Capstone Healthcare of Hughes Springs

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen (1 of 1 kitchen) reviewed for food safety requirements. 1. The facility failed to ensure the food mixer was free of a blackish/grey dried substance on the [NAME] head on 06/01/2026. 2. The facility failed to ensure the toaster oven was free of a thick, sticky layer of brown, black and yellow crumbs on 06/01/2026. 3. The facility failed to ensure the plates and trays were appropriately dried before storing on 06/01/2026. 4. The facility failed to ensure the ice machine was free of an orange liquid substance on the interior portion of the top of the cooler on 06/01/2026. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic drugs and residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; and PRN orders for psychotropic drugs were limited to 14 days for 2 of 5 residents (Resident #8 and Resident #26) reviewed for unnecessary psychotropic drugs. 1. The facility failed to ensure Resident #8 did not have a PRN order for lorazepam 0.5 mg (a prescription medication used to treat anxiety disorders: feelings of fear, dread, and uneasiness) after 14 days without an evaluation by the physician for continued treatment with a rationale in the resident's medical record. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 4 residents (Resident #26) reviewed for PASRR. The facility failed to complete an HHSC 1012 form and submit a new PASRR Level 1 form to the local health authority, when Resident #26 received a new diagnosis of major depressive disorder (a serious mood disorder characterized by persistent sadness, loss of interest in activities, and an inability to function normally) on 10/06/25. This failure could place residents at risk for their specialized services not being provided in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 2 of 4 residents (Resident #12 and Resident #36) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #12. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (schizoaffective disorder, bipolar type) was present upon Resident #12's admission date on 09/22/25. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #36. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (major depressive disorder) was present upon Resident #36's admission date on 09/01/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 17 residents (Resident #16) reviewed for comprehensive care plans. The facility failed to ensure Resident #16's refusal to wear her splint for contracture management was included in the comprehensive care plan. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure in accordance with State and Federal laws, that all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 18 residents (Resident #12 and Resident #36) reviewed for storage of medication. 1. The facility failed to securely store Resident #12's dermal wound cleanser on 06/01/26. 2. The facility failed to securely store Resident #36's stomach relief medication (bismuth subsalicylate 525 mg) on 06/01/26, 06/02/26, and 06/03/26. These failures could place residents at risk for adverse reactions to medications or overdose.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure menus met the nutritional needs of residents in accordance with established national guidelines for 1 of 2 meal (the lunch meal) reviewed for food and nutrition services. The facility failed to ensure [NAME] F followed the recipe for pureeing the rice pilaf on 06/02/26 for the lunch meal. This failure could place residents at risk for weight loss, not having their nutritional needs met, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 facility, 1 of 1 dining room and 7 of 7 residents reviewed for environment. (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6)The facility failed to repair a leaking roof and ensure ceiling tiles were in good repair in the dining room, the area in front of the ice machine leading into the dining room, the rooms for Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7. This failure placed residents at risk of an uncomfortable environment and a decrease in quality of life and self-worth. During an observation on 02/18/26 at 9:35 a.m., in the far back right corner of the dining room above a metal cabinet there were 2 bulging ceiling tiles. [...]

Inspectors wroteBased on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 3 of 22 residents reviewed for care plans (Resident #8, Resident #29, and Resident #41). 1. The facility failed to develop a comprehensive person-centered care plan for Resident #29's depression and impaired coping with interventions following aggressive behaviors (scratched roommate on face) on 2/21/2025 and calling the police telling them he was being held hostage at gunpoint on 3/18/2025. 2. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 10 of 10 residents in a confidential group meeting (Anonymous Resident (AR)1-Anonymous Resident (AR) 10), and 1 of 1 meal (Lunch meal) reviewed for food and nutrition services. The facility failed to ensure on 4/1/25, AR 1through AR 10 were not served hard, burnt dinner rolls at the noon lunch meal. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observations, interviews, 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 2 of 15 residents (Residents #7 and Resident #41) reviewed for infection control practices. 1. The facility failed to ensure CNA D performed hand hygiene and changed gloves appropriately prior to, during, and after providing incontinent care/indwelling urinary catheter care to Resident #7. 2. The facility failed to ensure CNA D did not contaminate Resident #7's clothing, clean brief, bed, bedding, bed remote, positioning wedge, and urinary catheter bag after CNA D had performed bowel incontinent care and incontinent/urinary catheter care. 3. [...]

