauce and unsealed boiled eggs, contrary to facility policy and FDA guidelines.
The facility failed to maintain an effective Infection Prevention and Control Program, as CNAs did not change soiled gloves during incontinence care for two residents. One resident, dependent on assistance for toileting hygiene, had gloves not changed after cleaning, and the same gloves were used to place a clean brief. Another resident, requiring moderate assistance, had cream and a clean brief applied with contaminated gloves. Facility policies on perineal care and infection control were not followed.
The facility failed to secure medication carts, leaving them unlocked and unattended in hallways. RN, LVN, and MA acknowledged the carts should be locked to prevent unauthorized access. The carts contained various medications, and the facility's policy did not address medication security. The DON confirmed the expectation for carts to be locked at all times.
The facility failed to maintain safe operating conditions for kitchen equipment, with leaking pipes in the walk-in refrigerator and ice build-up in the freezer. Observations showed a bucket collecting water from a leaking fan-cooler unit and ice forming on food boxes. Interviews revealed that the issues were known but unresolved for an unspecified duration.
The facility failed to maintain an effective pest control program, leading to the presence of gnats, flies, and roaches in the kitchen, resident rooms, and dining areas. Residents reported frequent sightings of pests, and staff interviews revealed a lack of awareness about pest reporting procedures. The pest sighting log confirmed a roach sighting in the kitchen, with pest control visits occurring monthly.
A resident at risk for falls, with a history of malnutrition and urinary tract infection, fell and sustained skin tears when a PTA failed to use a gait belt during ambulation. The resident required partial to moderate assistance, and the facility's policy mandated the use of a gait belt, which was not followed.
A facility failed to respect a resident's privacy and dignity when a medical assistant entered the resident's room without knocking or requesting permission. The resident, who was cognitively intact and had a history of mental health disorders, expressed distress at the intrusion. Interviews confirmed the importance of knocking and obtaining permission, as outlined in the facility's policy on resident rights.
The facility failed to maintain a safe, clean, and homelike environment in two resident rooms. In one room, tiles in the bathroom were missing pieces, exposing bare concrete, while another room had tiles with gaps and a cracked tile. The Maintenance Supervisor was aware of the issue but stated that the repair crew had stopped operations months ago. The DON noted the potential trip hazard posed by the damaged tiles.
A resident with an indwelling urinary catheter was found with a leaking catheter bag that had not been changed for two months, despite facility policy and physician orders requiring regular monitoring and changes as needed. The urine was cloudy with sediment, and staff interviews confirmed awareness of the need to change dirty or leaking catheters to prevent infection, yet no action was taken.
A facility failed to implement policies and procedures to prevent neglect, resulting in a resident being missing for 15 hours after a hospital visit. The resident, who was cognitively intact and generally independent, checked himself into the ER and was later released to a homeless shelter without the facility's knowledge. The incident was not reported to the State Survey Agency.
The facility failed to report an incident involving a missing resident who was found at a homeless shelter after being released from the hospital. The resident, who was cognitively intact, was taken to the hospital for an appointment and later checked himself into the ER. The hospital released him with a bus pass, and the facility staff could not locate him until the next day. The incident was not reported to the State Survey Agency within the required timeframe.
Failure to Supervise High-Risk Resident Resulting in Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and assistive devices to prevent accidents, resulting in a resident’s elopement from the building without staff knowledge. The resident was an elderly male with dementia, prior cerebral infarction, hemiplegia/hemiparesis, generalized muscle weakness, and atherosclerotic heart disease. His admission MDS showed a BIMS score of 1, indicating severe cognitive impairment. An Elopement Risk Assessment completed shortly after admission scored him at 16, identifying him as at high risk for elopement, but his care plan dated 03/02/26 did not include elopement risk as a focus with goals or interventions. Progress notes from admission through the date of the incident documented no prior elopement attempts or exit-seeking behaviors. On the night of the incident, the east exit door alarm sounded at approximately 01:00 a.m. The nurse on duty, RN A, reported that she immediately went to the door and looked but did not see any residents; she then conducted a head count and discovered that the resident was missing. The DON stated that RN A did not go outside the building to look for the resident when the door alarm sounded, and the administrator stated it was the nurse’s responsibility to go around the building at the time of the alarm. While the alarm had sounded and staff were searching, a CNA who worked on another floor encountered the resident outside around 12:30 a.m.; the CNA later stated in writing that he thought the man was homeless and did not recognize him as a resident because he worked on a different floor and had never seen him before. After the resident was identified as missing, staff initiated the facility’s elopement/missing resident protocol and searched the building and surrounding premises, and local law enforcement was notified. Within a short time, police contacted the facility to report that the resident had been found wandering off facility grounds and transported him to a hospital for evaluation. The administrator reported that the resident was found near a hospital or a crossing bridge near the hospital, at least as far as the main road and not near the facility, estimating the distance as a 5–10 minute walk or longer for this resident. Hospital evaluation and subsequent skin assessment on return documented no injuries or acute issues. The DON later acknowledged that the resident’s high elopement risk score had been known, that the care plan should have reflected monitoring for elopement/exit-seeking behaviors, and that staff had not notified her when the resident’s initial elopement assessment score exceeded the facility’s high-risk threshold.
