Oak Park Nursing: Care Plan Failures Leave Residents at Risk - TX
The oversight left him without proper documentation for a therapy he received on an as-needed basis, sometimes during morning hours....
Latest reports, citations, and penalties from CMS data
The oversight left him without proper documentation for a therapy he received on an as-needed basis, sometimes during morning hours....
Federal inspectors found the violation at Forest Hills Healthcare Center on November 5, when they observed the laptop open at 11:07 a.m....
Resident #11's injury was discovered on September 22 when staff noticed discoloration on her left hand and wrist....
The injury at Forest Hills Center represents exactly the type of unexplained harm that federal regulations require facilities to report immediately....
The resident's primary care physician told investigators he expected basic maintenance to continue even when feedings stopped....
Housekeeper E told inspectors during a November 5 interview that she was assigned to clean Resident #1's room....
The missing documentation raises fundamental questions about whether residents actually received prescribed treatments....
The incident occurred when the agency CNA lined up a shower stretcher next to the resident's bed and pulled them across using a sheet....
The resident required two-person physical assistance for all care according to their assessment dated July 21st....
The worker resigned November 5 after state inspectors began asking questions....
The resident cannot walk independently and requires assistance with transfers, according to her most recent assessment....
RN Supervisor #700 arrived on the unit shortly after the incident during routine rounds....
The facility only assigned round-the-clock supervision after the September 29 incident involving two residents....
The supplements are nutritional drinks prescribed by doctors for residents who need additional calories or nutrients....
The Estates of Perryville imposed a two-week restriction on Resident #1's ability to leave alone after the person returned to the facility intoxicated....
The October 22 incident at Envive of Liberty involved a resident with multiple serious conditions including heart disease, diabetes, and a history of stroke....
When inspectors arrived on October 30, they found the family's concerns were justified....
The violations occurred on the facility's second floor, where inspectors discovered multiple food safety breaches during their October 30 review....
The Assistant Director of Nursing explained to inspectors that staffing complications contributed to the problem....
Resident 1 crashed onto the floor mat on August 14, 2025, while a certified nursing assistant provided care alone....