F659 in Texas. Pick another state for the same tag.
Against expectation — 2025
Texas cites F659 less often than its own record predicts
Versus expected share0.27×
0.27 times the national share — cited less often here than elsewhere.
Share of Texas citations0.01%
Of every deficiency written in Texas in 2025, this is the portion that was F659.
Texas0.01%
National0.04%
Share of all citations that were F659.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Texas surveyors wrote
F659 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.
J · Immediate jeopardy, isolatedMay 31, 2024
Based on observation, interview, and record review the facility failed to ensure services provided or arranged by the facility, as outlined by the comprehensive care plan were provided by qualified persons in accordance with each residents written plan of care for one (Resident #1) of four residents reviewed for qualified persons.
The facility failed to ensure Resident #1 received assessment after an unwitnessed fall by a qualified staff member
on 05/03/2024 when CMA A stated she conducted range of motion assessment, transferred the resident from the floor to the wheelchair and did not inform administrative staff.
An Immediate Jeopardy (IJ) situation was identified on 05/30/2024 at 6:05 PM. …
Based on observation, interview, and record review, the facility failed to ensure the written plan of care was followed for 1 of 4 residents reviewed for wound care orders. (Resident #1)
The facility did not provide daily wound care as ordered for 6 weeks for Resident #1. Resident #1 developed a stage 2 pressure injury to his right trochanter (hip) wound that worsened into an unstageable pressure injury.
This failure could place residents at risk of not receiving care and services to meet their needs
Findings included:
A face sheet dated 06/28/19 indicated Resident #1 was [AGE] years old, admitted on [DATE], and discharged home on[DATE]. His [DIAGNOSES REDACTED].
A Minimum (MDS) data set [DATE] indicated Resident #1 had intact cognition, made himself understood, and understood others. …
D · No harm, potential for more than minimal, isolatedAugust 18, 2026
Based on observation, interview, and record review the facility failed to ensure that the services provided or arranged by the facility, as outlined by the comprehensive care plan, were provided by qualified persons in accordance with each resident's written plan of care for 1(Resident #1) of 3 residents reviewed for personal property in that : The facility failed to ensure Van Driver A, who was not trained to handle financial transactions for residents, was requested to accompany Resident #1 to the bank to obtain bank statements.This failure could place residents at risk of not having the right personnel to manage their services. …
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