Removal Plan
- All staff received training on abuse and neglect as well as training on elopement response with emphasis on the need to check outside the building in response to door alarms.
- All residents were reassessed for elopement risks.
- An AD Hoc QAPI meeting was conducted to review the elopement.
- Door locks and alarms were checked and are checked daily.
- Door alarm monitoring and missing resident/elopement monitoring are completed daily.
- Door alarm codes continue to be changed monthly.
- Elopement drills are conducted three times per week.
- The DON monitors all residents' elopement scores daily by generating and reviewing a daily report for changes and scores over 10.
Failure to Allow Hospitalized Resident to Return Due to Financial Approval Issues
Penalty
Summary
The deficiency involves the facility’s failure to establish and follow a written policy permitting residents to return after hospitalization, resulting in a resident not being allowed to return and instead being effectively discharged while hospitalized. The resident was an older female admitted with a primary diagnosis of unspecified cerebral infarction (stroke) and secondary diagnoses including hemiplegia and hemiparesis affecting the right dominant side, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Admission records showed she was admitted on 02/23/2026, and the MDS entry tracking reflected that admission date. The following day, an MDS discharge record documented an unplanned discharge to a short-term general hospital, and the discharge summary stated she was sent to the hospital for evaluation due to G-tube issues and possible aspiration with slightly coarse sounds in the upper right lobe, though she denied cyanosis or respiratory distress. Interviews with facility staff revealed that the resident was clinically approved for admission but not financially approved. The DON stated the resident did not return from the hospital because she was not financially approved. The Marketer/Admissions staff reported that the resident was not funded and lacked an identification card, having only a green card, and therefore was not approved for admission based on funding. The ADON and BOM both confirmed that the resident was clinically but not financially approved, and that she was admitted by confusion while management was not in the building, as the facility had been expecting two other new admissions. The BOM indicated transportation had been set up for the wrong person, leading to this resident’s arrival, and that once the discrepancy was recognized, the plan was to transfer her back to the sending facility; however, she was instead sent to the hospital for treatment and not allowed to return. The facility’s discharge planning policy referenced completing discharge planning when anticipating discharge to another setting, but the report did not show that this policy was followed to permit the resident’s return after hospitalization.
Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, type 2 diabetes, anxiety disorder, and acute respiratory failure with hypoxia exited the facility without supervision and walked approximately two miles to a family member's residence. The resident, who had a BIMS score of 12 indicating moderately impaired cognition and was being treated for a urinary tract infection, was last seen in her room after requesting to eat breakfast there. Staff discovered the resident missing during a routine medication pass and initiated a search of the facility and surrounding area. Video surveillance revealed that the resident exited her room using a walker and approached the front door shortly after a delivery person had used the keypad to exit. The resident was observed attempting to use the keypad and successfully opened the door, leaving the facility unsupervised. No staff were present in the hallway or at the front entrance during this time. The resident was later found at a family member's apartment, appearing stressed, lethargic, hungry, dehydrated, with low blood sugar and elevated blood pressure, and was subsequently taken to the hospital. Interviews with facility staff and administration confirmed that the resident had not previously expressed a desire to leave the facility and had not attempted to elope before. Staff also reported that the resident had been seen lingering near the front lobby in the days prior to the incident. The facility's elopement prevention and response policies required staff to report any resident attempting to leave or suspected of being missing, but the resident was able to observe and use the door code without staff intervention, resulting in her unsupervised exit.
