THE SHOAL
For profit - Limited Liability company
134 Beds
PUREHEALTH
Data: November 2025
Trust Grade
50/100
#593 of 1168 in TX
Photo by The Shoal
Photo by The Shoal
Photo by The Shoal
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Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Shoal nursing home has a Trust Grade of C, which means it is average and falls in the middle of the pack among similar facilities. It ranks #593 out of 1168 in Texas, placing it in the bottom half, and #5 out of 12 in Galveston County, indicating there are only four local options that are better. The facility is worsening, with the number of issues rising from 4 in 2024 to 6 in 2025. Staffing is a relative strength, with a rating of 3 out of 5 stars and a turnover rate of 45%, which is lower than the Texas average. While there are no fines on record, which is a positive sign, there have been serious concerns. For instance, one resident experienced verbal abuse from staff, and there were failures to accurately assess the medical needs of several residents, along with issues in food safety that could impact resident health. Overall, while The Shoal has strengths in staffing and no fines, the increase in issues and specific incidents of concern warrant careful consideration.
- Trust Score
- C
- In Texas
- #593/1168
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 45% turnover. Near Texas's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Texas facilities.
- Skilled Nurses ○ Average
- Each resident gets 35 minutes of Registered Nurse (RN) attention daily — about average for Texas. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 12 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Top 50%
Review needed
4 → 6 violations
★★★☆☆
3.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 6 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (45%)
3 points below Texas average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Texas average (2.8)
Meets federal standards, typical of most facilities
Staff Turnover: 45%
Near Texas avg (46%)
Typical for the industry
Chain: PUREHEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 12 deficiencies on record
1 actual harm
Apr 2025
6 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents had the right to be free from ab...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents had the right to be free from abuse for 1 (Resident #84) of 5 residents reviewed for abuse.
The facility failed to ensure that Resident #84 from was free from mental abuse, verbal abuse, and deprivation of services by staff when CNA K verbally abused Resident #84 on 4/23/25 and placed his call light out of his reach.
The failure could place residents at risk of mental abuse, verbal abuse, and deprivation of services by staff.
Findings included:
Record review of Resident #84's face sheet dated 4/24/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Epilepsy (seizure disorder) and Cognitive Communication Deficit (difficulty communicating).
Record review of Resident #84's quarterly MDS dated [DATE] revealed a BIMS score of 10 that suggested moderate cognitive impairment and a functional abilities code of 01 for toileting hygiene indicating he was dependent for others to complete.
Record review of care plan follow up for Resident #84 dated 4/22/25 revealed in-service to be conducted due to concern related to staff putting call light on the floor.
Record review of facility's Sign In Sheet for 4/22/25 revealed CNA K and CNA L worked 10 p.m. to 6 a.m. and LPN B worked 6 p.m. to 6 a.m. on the #100 Hallway where Resident #84 resided.
Record review of Resident #84's Care Plan Report printed 4/24/25 revealed Resident #84 was dependent on staff for meeting physical needs. Interventions included staff will approach Resident #84 in a calm, non-threating manner when interacting with him, encourage to use bell to call for assistance, and caregivers to provide opportunity for positive interactions.
Record review of Employee Inservice/Training for Abuse/Neglect revealed training was completed on 4/23/25.
Record review of Suspected Verbal Abuse Questionnaire revealed trainings completed on 4/23-5/5/25.
Record review of Employee Inservice/Training for Abuse, Neglect & Exploitation, Resident Rights, and Ensuring call [NAME] in reach of Residents revealed trainings were completed on 4/26/25.
Observation of video recorded on 4/23/25 at 2:32 a.m. revealed CNA K entered Resident #84's room. At 2:33 a.m. CNA K said, Shame on you [Resident #84] and Shame on you for trying to make everybody else's night awful. At 2:34 a.m. CNA K said I bet you won't get it back while she was holding the call light and leaves the call light on the floor. At 2:34 a.m. CNA K also said that ain't got nothing to do with why you are acting a fool. CNA K provided incontinence care to Resident #84 at 2:36 a.m. and exited the room [ROOM NUMBER]:38 a.m. At 2:38 a.m. the call light could be seen on the floor near the curtain in the middle of the room.
During interview on 4/23/25 at 10:07 a.m., Resident #84's family member said there was an incident around 2 a.m. on 4/23/25 and they had a video of the incident. Surveyor viewed the video with time stamp that started on 4/23/25 at 2:25 a.m. on Resident #84's family member's phone. Resident #84's family member said CNA K member was saying you are not going to mess up our night and you are messing everybody else's night up and the surveyor was shown sections of the video where Resident #84's family member said this was occurring. At the time the surveyor viewed in the video CNA K was also seen placing the call light near the curtain in the middle of the room and saying, I bet you won't get that back.
Observation on 4/23/25 at 10:07 a.m., Resident #84 was tearing up while his family member was showing the surveyor the video of the incident on 4/23/25 at 2:25 a.m.
During interview on 4/23/25 at 10:58 a.m., when Resident #84 was asked how he felt last night when CNA K came into the room he said, they don't care. When asked if staff does not speak to him nicely, Resident #84 shook his head yes. When asked if he was afraid last night, Resident #84 shook his head yes.
During interview on 4/23/25 at 10:58 a.m., Resident #84's family member said they did not know the names of the staff members in the video that started on 4/23/25 at 2:25 a.m. Surveyor requested Resident #84's family member to provide a copy of the video as soon as possible. Resident #84's family member said that they were not going to show the video to anyone at the facility before leaving and they would send a copy to the administration this afternoon when they send the other videos.
On 4/23/25 at 12:33 p.m., surveyor attempted to contact CNA K via phone but received message that wireless customer was not available.
On 4/23/25 at 12:44 p.m., surveyor called CNA L via phone and a male voice answered but was disconnected. Surveyor called CNA L back immediately and left a message with request to call surveyor, but no call back received prior to survey exit.
On 4/23/25 at 12:47 p.m., surveyor called LPN B via phone and left a message with request to call surveyor, but no call back received prior to survey exit.
