Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Aviston Countryside Manor during CMS and state inspections, most recent first.
A resident with multiple chronic conditions and intact cognition was mistakenly given Keppra 750 mg and Metoprolol 100 mg by an LPN during a shared med pass, even though there were no orders for these drugs for that resident. Progress notes documented the error and monitoring, but the DON and ADON reported being unaware of any medication errors, and no medication error reports were on file despite facility policy requiring incident reporting and notification of nursing administration and the consultant pharmacist. The administrator also stated he was not informed of the event until questioned by surveyors.
Multiple residents with cognitive impairment and significant medical and psychiatric conditions were subjected to verbally and mentally abusive interactions by an LPN, including loudly telling a resident repeatedly asking for her mother that her mother was dead, yelling at a resident to get out of bed and not allowing her to call her son when she was crying, and forcing another resident who feared mechanical lifts and usually received bed baths to get up for a shower while she cried and screamed. Staff witnesses described the LPN as rude and verbally mean to residents, observed residents crying and emotionally distressed, and in several cases did not report these incidents to leadership despite care plans and facility policy requiring prompt reporting of suspected abuse.
Staff failed to recognize and immediately report suspected verbal abuse by an LPN toward three cognitively impaired residents. One resident with severe cognitive impairment and a care plan identifying abuse risk was reportedly yelled at and told her mother was dead, causing her to cry, but the witnessing therapy director did not report the incident. Another severely cognitively impaired resident was described by nursing staff as being yelled at to get out of bed and being denied timely access to call her son, yet these concerns were not reported due to fear of retaliation. A third resident with physical disabilities, vascular dementia, and fear of mechanical lifts was made to get up for a shower despite her refusals, with multiple staff describing the LPN loudly insisting on a shower while the resident cried and screamed; these events were also not reported to facility leadership. These actions and omissions violated the facility’s abuse prevention policy requiring immediate internal reporting of any suspected abuse.
Two residents experienced falls related to the facility’s failure to follow its own safety policies for wheelchair use and gait belt application. A resident with severe cognitive impairment and a history of falls, who required substantial assistance and cueing, was pushed in a manual wheelchair without footrests in place; the resident put her feet down, a foot became caught in the wheel, and she fell forward to the floor, reopening a prior forehead laceration and injuring an elbow. Another resident with multiple medical conditions, known balance issues, and a need for partial/moderate assistance was assisted by a CNA from a recliner to the bathroom with a walker but without a gait belt, contrary to facility policy; the resident became off balance, was guided to the floor, and later was found to have a left shoulder separation. Staff interviews and documentation confirmed that required wheelchair footrest positioning and gait belt use were not implemented at the time of these events.
A resident with significant mobility impairments and a history of falls was left unattended by a CNA during post-shower care, despite requiring two staff for safe repositioning. The CNA, working alone and without placing a blanket on the low air mattress as required, attempted to turn the wet resident to apply lotion, resulting in the resident slipping off the bed and sustaining an abrasion. The DON confirmed that proper procedures were not followed.
A resident with orthostatic hypotension fell while using a bedside commode unsupervised, resulting in facial bruising and a hematoma. Despite being on blood thinners and requiring substantial assistance for transfers, the resident was left alone after requesting privacy. The care plan did not adequately address her condition, and staff interviews indicated a lack of adherence to fall prevention protocols.
Failure to Administer Medications as Ordered and to Report Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered as ordered and to properly recognize and manage a medication error for one cognitively intact resident. The resident was admitted with multiple diagnoses including a left pubis fracture, UTI, heart failure, atrial fibrillation, hypertension, chronic kidney disease, and hyperkalemia, and had a BIMS score of 15. Progress notes show that on one shift the resident was given Keppra 750 mg and Metoprolol 100 mg in error, despite having no physician orders for either medication in the order history covering the relevant period. Nursing documentation states that the error was recognized, the on‑call nurse practitioner was notified, vital signs were monitored, and no adverse reactions were noted, with a subsequent note indicating no adverse side effects from the medication error on the following shift. However, the facility’s leadership and systems did not identify or track this medication error as required. The DON initially stated there had been no medication errors and that the facility had no medication error reports. One LPN reported that a night‑shift nurse had given the wrong medications to the wrong resident and that this had been reported to the DON, but the DON and the ADON both stated they were not aware of any medication errors. The LPN who made the error later described helping another nurse with a med pass, pulling medications from the med cart for a resident in one room but administering them to a different resident in another room, and stated she reported the incident and documented it. The DON subsequently acknowledged only learning of the event days later during surveyor questioning and had to review charts to determine which resident was involved. The administrator also stated he was not made aware of the medication error until the survey, despite facility policy requiring documentation of the error and forwarding incident reports to nursing administration and the consultant pharmacist.