Expired CNA Certifications Result in Deficiency
Penalty
Summary
The facility failed to ensure that three certified nurse aides (CNAs) maintained current nurse aide certifications while employed and actively providing care to residents. Record reviews showed that CNA A, CNA B, and CNA C all had expired certifications according to the Nurse Aide Registry, yet each continued to work scheduled shifts during the period their certifications were not valid. Timecard reports confirmed that these CNAs worked multiple shifts while their certifications were expired. Interviews with staff revealed that CNAs were responsible for notifying Human Resources (HR) and administration when their certifications expired, but CNA A did not inform staff of her expired license. The Director of Nursing (DON) and the Administrator both stated that HR was expected to complete background and registry checks prior to hire and annually thereafter, and that staff were responsible for notifying HR of expiring certifications. The facility was unable to provide a policy for nurse aide registry verification when requested.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical status. The resident, an older female with acute respiratory failure, chronic diastolic heart failure, end stage renal disease, and dependence on renal dialysis, experienced an episode of shortness of breath while being transported to a scheduled dialysis appointment. As a result, she missed her dialysis session. Documentation showed that the resident was on continuous oxygen therapy and had orders to maintain oxygen saturation above 92%. Review of the resident's medical record revealed no evidence that a Change in Condition Assessment was completed following the episode of shortness of breath, nor was there documentation that the physician was notified at the time of the event. A late entry was made two days later, but both the physician and nurse practitioner confirmed during interviews that they were not made aware of the episode when it occurred. The nurse practitioner and physician both stated that shortness of breath in this resident, given her comorbidities, would be considered a change in condition that warranted notification. Interviews with facility staff indicated that the ADON instructed the LVN to notify the physician and complete a Change in Condition Assessment, but the LVN only left a voice message for the physician and did not document this action or complete the assessment. The LVN cited the timing of the shift change as a reason for not completing the documentation, assuming the oncoming nurse would do so. The facility's policy required immediate notification and documentation of significant changes in status, which was not followed in this instance.
Unsecured and Disorganized Storage Room Poses Safety Risks
Penalty
Summary
The facility failed to ensure that equipment in the second-floor storage room was secure and inaccessible to unauthorized staff and residents. During an observation, the storage room was found unlocked, unorganized, and dirty, containing various broken and potentially hazardous equipment such as wheelchairs, a bed frame with sharp edges, and an overbed table with missing veneer. Additionally, the room contained poles for g-tube feeding, a broken bedside table, repair parts, stacked mattresses, and various liquids and items scattered on the floor. The equipment was piled haphazardly, indicating a lack of organization and safety measures. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN), and Certified Nursing Assistant (CNA), revealed inconsistencies in the understanding and enforcement of the storage room's security protocols. The ADON admitted to having been in the room earlier and believed it was locked afterward, but was unsure of how many keys existed or who had access. The LVN and CNA both acknowledged the room should be locked but were uncertain about key access and the room's security status. The facility's Administrator confirmed the expectation that storage rooms remain locked to prevent unauthorized access and potential harm, aligning with the facility's policy that mandates monthly sweeps and organized storage of equipment.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, the facility did not properly store, prepare, distribute, and serve food, which could potentially lead to food-borne illnesses among residents. During the inspection, it was noted that a 1-gallon container of Teriyaki Sauce, opened and dated 05/05/24, was not refrigerated as required by the manufacturer's instructions. Additionally, a container of apple sauce and a bag of boiled eggs were found in the walk-in refrigerator past their use-by dates, with the apple sauce dated 07/13/24 and a use-by date of 07/16/24, and the eggs dated 07/13/24 with a use-by date of 07/18/24. The eggs were also not sealed properly, leaving them exposed to air. Interviews with the Kitchen Manager and a cook revealed that the facility's policy required all food to be dated upon receipt and when opened, with perishable items to be discarded by their use-by dates. However, the observed practices did not align with these policies, as evidenced by the presence of expired and improperly stored food items. The facility's policy, as well as the U.S. FDA Food Code, mandates that food be stored in covered containers or sealed bags to prevent contamination, which was not followed in these instances.
Infection Control Deficiency Due to Improper Glove Use
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper glove use during incontinence care for two residents. For Resident #60, a CNA did not change soiled gloves after cleaning the resident's peri area and buttocks, and continued to use the same gloves to place a clean brief and adjust the resident's blankets. This resident, who was dependent on assistance for toileting hygiene, had a BIMS score of 15, indicating no cognitive impairment, and was being monitored for signs of infection due to incontinence. Similarly, for Resident #75, another CNA failed to change gloves after cleaning the resident's soiled peri and buttocks area, and applied cream and a clean brief with the same contaminated gloves. This resident, who required moderate assistance with toileting hygiene, had a BIMS score of 14, suggesting intact cognition, and was diagnosed with a urinary tract infection. The facility's policies on perineal care and infection control precautions were not adhered to, as CNAs did not change gloves or perform hand hygiene as required.