On 4/23/25 at 1:24 p.m., surveyor notified Administrator and DON regarding Resident #84's family member showing video to surveyor with concerns of female staff member telling Resident #84 you are not going to mess up our night, you are messing everybody else's night up and I bet you won't get this back in regarding to the resident's call light.
During interviews on 4/23/25 at 1:24 p.m., the Administrator and DON said they were unaware of any reports of abuse regarding Resident #84. The Administrator and DON said the allegations in the video from Resident #84's family member was not acceptable practices for the CNA to act and they would be upset with these actions. The Administrator said she considered these actions to be abuse and would be reportable. The Administrator said she would suspend the staff right away and start an investigation.
During interview on 4/23/25 at 3:46 p.m., the Administrator and DON denied any concerns told to them regarding staff from the overnight shift. The Administrator said she had completed the self-report and was starting the investigation. The Administrator said she had not received any videos from Resident #84's family member.
During interview on 4/23/25 at 5:18 p.m., the Administrator said that both CNAs from the video were suspended pending the investigation and CNA L had provided a statement. The Administrator said she had tried to call Resident #84's family member and they did not answer but she would attempt to reach out again this evening.
Record review of Personnel Disciplinary Record dated 4/23/25 for CNA K revealed suspension with reason on suspension pending investigation.
During interview on 4/24/25 at 11:19 a.m., the DON said they had already started in-servicing staff regarding call lights.
Record review of written statement from LPN B dated 4/23/25 revealed they had made sure the call light was within easy reach of Resident #84. LPN B said they had never had any negative reports from residents regarding CNAs and had not received any messages from Resident #84's family with any concerns from the night of 4/22/25.
Record review of email dated 4/24/25 at 3:10 p.m. revealed Resident #84's family member had provided a copy of the video regarding the incident that occurred on 4/23/25 to the surveyor.
During interview on 4/24/25 at 11:19 a.m., the DON said they have abuse training quite often and have abuse in-services when they did a self-report and annually through their online in-service system. The DON said she monitored for abuse by talking to the residents and that the residents were open. The DON said she also watched interactions between residents and staff and stood outside the rooms to listen to conversations. The DON said she also looked at resident's skin assessments and looked for bruises.
Record review of Personnel Disciplinary Record dated 4/24/25 for CNA K revealed dismissal with reason termination due to abuse allegation. The Personnel Disciplinary Record was not signed by CNA K with note staff member not returning call.
During interview on 4/25/24 at 8:21 a.m., ADON A said staff had in-services monthly for abuse and neglect or when something happened. ADON A denied seeing any abuse or neglect at the facility or residents/family members reporting abuse to her.
On 4/25/25 at 10:33 a.m., the Administrator said an adverse effect of verbal abuse was the resident could be scared to ask for help, become isolated, their health could decline, or the resident could be afraid the same person could come back in and speak to them in the same manner. The Administrator said if a resident could not reach their call light, then their care would be affected or the staff's ability to meet the resident's needs. The administrator said she sat in on resident council meetings and reviewed resident rights and talked about abuse. The Administrator said they monitored for signs of abuse or neglect and did life satisfaction rounds randomly. The Administrator said they did abuse trainings at least quarterly. The Administrator said she would do more monitoring of the facility including life satisfaction surveys and town halls and that everyone would be responsible. The Administrator said CNA K had been dismissed.
On 4/25/25 at 10:33 a.m., the DON said an adverse effect of verbal abuse was the resident could be scared to ask for help, be afraid that the same person could come back in and speak to them in the same manner, the resident's health could decline, or the resident could become isolated. The DON said if a resident cannot reach their call light, then the resident could have a delay in care.
Record review of CNA K's personnel file on 4/25/25 at 12:16 p.m. revealed New Hire Application Checklist dated 4/30/24 and current nurse aide license to expire 4/9/2026. CNA K was not listed on the Employee Misconduct Registry dated 4/30/24. No disciplinary actions noted in CNA K's personnel file.
During Interview on 4/25/25 at 2:05 p.m., the Administrator said she did not think CNA K had any prior disciplinary actions. The Administrator said she believed disciplinary actions would be in the employee's file, but human resources was on vacation this week and she was unsure if they kept the disciplinary actions in another place.
Record review of CNA K's User Learning dated 4/25/25 revealed she had completed Communicating Effectively on 3/4/25, Abuse, Neglect, and Exploitation on 12/8/24 and Elder Abuse: The Elder Justice Act on 12/7/24.
Record review of facility's policy Perineal Care revised 8/2024 revealed that after providing incontinence care staff should place the call light within easy reach of the resident.
Record review of facility's policy Abuse Prevention Program revised December 2016 revealed residents have the right to be free from abuse that includes but was not limited to verbal and mental abuse.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0557
(Tag F0557)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident had the right to be treated with r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 (Resident #84) of 5 residents reviewed for respect and dignity .
The facility failed to provide Resident #84 privacy when providing incontinence care on 4/23/25 as the door to the room was open and the privacy curtains were not pulled.
The failure could place residents at risk of emotional distress, embarrassment, and lower self-esteem.
Findings included:
Record review of Resident #84's face sheet dated 4/24/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Epilepsy (seizure disorder) and Cognitive Communication Deficit (difficulty communicating).
Record review of Resident #84's quarterly MDS dated [DATE] revealed a BIMS score of 10 that suggested moderate cognitive impairment.
Record review of facility's Sign In Sheet for 4/22/25 revealed CNA K and CNA L worked 10 p.m. to 6 a.m. and LPN B worked 6 p.m. to 6 a.m. on the #100 Hallway where Resident #84 resided.
Record review of Employee Inservice/Training for Ensuring Privacy during Residents Care was completed on 4/26/25.
Observation of video on 4/23/25 at 2:35 a.m. revealed CNA K provided incontinence care to Resident #84 and left the door to the hallway open and privacy curtains were left open.
On 4/23/25 at 12:33 p.m., surveyor attempted to contact CNA K via phone but received message that wireless customer was not available.