Inspectors wroteBased on record review, observation, and interview , the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 15 residents reviewed for resident rights. (Resident #31) The facility failed to treat Resident #31 with dignity and respect by CNA F denying his request to have food brought by his family reheated on 02/12/2025. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 3 residents (Residents #7) reviewed for urinary catheters. 1. The facility failed to ensure CNA D performed hand hygiene and changed gloves appropriately during and after providing incontinent care to Resident #7. 2. The facility failed to ensure CNA D performed hand hygiene and changed gloves appropriately prior to providing indwelling urinary catheter care to Resident #7. These failures could place residents at an increased risk for urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 1 medication storage room (medication storage room [ROOM NUMBER]) reviewed for medication storage. The facility failed to ensure Zinc 50mg was not expired in medication storage room [ROOM NUMBER]. The unopened bottle of Zinc expiration date was 3/2025. The facility failed to ensure Acetaminophen Suppositories 650mg were not expired in the medication storage room [ROOM NUMBER]'s medication refrigerator. The suppositories expiration date was 12/10/24. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure residents were free from abuse for 4 of 42 residents (Resident #1, #2, #4, and #5) reviewed for resident abuse. The facility did not ensure Resident (Resident #1, #2, #4, and #5) were free from abuse. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. The facility failed to ensure the ceiling was in good repair in the kitchen. This failure could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 5 of 13 residents (Resident #31, Resident #18, Resident #38, Resident #33, and Resident #30) reviewed for resident rights. 1. The facility failed to ensure Resident #31 had a dignified existence by allowing her to use the working bathroom commode in her room. 2. The facility failed to ask Resident #18 to remove a food item from her plate prior to reaching into her plate during her lunch meal. 3. The facility failed to provide Resident #38 with a knife to cut his meat during meals. 4. The facility failed to provide Resident #33 with a requested knife to his cut meat during the lunch meals on 03/18/2024 and 03/19/2024. 5. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment 4 of 15 residents reviewed for environment. (Resident #1, Resident #41, Resident #29, and Resident #31) 1. The facility failed to ensure Resident #1, Resident #29, and Resident #41's bedroom ceiling tiles did not have brown water stains. 2. The facility failed to ensure Resident #31 was allowed to use the working commode in her room. These failures could place residents at risk of an unsafe, unsanitary, uncomfortable environment, embarrassment due to room not appearing homelike, and a decrease in quality of life and self-worth.

Inspectors wroteBased on interviews and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #11) The facility failed to document vital signs and an assessment of the access site after Resident #11 returned from dialysis. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate behavior monitoring) for 4 (Resident # 2, Resident # 11, Resident # 16, and Resident # 41) of 13 residents whose medications were reviewed in that: 1. The facility failed to ensure Resident #2 had behavior monitoring for his prescribed Zoloft (is an antidepressant used to treat major depression). 2. The facility failed to ensure Resident #11 had behavior monitoring for his prescribed Lexapro (is an antidepressant used to treat depression). 3. The facility failed to ensure Resident #16 had behavior monitoring for his prescribed Ativan (is used to treat anxiety), Buspirone (is used to treat anxiety disorders) and Lexapro (is an antidepressant used to treat depression). 4. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for one of four nurse medication carts (Hall 100 nurse medication cart). 1. The facility failed to ensure LVN D did not leave 2 Insulin pens on top of nursing cart unsupervised. 2. The facility failed to ensure LVN D's medication cart was not left unlocked and supervised. These deficient practices placed residents at risk of drug diversion and having access to medications not prescribed for them which could result in injury and hospitalization.

Inspectors wroteBased on interviews and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 5 residents reviewed for assessments. (Resident #1) The facility failed to ensure Resident #1's MDS assessment did not improperly code Cilostazol (in a class of medications called platelet-aggregation inhibitors (antiplatelet medications)) as an anticoagulant instead of an antiplatelet. This failure could place residents at risk of not having individual needs met.

Inspectors wroteBased on interviews and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 of 3 residents (Resident #2) reviewed for resident assessments. The facility failed to review Resident #2's PASRR level 1 assessment for accuracy. Resident #2 was diagnosed with Bipolar, and the mental health question was answered no. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 13 residents (Residents #1 and Resident #11) reviewed for care plans. 1. The facility failed to revise and update Resident #1's comprehensive care plan for the type of blood thinner, Cilostazol (is in a class of medications called platelet-aggregation inhibitors (antiplatelet medications)), he was prescribed instead of Plavix (is an antiplatelet drug you can take to prevent blood clots) and Eliquis (is a blood thinner medicine that reduces blood clotting.). 2. The facility failed to revise and update Resident #11's comprehensive care plan for his diet, fluid restriction, and increase protein need for dialysis. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents reviewed for infection control during wound care. (Resident #1) The facility failed to ensure WCN practiced infection control measures by using hand gel or washing hands after the removal of gloves. This failure could place residents at risk for cross-contamination and at an increased risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 5 residents reviewed for- residents rights. (Resident #5) The facility failed to ensure Resident #5 was provided privacy when she used a bedside commode in her room. This failure placed residents at risk for diminished quality of life, loss of dignity and decrease in comfort.