Medication Security Lapses in Facility
Penalty
Summary
The facility failed to ensure that medications were secure and inaccessible to unauthorized staff or residents, as observed in three out of four medication carts reviewed. Specifically, the medication carts for Unit 2, Unit 3, and Unit 23 were found unlocked and unattended in the hallways. RN H left the medication cart for Unit 2 unlocked while attending to a task in a resident's room, acknowledging that the cart should always be locked to prevent unauthorized access. Similarly, MA I left the medication cart for Unit 23 unlocked while administering medications in a resident's room, and LVN J left the medication cart for Unit 3 unlocked while washing hands in a bathroom, both acknowledging the importance of keeping the carts locked. The facility's policy on medication storage did not address the security of medications, and no additional policy was provided upon request. The Director of Nursing (DON) confirmed the expectation that medication carts should be locked at all times. The unsecured medication carts contained various medications, including Gabapentin, Midodrine, Lasix, Naproxen, Famotidine, Depakote, Zyprexa, Metoprolol, Cyproheptad, and Insulin Lispro, among others. This oversight could potentially lead to unauthorized access and ingestion of medications by residents or staff.
Equipment Maintenance Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition, specifically in the kitchen area. During an observation, a five-gallon bucket was found half full of a water-like substance, with liquid dripping from a pipe connected to the fan-cooler unit in the walk-in refrigerator. The fan-cooler unit was also making a clanking noise. In the walk-in freezer, both fan-cooler units had ice build-up, forming icicles that dripped onto food boxes below, accumulating 2-3 inches of ice on top of the food boxes. Interviews revealed that the facility's administration and maintenance staff were aware of the issues. The Administrator mentioned that the fan-cooler units had been fixed but could not specify how long the pipes had been leaking. The Maintenance Supervisor stated that he had addressed the leaking pipes by blowing them out but was unsure of the duration of the leak, estimating he had been in the area the previous week. The facility's policy on Preventive Maintenance/Work-Order Request, dated 2003, indicates that the facility should repair or replace damaged or broken equipment as needed.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests in various areas, including the kitchen, resident rooms, and dining areas. Observations revealed live gnats and small flies in a resident room and dining areas, with residents reporting frequent sightings of these pests. One resident mentioned seeing a roach in her room, while another resident reported seeing gnats in her room and the dining area. The presence of these pests during meal services and in resident living spaces indicates a lapse in maintaining a pest-free environment. Interviews with staff and residents highlighted a lack of awareness and communication regarding pest sightings. Several CNAs were unaware of the pest sighting log's location and procedures, although they acknowledged seeing gnats and occasionally roaches. The Maintenance Supervisor confirmed that staff should report pest sightings in the log, which is used to inform pest control treatments. The Director of Nursing expressed concerns about the potential cross-contamination risks posed by roaches in the kitchen. The pest sighting log confirmed a roach sighting in the kitchen, and the pest control company visits the facility monthly or more frequently if needed.
Failure to Use Gait Belt Leads to Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received the necessary assistance devices to prevent accidents, specifically for one resident reviewed for accidents. The incident involved a physical therapy assistant (PTA) who did not apply a gait belt to the resident before ambulating in the hallway. As a result, the resident fell and sustained a skin tear to the left elbow and right forearm. The PTA acknowledged the importance of using a gait belt to secure the resident and admitted to not using it because they were only planning to take a few more steps. The resident involved was of advanced age and had diagnoses of moderate protein-calorie malnutrition and a urinary tract infection. The resident's care plan indicated a risk for falls, and the Minimum Data Set (MDS) showed that the resident had a fall within the last month and required partial to moderate assistance with ambulating. Observations confirmed the absence of a gait belt at the time of the fall, and interviews with the Director of Physical Therapy reinforced the expectation that all PT staff should use a gait belt when working with residents. The facility's policy on moving a resident also required the use of a gait belt.