On 4/23/25 at 12:47 p.m., surveyor called LPN B via phone and left a message with request to call surveyor, but no call back received prior to survey exit.
On 4/25/25 at 10:33 a.m., the Administrator said the curtains and door should be closed when providing care. The Administrator said training regarding privacy was through online training and in-services that was completed upon hire, annually and as needed if issues. The Administrator said to monitor for resident privacy that they did daily rounds. The Administrator said if a resident did not have privacy, then a negative effect on the resident would be due to resident dignity. The Administrator said CNA K had been dismissed.
On 4/25/25 at 10:33 a.m., the DON said residents' curtains and door should be closed when providing care. The DON said training regarding privacy was through online training and in-services that was completed upon hire, annually and as needed if there were issues. The DON said if a resident did not have privacy, it could have a negative effect on the resident due to resident dignity.
On 4/25/25 at 11:26 a.m., ADON A said the expectation regarding resident privacy was that the door will be closed. and curtain pulled when providing care. ADON A said she monitored for privacy when she was out on the unit. ADON A said that failing to provide privacy for a resident was a dignity issue and the resident could feel like no care if privacy was not provided.
Record review of Personnel Disciplinary Record dated 4/24/25 for CNA K revealed dismissal with reason termination due to abuse allegation. The Personnel Disciplinary Record was not signed by CNA K with note staff member not returning call.
Record review of facility's policy Perineal Care revised 8/2024 revealed Avoid unnecessary exposure of the resident's body.
Record review of facility's policy Confidentiality of Information and Personal Privacy revised October 2017 revealed the facility will strive to protect the resident's privacy regarding personal care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure the MDS assessment accurately reflected resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure the MDS assessment accurately reflected resident's status for 1 (Resident #22) of the 6 residents reviewed for accuracy of assessments.
Resident # 22's assessment did reflect her hearing loss on section B0200 hearing inadequate on, quarterly, and annual assessment since admission date 9/22/2017 and readmission date 01/01/2018
This deficient practice could affect residents at the facility by contributing to inadequate care based on inaccurate assessments.
The findings included:
Record review of Resident # 22 face sheet revealed resident is an [AGE] year-old female and was admitted [DATE] with a diagnosis of upper respiratory tract, depression disorder, pain, hyperkalemia (high potassium), dementia, bipolar disorder, and diabetes type II.
Record review of Residents #22 5-day admission dated 9/27/2017 section B category B0200. Hearing ability to hear was code 0 Adequate - no difficulty in normal conversation, social interaction, listening to TV. Section B0300 of Resident's #22 MDS dated [DATE] revealed the following: Hearing Aid Enter Code, 0 Hearing aid or other hearing appliance used in completing B0200.
Record review of Resident #22's Quarterly MDS revealed Resident #22 had a BIMS of 14 which indicates moderate cognitive impairment.
Record review of Resident #22 physicians' orders and care plan revealed no documentation pertaining to hearing aids.
Interview and observation with Resident #22 on 4/22/25 at 9:45AM, Resident expressed she was unable to hear the questions being asked of her and that surveyor would have to speak up and to speak loudly, close to her ear. Even speaking up Resident #22 had difficulty understanding the surveyor. Resident #22 said I cannot hear good I am hard of hearing, and I don't know where my hearing aides are. Resident #22 said I told the nurse, and the people up front I cannot hear and wanted to see a doctor. Resident #22 said I had hearing aid when I came here a while back, I guess they are lost. Observation of Resident #22 on 4/22/25 at 10:00AM revealed no hearing aid present, resident was moving close to roommate to see if she would be able to tell her what was being said.
Interview with CNA #2 on 4/22/2025 at 10:00AM, she reported that she had never seen hearing aids for Resident #22. I just speak loudly when I assisted her so she can hear and understand me. I do know she needs them because we have to yell in her ear, and she is able to respond to us that way. CNA #2 reported it is our responsibility to make sure we report to nurse or the upper management that a resident is having trouble hearing. CNA #2 reported if a resident cannot hear us talking to them than they may not understand what is going on and they may not be able to tell us what is going on or answer the questions right.
Interview on 4/22/2025 at 10:15AM, CNA #5 stated I remember Resident #22 having hearing aids. I just speak loudly when I am talking to her.
Interview with LVN #1 on 4/22/2025 at 10:25AM, she reported that she was unaware of Resident #22 having an issue with hearing, I notice her roommate would answer the questions for her, but I thought it was because they have been roommates for so long and they just knew each other like that. LVN #1 stated if she (Resident #22) had a hearing problem I would let the social worker know and she will take it from there. I would also tell the doctor and family. If Resident #22 lost her hearing that will affect her overall care as well.
Interview with SW on 4/22/2025 at 11:00AM, SW stated I send residents out to UTMB for hearing, and she was not one of them. I do sections CDE of MDS and the MDS nurse does the coding for hearing, vison. I was not told Resident #22 had issues with hearing. I do know I had to talk loudly to her sometimes. I believe she had some hearing aids when she was admitted . I will get her on the list for UTMB to be seen today.
Interview on 4/22/2025 at 11:30AM, the MDS nurse said I do sections B, sometimes I do all the sections of the MDS. Yes, I coded Resident #22 MDS quarterly and annual that she had no issues with hearing and no hearing aid was present. I did interview her. MDS nurse confirmed that Resident #22 MDS all of them were inaccurate and that could lead to her not getting or receiving the proper care she needed. MDS section B should have reflected she had hearing aids and inadequate hearing.
Review of facility policy, Resident Assessment reviewed on 4/22/2025, read in part it is the policy of this facility to ensure that the assessment accurately reflect the resident's status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure that residents receive proper treatment and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain hearing abilities, for 1 (Resident #22) of the 6 residents reviewed for the use of assistive device in that-
Resident #22 was not assessed and did not receive care for her hearing deficit.
This failure could place residents at risk of not receiving appropriate care and services needed to maintain their health and quality of life.
