Based on interviews, and record reviews, the facility failed to ensure professional staff was licensed in accordance with applicable State laws for 1 (Staff Member G) of 24 personnel reviewed for licensed nursing. The facility failed to verify if Staff Member G was licensed to practice as a GVN through the TX-BON. As a result, Staff Member G was allowed to provide care/services/treatment to residents including PICC line normal saline flushes, short, long and sliding scale insulins, narcotics administration, stage 3 wound care, monitoring of dialysis ports and catheters for 26 of 92 residents on 400 hall. An Immediate Jeopardy to residents' health and safety was identified on 02/16/24. The Immediate Jeopardy Template was provided to the ADM on 02/16/24 at 8:55PM. …
F839 citations in Texas
Administration Deficiencies
Employ staff that are licensed, certified, or registered in accordance with state laws.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Texas cites F839 more often than its own record predicts
1.85 times the share F839 takes of citations nationally.
Of every deficiency written in Texas in 2025, this is the portion that was F839.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Texas surveyors wrote
F839 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 interviews and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 (CNA A) of 3 CNA's reviewed for proficiency of nurse aides. The facility failed to ensure CNA A had an active CNA license before allowing her to perform CNA tasks, working a total of 83.88 hours between [DATE] and [DATE], with an expired CNA license. This deficient practice had the potential to affect all residents in the facility who CNA A worked with when CNA A failed to maintain a current nurse aide certification. Findings included:Review of an initial EMR check conducted by the facility on [DATE] revealed CNA A was employable and had a nurse aide certification that expired on [DATE]. …
Based on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 12 staff (Respiratory Therapy Director) reviewed for staff qualifications. The facility failed to ensure the Respiratory Therapy Director, while working as a Respiratory Therapist, was licensed to practice as a respiratory therapist in the state of Texas from August 2021 to August 2024. This failure could place residents at risk of not receiving care and services from staff who were properly licensed. The findings included: Record review of the Respiratory Therapy Director's personnel file revealed a license from the National Board for Respiratory Care. …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 0.07% | 1.67× |
| 2024 | 0.16% | 2.78× |
| 2025 | 0.10% | 1.85× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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