Failure to Respect Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, specifically in the case of one resident. During an observation, a medical assistant (MA K) entered the room of a resident without knocking or requesting permission. This action was contrary to the facility's policy, which emphasizes the importance of knocking and obtaining permission to respect the resident's privacy and dignity. The resident, who was cognitively intact and had a history of bipolar disorder, major depressive disorder, anxiety, and post-traumatic stress disorder, expressed distress by yelling at MA K to leave the room. Interviews conducted with both the resident and MA K revealed that the resident did not want MA K in her room, and MA K acknowledged the importance of knocking before entering a resident's room. The facility's administrator also confirmed that staff should knock for privacy reasons and need permission to enter a resident's room. The facility's policy on resident rights, revised in 2016, supports the resident's right to personal privacy and a homelike environment, which was not upheld in this instance.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents in two of the five rooms observed. In room #1125, the bathroom floor had two pieces of tile directly in front of the toilet with approximately 2-inch by 2-inch pieces missing, exposing the bare concrete below. In room #1207, the bathroom floor had five pieces of tile bordering the toilet with 1/4 inch gaps between them, exposing the concrete below, and one tile had a large 1/2 inch crack down the middle. The Maintenance Supervisor acknowledged awareness of the tile issues and mentioned that the crew responsible for repairs had ceased operations months ago. The Director of Nursing (DON) noted that cracked or loose tiles could pose a trip hazard if the tiles slipped or if the edges were raised. The facility's policy on Preventive Maintenance/Work-Order Request, dated 2003, indicated that the facility would repair or replace damaged or broken equipment or building amenities as needed. However, the failure to address the tile issues in the bathrooms of the observed rooms could lead to an unsanitary and uncomfortable environment for the residents.
Failure to Change Leaking Catheter Bag
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a deficiency in preventing urinary tract infections. The resident, a male with a diagnosis of Obstructive and Reflux Uropathy, was observed with a leaking catheter bag that had not been changed for two months. The urine in the tubing was cloudy with white sediment, and the catheter bag was stained and leaking despite the clamp being closed. The resident's care plan and physician orders required monitoring of the catheter for leakage, blockage, sediment buildup, or low output every shift, but there were no progress notes regarding the catheter from 07/08/24 to 07/22/24. Interviews with facility staff, including CNAs and LVNs, revealed that they were aware of the need to change dirty or leaking catheters to prevent infection. However, the catheter was not changed despite its condition, and the facility's policy required that catheters and drainage systems be changed as needed unless ordered otherwise by the physician. The failure to change the leaking catheter bag placed the resident at risk of infection, as confirmed by staff interviews.
Failure to Implement Policies and Procedures to Prevent Neglect
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent neglect, as evidenced by an incident where a resident was missing for approximately 15 hours after leaving the hospital for a doctor's appointment. The facility did not follow its policy to report the incident to the State Survey Agency. This failure could place residents at risk of lacking timely reporting of incidents. The resident involved was a cognitively intact male with a BIMS score of 15, who used a wheelchair for mobility. He was taken to the hospital for an appointment and subsequently checked himself into the ER, reporting suicidal thoughts. The hospital staff released him with a bus pass to a homeless shelter, and the facility was not informed. The resident spent the night under an overpass before being found at the homeless shelter the next day. Interviews with facility staff revealed that the resident was generally independent, alert, and oriented, and did not require a staff member to accompany him to appointments. The facility staff and police searched for the resident when he was not found at the hospital. The facility did not report the incident to the State Survey Agency, believing the resident was never truly missing and was not in danger.
Failure to Report Missing Resident Incident
Penalty
Summary
The facility failed to report an incident involving a resident who went missing for about 15 hours after leaving the hospital for a doctor's appointment. The resident, who was cognitively intact and able to make his own decisions, was taken to the hospital by a van driver. After the appointment, the resident checked himself into the ER, claiming to have suicidal thoughts. The hospital staff released the resident with a bus pass to a homeless shelter without informing the facility. The facility staff, including the DON and the van driver, attempted to locate the resident and eventually contacted the police when they could not find him. The resident was found the next day at a homeless shelter and expressed that he did not want to return to the facility. He signed an AMA discharge form and was assessed to have no visible concerns or injuries. The facility's failure to report the incident to the State Survey Agency within the required timeframe was a significant deficiency. The DON and the Administrator believed that the resident was not in danger and that they had 24 hours to report the incident. However, the facility's policy required immediate reporting of such incidents. The facility staff, including the DON, ADON, and Administrator, all acknowledged that the resident was alert, oriented, and able to make his own decisions. Despite this, the incident should have been reported promptly to ensure proper follow-up and intervention. Interviews with the resident, his family, and various facility staff revealed that the resident was generally quiet, compliant with care, and had never expressed a desire to leave the facility. The resident's family expressed concerns about the resident's mental state and the facility's decision to send him to the appointment unattended. The facility's policy on abuse and neglect required prompt reporting of such incidents, but this was not adhered to in this case, leading to a delay in addressing the resident's situation and ensuring his safety.
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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