The findings included:
Record review of Resident # 22 face sheet revealed resident is an [AGE] year-old female and was admitted [DATE] with a diagnosis of upper respiratory tract, depression disorder, pain, hyperkalemia (a condition characterized by abnormally high levels of potassium in the blood), dementia, bipolar disorder, and diabetes type II.
Record review of Residents #22 5-day admission dated 9/27/2017 section B category B0200. Hearing ability to hear was code 0 Adequate - no difficulty in normal conversation, social interaction, listening to TV. Section B0300 of Resident's #22 MDS dated [DATE] revealed the following: Hearing Aid Enter Code, 0 Hearing aid or other hearing appliance used in completing B0200.
Record review of Resident #22's Quarterly MDS revealed Resident #22 had a BIMS of 14 which indicates moderate cognitive impairment.
Record review of Resident #22 physicians' orders and care plan revealed no documentation pertaining to hearing aids.
Interview and observation with Resident #22 on 4/22/25 at 9:45AM, Resident expressed she was unable to hear the questions being asked of her and that surveyor would have to speak up and to speak loudly, close to her ear. Even speaking up Resident #22 had difficulty understanding the surveyor. Resident #22 said I cannot hear good I am hard of hearing, and I don't know where my hearing aides are. Resident #22 said I told the nurse, and the people up front I cannot hear and wanted to see a doctor. Resident #22 said I had hearing aid when I came here a while back, I guess they are lost. Observation of Resident #22 on 4/22/25 at 10:00AM revealed no hearing aid present, resident was moving close to roommate to see if she would be able to tell her what was being said.
Interview with CNA #2 on 4/22/2025 at 10:00AM, she reported that she had never seen hearing aids for Resident #22. I just speak loudly when I assisted her so she can hear and understand me. I do know she needs them because we have to yell in her ear and she is able to respond to us that way. CNA #2 reported it is our responsibility to make sure we report to nurse or the upper management that a resident is having trouble hearing. CNA #2 reported if a resident cannot hear us talking to them than they may not understand what is going on and they may not be able to tell us what is going on or answer the questions right.
Interview on 4/22/2025 at 10:15AM, CNA #5 stated I remember Resident #22 having hearing aids. I just speak loudly when I am talking to her.
Interview with LVN #1 on 4/22/2025 at 10:25AM, she reported that she was unaware of Resident #22 having an issue with hearing, I notice her roommate would answer the questions for her, but I thought it was because they have been roommates for so long and they just knew each other like that. LVN #1 stated if she (Resident #22) had a hearing problem I would let the social worker know and she will take it from there. I would also tell the doctor and family. If Resident #22 lost her hearing that will affect her overall care as well.
Interview with SW on 4/22/2025 at 11:00AM, SW stated I send residents out to University of Texas Medical Branch (UTMB) for hearing, and she was not one of them. I do sections CDE of MDS and the MDS nurse does the coding for hearing, vison. I was not told Resident #22 had issues with hearing. I do know I had to talk loudly to her sometimes. I believe she had some hearing aids when she was admitted . I will get her on the list for UTMB to be seen today.
Interview on 4/22/2025 at 11:30AM, the MDS nurse said I do sections B, sometimes I do all the sections of the MDS. Yes, I coded Resident #22 MDS quarterly and annual that she had no issues with hearing and no hearing aid was present. I did interview her. MDS nurse confirmed that Resident #22 MDS all of them were inaccurate and that could lead to her not getting or receiving the proper care she needed. MDS section B should have reflected she had hearing aids and inadequate hearing.
Review of facility policy, Resident Assessment reviewed on 4/22/2025, read in part it is the policy of this facility to ensure that the assessment accurately reflect the resident's status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all drugs and biologicals used in the faci...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all drugs and biologicals used in the facility must include the expiration date when applicable for one (#100 Hallway medication aide medication cart) out of four medications carts reviewed for labeling of drugs.
The facility failed to ensure that Latanoprost eye drops (Latanoprost is used to treat certain types of Glaucoma (eye condition that damages the optic nerve) and other causes of high pressure inside the eye) were labeled with expiration date on all medication carts.
This failure could place residents at risk of not receiving the intended therapeutic effects of prescribed medications or receiving potentially harmful side effects from prescribed medications.
Findings included:
Record review of Resident #42's face sheet dated 4/24/2025, revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus (high blood sugar) without Complications and unspecified Open-Angle Glaucoma (eye condition that damages the optic nerve).
Record review of Resident #42's quarterly MDS dated [DATE] revealed a BIMS score of 13 that suggested cognition was intact (13-15).
Record review of Resident #42's Order Summary Report dated 4/24/25 revealed Latanoprost Ophthalmic Solution 0.005% with instructions to instill 1 drop in both eyes at bedtime for Open Angle Glaucoma with order date of 8/2/2024.
Record review of Resident #42's April MAR printed 4/24/25 revealed Latanoprost Ophthalmic Solution 0.005% with instructions to instill 1 drop in both eyes at bedtime with administration dates from 4/1-4/23/25.
Record review of Resident #42's Care Plan Report printed 4/24/25 revealed Resident #42 had impaired visual function related to Glaucoma (eye condition that damages the optic nerve) with Latanoprost drops daily.
Observation on 4/23/25 at 9:15 a.m. revealed Latanoprost 0.005% eye drops for Resident #42 with no open date documented found on the #100 Hallway medication aide medication cart.
During interview on 4/23/25 at 9:20 a.m., MA G said eye drops should be dated when they were opened. MA G said if a resident is given eye drops past the use by date the resident could get an eye infection and if the eye drops were not dated when they were opened then they would not be able to know when to dispose of the eye drops.
During interview on 4/24/25 at 11:19 a.m., the DON said the medication aides and nurses were responsible for checking their medication carts. The DON said the DON and ADON audited the medication carts weekly, and the pharmacist also checked medication carts monthly. The DON said if a medication was given past the use by date, then there could be decreased effectiveness of the medication or adverse reactions depending on the medication.
