Based on observation, interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 4 of 8 Residents (CR#1, Resident #1, Resident #2, Resident #3) reviewed for Advance Directives. - The facility failed to ensure there was a system in place to ensure all residents wishes for advanced directives were implemented and discrepancies regarding DNR wishes were addressed immediately upon admission.- The facility failed to clarify discrepancies in CR #1's wishes of DNR when she admitted on [DATE]. On [DATE] CR #1 was found unresponsive and received CPR from 06:26 AM to 07:04 AM in the facility and until 07:28 AM in the hospital until the POA notified the staff of the DNR wishes and rescue efforts were stopped. CR #1 expired at 07:28 AM. …
F578 citations in Texas
Advance directives · Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Texas cites F578 less often than its own record predicts
0.69 times the national share — cited less often here than elsewhere.
Of every deficiency written in Texas in 2025, this is the portion that was F578.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Texas surveyors wrote
F578 findings written in Texas, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation, interview and record review the facility failed to ensure the right for a resident to refuse or discontinue treatment for 1 of 6 Residents (Resident #155) whose records were reviewed for resident rights. LVN H/Treatment Nurse, failed to stop wound treatment after Resident #155 yelled out in pain multiple times for her to stop on 5/13/25. This deficient practice could affect any resident and could result in residents believing their right to say stop does not matter. The findings were: Review of Resident #155's face sheet, dated 5/14/25, revealed she was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy (according to Cleveland Clinic: it is a change in how your brain works due to an underlying condition. …
Based on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 of 19 residents (Resident #23) reviewed for advanced directives. Resident #23's OOH-DNR was not correctly completed as Resident #23's second witness signature was signed on the attending physician line. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR could cause harm and goes against resident's wishes.Findings Included:Record review of Resident #23's face sheet, dated [DATE], revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 0.92% | 0.86× |
| 2024 | 0.72% | 0.73× |
| 2025 | 0.66% | 0.69× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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