Based on observation, interview, and record review the facility failed to ensure coordination of care to ensure hospice services were provided according to the services the LTC facility provided based on resident's care plan for 1 of 9 residents (Residents #1) reviewed for hospice services. The facility failed to coordinate with hospice interdiciplinary team to coordinate care to the resident provided by facility staff and hospice staff for those residents receiving these services. The Hospice Aide failed to transfer Resident # 1 on 04/23/25 with a Mechanical lift and two-person assistance that resulted in a fall. …
F849 citations in Texas
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Texas cites F849 more often than its own record predicts
1.03 times the share F849 takes of citations nationally.
Of every deficiency written in Texas in 2025, this is the portion that was F849.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Texas surveyors wrote
F849 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 interview and record review, the facility failed to promptly communicate and collaborate with hospice representatives in coordinating hospice care planning following a significant change in condition of a resident that suggested a need to alter the plan of care and treatment for one of eight residents (CR#1) reviewed for hospice services in that: -The facility failed to immediately contact and communicate with CR#1's hospice provider after he sustained numerous ant bites which left open wounds around and inside CR#1's mouth, eyes, and ears and all over his body. CR#1 died at the facility within 4 hours after sustaining the ant bites. These failures placed residents who were on hospice at risk of experiencing pain and physical and emotional distress. …
Based on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 6 residents (Resident #12, Resident #36, and Resident #32) reviewed for administration.1.The facility failed to maintain Resident #12's hospice binder with form 3074 (Texas Medicaid Physician Certification of Terminal Illness form. …
The short window
Recent years
| Year | Share of Texas citations | vs expected |
|---|---|---|
| 2023 | 0.55% | 1.75× |
| 2024 | 0.45% | 1.48× |
| 2025 | 0.28% | 1.03× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Texas surveyors cite →
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