During interview on 4/25/24 at 8:21 a.m., ADON A said the medication aides were responsible for checking the medication carts. ADON A said the DON and ADONs spot checked the medication carts weekly. The ADON A said that the Pharmacist comes to the facility monthly and checked the medication carts. The ADON A said if a medication had a use by recommendation and no open date is documented then the resident could get an eye infection. The ADON A said if a medication that had a used by recommendation and no open date was documented then staff would not know when to dispose of the medication and they would need to get a new medication. ADON A said staff had in-services or trainings at least monthly related to medications.
During interview on 4/25/24 at 8:40 a.m., the Pharmacist said they tell staff to date everything when opened to be on the safe side. The Pharmacist said Latanoprost 0.005% needs to be disposed of after six weeks from opening. The Pharmacist said they come to the facility monthly and performed spot checks of medication carts. The Pharmacist said if they saw a problem then they will do one on one training of the staff. The Pharmacist said an adverse reaction that a resident could experience if it unknown how long a medication had been opened for and used past the recommendations was the medication could be less effective.
Record review of facility's policy Medication Storage dated 1/25 revealed outdated, contaminated, discontinued, or deteriorated medications are immediately removed from stock. Record review also revealed medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and con...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 (Resident #84) of 5 residents that were reviewed for infection control practices.
The facility failed to ensure that CNA K followed proper infection control while providing care to Resident #84 on 4/23/25.
The failure could place residents at risk of infection, decline in health, or cross contamination.
Findings included:
Record review of Resident #84's face sheet dated 4/24/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Epilepsy (seizure disorder) and Cognitive Communication Deficit (difficulty communicating).
Record review of Resident #84's annual/quarterly MDS dated [DATE] revealed a BIMS score of 10 that suggested moderate cognitive impairment.
Record review of Resident #84's Care Plan Report printed 4/24/25 revealed focus of bladder incontinence with intervention to clean peri-area with each incontinence episode.
Record review of facility's Sign In Sheet for 4/22/25 revealed CNA K and CNA L worked 10 p.m. to 6 a.m. and LPN B worked 6 p.m. to 6 a.m. on the #100 Hallway where Resident #84 resided.
Observation of video on 4/23/25 at 2:32 a.m. revealed CNA K entered Resident #84's room. At 2:33 a.m. CNA K reached into her right scrub pocket with her right hand and pulled a bag out and ate from the bag using her right hand to place food in her mouth. CNA K picked up a pillow from the floor using her right hand and placed it on the bed. At 2:34 a.m. CNA K put food in her mouth twice using her hands, touched the curtain and picked up the call light from the right side of the bed while holding a bag of food in her left hand. At 2:34 a.m. CNA K put food in her mouth using her right hand. CNA K then touched Resident #84's right arm, pulled down his sheet and touched his diaper with her right hand. At 2:35 a.m. CNA K poured food in her left hand and ate the food putting her hand to her mouth. At 2:35 a.m. CNA K picked up a box of gloves with her left hand, a brief with her right hand and put on a pair of gloves. At 2:36 a.m. CNA K wiped Resident #84's bottom using the dirty diaper and did not use wipes during incontinence care. At 2:36 a.m. CNA K threw the dirty diaper on the floor knocking the clean diaper on the floor which she picked up and placed on Resident #84. At 2:37 a.m. CNA K placed Resident #84's blankets over him while wearing the gloves she used to change his dirty diaper and then picked up the dirty diaper off the floor and placed in the trash. Then CNA K removed her gloves and placed them in the trashcan. At 2:38 a.m., CNA K exited the room and shut the door. CNA K was not observed entering or exiting restroom or using hand sanitizer during the time she was in Resident 84's room during the video .
During interview on 4/23/25 at 10:07 a.m., Resident #84's family member showed surveyor the video from 4/23/25 that started at 2:25 a.m. At 10:58 a.m. Resident #84's family member said they were not going to speak to anyone at the facility regarding the video prior to leaving the facility. Resident #84's family member said they would send the video from 4/23/25 to the administrator when she sends other videos that she was sending to the administrator. Surveyor received copy of the video on 4/24/25 at 3:10 p.m. from Resident #84's family member.
On 4/23/25 at 12:33 p.m., surveyor attempted to contact CNA K via phone but received message that wireless customer was not available.
On 4/23/25 at 12:47 p.m., surveyor called LPN B from via phone and left a message with request to call surveyor, but no call back received prior to survey exit .
During interview on 4/25/25 at 8:21 a.m., ADON A said the Infection Control Preventionist was who monitored for infection control . ADON A said staff should wash their hands if they touch anything soiled, before and after providing resident care. ADON A said staff should use hand sanitizer between each resident interaction. ADON A said staff should wear gloves when staff had direct contact. ADON A said staff had in-services when something new comes out regarding infection control of if they see high infection rates.
On 4/25/25 at 10:33 a.m., the Administrator said it was an expectation for staff to follow the regulations regarding infection control and nursing was who monitored for infection control. The Administrator said if staff did not use proper infection control practices like washing hands and using hand sanitizer then the resident could get a possible infection. The Administrator said she monitored for infection control when making daily rounds. The Administrator said CNA K had been dismissed.
On 4/25/25 at 10:33 a.m., the DON said she did daily rounds and throughout the day multiple times a day to monitor for infection control. The DON said staff should use gloves when providing care especially for incontinence care, wound care, touching food on the trays and showers. The DON said staff should wash their hands before and after applying gloves. The DON said staff had annual training and training as needed regarding infection control. The DON said if Infection Control saw any trends, then she would do trainings as needed. The DON said if staff did not use proper infection control practices like washing hand and using hand sanitizer then the resident could get a possible infection.
On 4/25/25 at 11:32 a.m., Infection Control said expectations was staff was following standard precautions and washing hands before and after using gloves. Infection Control said they did in-services and trainings regarding infection control and that online trainings were monthly and was unsure how often infection control trainings were completed but probably quarterly. Infection Control said she did pop up inspections about 3-4 times a week to make sure staff were following infection control. Infection Control said a staff member should not be eating in a resident's room and had not seen any staff eating in resident rooms. Infection Control said if staff did not use proper infection control, then an infection could pass from one resident to another.
Record review of facility's Employee Inservice/Training form dated 4/25/25 revealed training for staff to remove gloves after being soiled, no eating in resident rooms and to wash hands with hand sanitizer or soap and water after removing globes.
Record review of CNA K's User Learning dated 4/25/25 revealed she completed About Infection Control and Prevention on 12/8/24, Bloodborne Pathogens and the Use of Standard Precautions on 3/6/25, Hand Hygiene Basics on 11/24/24 and Infection Control: Basic Concepts on 11/24/24.
Record review of Personnel Disciplinary Record dated 4/24/25 for CNA K revealed dismissal with reason termination due to abuse allegation. The Personnel Disciplinary Record was not signed by CNA K with note staff member not returning call.
Record review of facility's policy Perineal Care revised 8/2024 revealed staff should wash and dry hands thoroughly prior to starting and after providing care. Record review also revealed that perineal and rectal/buttocks area should be washed using wet washcloth and soap or skin cleansing agent.
Record review of facility's policy Infection Control - Standard Precautions revised October 2018 revealed that hands are washed with soap and water after removing gloves and before eating. Record review also revealed that hand hygiene (handwashing with soap or use of alcohol-based rub) was to be performed before and after contact with the resident, after contact with items in the resident's room and after removing personal protective equipment. Record review also revealed gloves are removed promptly after use and before touching non-contaminated items and environmental surfaces. Record review also revealed that hands are to be washed immediately after gloves are removed to avoid the transfer of microorganisms to other residents or environments.
Feb 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete and transmit an MDS for 1 of 3 (CR #90) residents reviewed ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to complete and transmit an MDS for 1 of 3 (CR #90) residents reviewed for closed records.
The facility failed to complete and transmit a discharge MDS for CR #90
This failure could place residents at risk of facility not providing complete and specific information for payment and quality of measure purposes.
Finding included:
Record review of CR #90's electronic face sheet, on 02/14/24 revealed a [AGE] year-old male, initially admitted to the facility on [DATE] readmitted on [DATE], readmitted on [DATE], 03/09/23, and discharged from the facility on 09/06//23. His diagnoses included, heart diseases, chronic kidney disease, end stage renal disease, hypertension, anemia, diabetes, Arthritis, lack of coordination, pain, and muscle wasting.
Record review of CR #90' last completed MDS was dated ARD 09/06/23 was sign as completed on 02/05/24, 5 months after being discharge from the facility.
Record review of nurse's notes dated 09/12/23 undated, unsigned read in part Patient with elevated BUN 113 CR 4.7, unable to obtain IV access. VSS. Patient AOX#, no c/o voiced. Received order to send to local hospital ER for further evaluation.
Record review of nurses note dated 9/21/2023 14:12 (2:12PM) unsigned read in part COMMUNICATION - with POA: Tried to LVM for Resident #90's POA to check on CR #90. Was told CR #90 was sent to another facility so I wanted to follow up with POA to discuss why.
During an interview with MDS Coordinator B on 02/14/24 at 2: 10PM, stated she was new to the position of MDS and was still in training. She said she could not explain why it was not done but she would complete the MDS and transmit it.
Policy on MDS completion was requested from the MDS coordinator. The policy was not provided prior to exit on 02/14/24 at 5:00PM
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the comprehensive care plan was completed and re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the comprehensive care plan was completed and reviewed and revised by the Interdisciplinary team after each assessment for 1 of 18 residents reviewed for care plan accuracy (Resident # 96).
--Resident # 96 comprehensive care plan was not completed by the review date and did not contain goals and interventions as coded in the baseline care plan.
This failure placed residents at risk of not receiving proper care and services according to their individual status.
Finding include:
Record review of Resident # 96's face sheet dated 1/15/24 revealed admission date 1/15/24 with diagnoses including dementia (loss of cognitive functioning, memory, reasoning), heart disease (conditions affecting the vessels, arteries, structure of the heart), hypertension (high blood pressure), arthritis inflammation or swelling of joints), depression (feeling sad, irritable, empty), and Diabetes (elevated blood glucose levels).
Observation and interview of Resident # 96 on 2/12/24 at 9:15 am revealed he was in his room, resting in bed, and was easily awakened. He said he was fine and just came here last month for rehab, which was going well and he was getting stronger. He said he needed the therapy so he could get strong enough to walk after his health decline.
Record review of the admission MDS dated [DATE] revealed triggered care areas of functional abilities, cognitive loss/dementia, urinary incontinence, dehydration/fluid maintenance, nutritional status, pressure ulcer, and return to community referral
Record review of the Baseline Care Plan dated 1/16/24 revealed the following sections were completed on the following dates: functional abilities and goals (1/16/24), health conditions (1/16/24), dietary/nutritional status, therapy, and social services (1/24/24), and plan of care.
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Record review of Resident #96's comprehensive care plan revealed date initiated 1/15/24, and next review date 2/4/24. The comprehensive care plan had not been reviewed by the review date of 2/4/24 and did not contain goals/interventions for MDS triggered care areas of functional abilities, cognitive loss/dementia, urinary incontinence, dehydration/fluid maintenance, nutritional status, pressure ulcer, and return to community.
In an interview with the MDS nurse on 2/14/23 at 1:40 pm, she said she just took over this job in January 2024 and had been busy. She said they have 21 days to complete the care plan, and knew it was late, but she did not have time to complete it. She said the other nurses and managers would give her input for the care areas for the residents and she would complete the care plan. She said the risk of having an incomplete care plan would be the resident not receiving correct care, but she would hope the CNAs would ask someone about the care for a certain resident if it was not on the Kiosk.
In an interview with the DON on 2/14/23 at 1:55 pm, she said they have had some changes in staff recently, which could be why the comprehensive care plan was late. She said if she revised the [NAME], her name would be listed as reviewer. She said the resident would not receive proper care if the care plan was incomplete.
The facility policy on Care Plans was requested from Administration on 2/14/24 but had not been received by the exit.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interview and record review, the facility failed to complete a comprehensive, accurate, standardized repro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Observation, interview and record review, the facility failed to complete a comprehensive, accurate, standardized reproducible assessment for 3 (Resident #11, #29, & #50) of 18 residents reviewed for comprehensive assessment.
1 The facility failed to accuretly assess Resident #11's lack of teeth and no dentures.
2 The facility failed to accurately assess Resident # 29 for her hearing deficit.
3 The facility failed to accurately assess Resident #50 for his oral cavity.
These failures could place the residents at risk of not having all medical needs assessed and met.
Findings included:
1.Record review of Resident # 11's electronic face sheet on 02/13/24 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia, hypertension, muscle wasting, abnormal weight loss, diabetes, schizophrenia, anxiety, and depression.
Review of Resident #11's Annual MDS dated [DATE] revealed a BIMS score of 7, indicating she was severely impaired on cognition. Her Functional Status indicated she required limited assistance with her ADLs. Her Dental Status did not note any broken or loosely fitting dentures. Section L (B) no natural teeth or tooth fragment(s) (edentulous) was left blank. L (Z) was coded as no problem.
Observation on 02/12/23 at 11:00AM revealed Resident #11 was on her wheelchair alert and oriented. She was observed snaking on chips.
Observation on 02/13/24 at 12:20PM revealed Resident #11 had lunch in the dining room she was served mechanical altered diet. She had hard time with the meat and requested for soup which was provided. Observation of her oral cavity revealed she had no teeth in her oral cavity.
2.Record review of Resident # 29's electronic face sheet on 02/13/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included Peripheral neuropathy (nerve damage caused by several different conditions) hypertension, muscle wasting, hearing loss ear, and heart failure.
Review of Resident #29's Annual MDS assessment dated [DATE] revealed she had a BIMS score of 12 that indicated she was cognitively intact. Her Functional Status indicated she required limited assistance with her ADLs. Record review of section B of the MDS hearing, speech, and vision, were all coded as adequate.
Record review of Resident 29's care plan initiated on 10/14/22 updated 10/27/23 read in part the resident has a communication problem related to hearing deficit.
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Intervention The resident will be able to make basic needs known daily basis through the review target date of 12/27/23.
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communication: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off television\radio to reduce environmental noise, Ask
yes/no questions if appropriate, use simple, brief, consistent words/cues, use alternative communication tools as needed.
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Monitor/document for physical/ nonverbal indicators of discomfort or distress, and follow-up as needed.
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Monitor/document frustration level. Wait 30 seconds before providing resident with
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Monitor/document residents' ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend.
Observation and interview on 02/12/24 at 9:40AM revealed Resident #26 was on wheelchair in front of her room. During an interview, Resident #29 said come closer and speak louder I can't hear you.
3.Record review of Resident # 50's electronic face sheet on 02/13/24 revealed a [AGE] year-old male admitted to the facility on initially on 12/13/2017 and readmitted on [DATE]. His diagnoses included muscle weakness, hypertension, type 2 diabetes mellitus with diabetic neuropathy, adult failure to thrive, depressive episodes, vitamin deficiency, heart disease, chronic kidney disease, and liver cirrhosis.
Review of Resident #50's Annual MDS dated [DATE] revealed a BIMS score of 12 indicated he was cognitively intact.
Record review section L (A) Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) was left blank section L(Z) was coded 0 no oral dental problem.
Observation and interview on02/13/24 at 1:0PM revealed Resident #50 was up on his bed eating his lunch which was mechanical diet. During an interview he open his mouth and said his lower teeth are grounded to his gum and he had three on his upper cavity. He said he had no dentures and had not seen any dentist. He continued with his meal.
During an interview on 02/14/23 at 1:30PM, MDS coordinator A said she started at the facility sometimes in June of 2023 and there was back flow of MDS that needed to be done. She said would look at Resident # 11, #29 and 50 to see what was wrong.
During an interview on 02/14/24 at 2:00PM, MDS coordinator A stated Resident #11 had no teeth in her oral cavity, Resident #29 had hearing loss and Resident #50 had few teeth on his upper cavity and all his lower teeth are grounded down to his gum. She said she would reassess all residents and update their MDS as pointed out. She said an inaccurate assessment would result in needed services not being provided to residents.
Policy on accuracy of MDS assessment was requested from the MDS coordinator A on 02/14/24 at 2:15PM. No policy was provided prior to exit on 02/14/24 at 5:00pm
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for k...
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Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation.
The facility failed to ensure that expired food products was not used in food preparation and served to resident.
The facility failed to ensure that dented cans of food were stored separately.
These failures could affect residents who ate food from the kitchen and place them at risk of food borne illness and disease.
Findings included:
Observation and interview of the facility kitchen on 02/12/24 at 8:40 AM revealed the dietary Manager opened a 4 oz carton of milk to use in food preparation. Observation of the carton revealed a used by date of 02/09/24. Further observation revealed two boxes of milk each with 25 cartons of 4oz milk all labeled used by 02/09/24. During an interview with the Dietary Manager at 8:48AM, the Dietary Manager said she did not notice the dates on the boxes because, the facility had just received the supply last week.
Observation and interview of the dry good storage room revealed 4-7Ibs of dented can of banana pudding all stored together with undented cans. The Dietary Manager took out the dented can off the shelve and said they are supposed to be stored separately and returned to the supplier. She said the dented cans would be returned for credit.
In an interview with the dietary Manager on 02/12/24 at 9:00AM, she said the expired milk products and dented can goods, could lead to food born illness. She said she would have an in-service to address all concerns. She said she was off over the weekend and did not have time to go over all the food that were received last week.
Record review of facility's policies and procedures for food and safe handling revised December 2024, titled Refrigerators and Freezers read in part, . #8 Supervisors will be responsible for ensuring food items in pantry. Refrigerator and freezers are not expired, or pass perish dates. Supervisor should contact vendors or manufacturers when expiration dates are in question. Further review of the policy did not address dented cans.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate an assessment with Preadmission Screening and Resident R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate an assessment with Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort and for 1 of 1 resident reviewed for PASRR services coordination and assessment. (Resident #1)
The facility failed to submit a complete and accurate NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #1 by a specific deadline and, as a result, Resident #1 had not received the CMWC.
This failure could place residents with a positive PASRR evaluation at risk for not receiving specialized PASRR services which would enhance their highest level of functioning and could contribute to a decline in physical, mental, psychosocial well-being and quality of life.
Findings included:
Record review of Resident #1's face sheet dated 07/06/2023 indicated Resident #1 was [AGE] year old male, admitted on [DATE], diagnosis included cerebral palsy.
Record review of Resident #1's MDS assessment dated [DATE] indicated Resident #1 was diagnosed with cerebral palsy, used a wheelchair for mobility.
Record review of Resident #1's care plan dated initiated 11/02/2022 indicated Resident #1 had an ADL self-care performance deficit related to impaired balance and limited mobility. Listed interventions indicated Resident #1 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, personal hygiene and bathing and included PT/OT evaluation and treatment.
Record review of Resident #1's care plan dated initiated 11/02/2022 indicated Resident #1 had a positive PASRR status due to a diagnosis of cerebral palsy requiring specialized services, CMWC. The listed goal indicated Resident #1 would have all identified needs met. Listed interventions included facility will coordinate services with the local mental health authority.
Record review of Resident #1's care plan dated initiated 11/02/2022 indicated Resident #1 had a diagnosis of cerebral palsy. The listed goal was Resident #1 would be able to function at the fullest potential possible as outlined by the treatment team. Listed interventions included:
Maintain good body alignment to prevent contractures .
OT to monitor/document and treat at indicated .Use assistive devices recommended .
PT to monitor/document and treat at indicated .
Record review of Resident #1's PCSP form dated 02/08/2023 indicated Resident #1, diagnosed with IDD, had an initial IDT meeting for specialized services review on 02/08/2023. This PCSP form indicated the IDT members recommended Resident #1 receive new services of CMWC, Specialized Assessment OT and Specialized Assessment PT.
Record review of a Simple LTC PASRR NFSS Activity for CMWC/DME assessment dated [DATE], signed by OT 05/22/2023 and signed by the physician 06/05/2023 indicated Resident #1 has a history of very thin, fragile skin, increased pressure at bony prominences due to low weight and malnutrition in community prior to entering the facility and decreased skin integrity with history of previous sacral skin breakdowns .due to severity of postural deficits and deformities. The section titled Describe Orthopedic conditions noted Resident #1 presents with severe and significant tightness, tone and contractures .contractures, scoliosis and severe lower extremities contractures .Resident #1 presents with significant deficits, poor balance, diminished sensation/cognitive awareness, very poor upper extremity and lower extremity strength and severe contractures . Per this same assessment the Reason Code for this assessment indicated HHSC did not receive information previously requested from the nursing facility necessary to establish eligibility for the service or item.
Record review of PASRR Compliance Call Report for March 2023 spreadsheet for Resident #1's IDD services PASRR Unit indicated the following:
*IDT meeting was held on 02/08/2023,
*PCSP was created on 02/21/2023,
*IDT date plus 30 days was 03/10/2023,
*NF contacted 05/16/2023,
*Due date for NF to submit NFSS form in LTC portal for DME/CMWC was 05/22/2023.
Record review of a Simple LTC PASRR NFSS Activity Portal History dated 06/12/2023 at 10:13 a.m. for Resident #1 indicated the NFSS form request for CMWC/DME was not submitted within 30 calendar days of the IDT meeting.
During an interview on 07/06/2023 at 4:15 p.m., the Administrator said OT/PT Specialized Assessment submissions were late in the LTC Portal and Resident #1 had not received the CMWC.
During an interview on 07/06/2023 at 5:20 p.m., the MDS/PASRR Nurse said on 05/19/2023 the facility entered the measurements Resident #1's CMWC but had to wait on additional information from DME, which was not received 06.12.2023. The MDS/PASRR said the same day (unknown) the facility received the information from the DME it was submitted in the portal. She said Resident #1 had not received the CMWC.
Record review of the March 2019 facility policy entitled admission Criteria (provided by the facility as the PASRR policy), section Nursing Facility Responsibilities read, 1 .b. admit residents who can be cared for adequately by the facility .6. Residents are admitted to this facility as long as their needs can be met adequately by the facility .
Record review the facility provided CMS 672 dated 07/05/2023 indicated there was one resident with intellectual and/or developmental disability.
Jun 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Texas facilities.
- • 45% turnover. Below Texas's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 harm violation(s). Review inspection reports carefully.
- • 12 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is The Shoal's CMS Rating?
CMS assigns THE SHOAL an overall rating of 3 out of 5 stars, which is considered average nationally. Within Texas, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is The Shoal Staffed?
CMS rates THE SHOAL's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 45%, compared to the Texas average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at The Shoal?
State health inspectors documented 12 deficiencies at THE SHOAL during 2023 to 2025. These included: 1 that caused actual resident harm and 11 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates The Shoal?
THE SHOAL is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by PUREHEALTH, a chain that manages multiple nursing homes. With 134 certified beds and approximately 101 residents (about 75% occupancy), it is a mid-sized facility located in TEXAS CITY, Texas.
How Does The Shoal Compare to Other Texas Nursing Homes?
Compared to the 100 nursing homes in Texas, THE SHOAL's overall rating (3 stars) is above the state average of 2.8, staff turnover (45%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting The Shoal?
Based on this facility's data, families visiting should ask: "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the substantiated abuse finding on record.
Is The Shoal Safe?
Based on CMS inspection data, THE SHOAL has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Texas. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at The Shoal Stick Around?
THE SHOAL has a staff turnover rate of 45%, which is about average for Texas nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was The Shoal Ever Fined?
THE SHOAL has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is The Shoal on Any Federal Watch List?
THE SHOAL is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.