Failure to Prevent and Report Verbal and Mental Abuse by Nursing Staff
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from verbal and mental abuse by a staff nurse and the failure of other staff to report witnessed or suspected abuse, resulting in emotional harm and distress. One resident with malignant neoplasm of the left breast, depression, generalized anxiety, unspecified mood disorder, mild cognitive impairment, and a BIMS score of 5 (severely cognitively impaired) repeatedly asked for her mother. The Director of Physical Therapy (V15) stated that an LPN (V11) turned to this resident and loudly told her that her mother was dead, which V15 characterized as hateful, verbally, and mentally abusive. V15 reported that the resident became very upset and cried after this statement. Although V15 believed the interaction was abusive, she did not report this incident to administration or the DON at the time it occurred, despite the resident’s care plan identifying her as at risk for abuse/neglect and directing staff to address complaints promptly and report suspected abuse immediately. Another resident with Alzheimer’s disease, unspecified dementia, major depressive disorder, insomnia, and a BIMS score of 5 (severely cognitively impaired) was also involved in alleged verbal abuse. Nursing staff (V3 and V4) reported that the same LPN (V11) was verbally mean and not nice to residents, and specifically that she yelled at this resident, who liked to sleep in, from the hallway telling her she needed to get out of bed and that she was getting up. V3 stated she did not report this behavior because she felt it would put a target on her back. V4 reported that on one occasion this resident was crying and asking to call her son, and V11 would not call him; V4 eventually called the son herself, which calmed the resident. V4 also described an incident where the resident was sitting near the nurse’s station and V11 was yelling at her in a very loud and rude manner, which upset the resident. The resident herself reported poor memory and uncertainty about whether staff had yelled at her, but did recall being very upset and mad when she was not allowed to use the phone to call her son. Her care plan, like that of the first resident, identified risk for abuse/neglect and directed staff to address complaints and report suspected abuse immediately. A third resident with cerebral palsy, paraplegia, vascular dementia, bipolar disorder, major depressive disorder, anxiety disorder, unspecified intellectual disabilities, and a BIMS score of 11 (moderately impaired) reported being forced to get out of bed for a shower when she normally received bed baths. She stated that the LPN (V11) told her in a loud voice that she had to get up and take a shower, despite her back and spine problems and her fear of the mechanical lift due to a prior fall from a lift sling at another facility. The resident reported that staff, at V11’s direction, got her up with the mechanical lift for the shower, and she was crying, very upset, and stated she was unhappy at the facility because they made her do things she did not want to do and raised their voices at her. Another LPN (V4) corroborated that V11 instructed staff to get this resident up for a “real shower” despite the resident’s refusals and fear of the lift, and that the resident was crying and screaming, very upset during the process. A CNA (V9) confirmed that she gave the resident a shower at V11’s direction despite the resident’s refusal to get out of bed, and another CNA (V21) reported hearing the resident yelling and screaming during the shower, noting it was the first time she had seen the resident get up out of bed for a shower. The resident’s care plan did not include a focus area for abuse, and staff who witnessed or were aware of these events did not report them to the administrator or DON at the time. Multiple staff interviews further described a pattern of verbally rude or mean behavior by the LPN (V11) toward residents, including telling another resident who was yelling out to stop because no one needed to hear that. The DON (V2) acknowledged that she had previously spoken to V11 about being rude to a resident but had not received additional reports until the surveyor’s inquiry, and stated that if the resident who feared the lift did not want a shower, V11 should not have made her get one, and that no staff should yell at any resident or prevent a resident such as the second resident from calling her son. The facility’s Abuse Prevention Program policy states the facility desires to prevent abuse, neglect, or misappropriation of property by establishing a resident-sensitive and resident-secure environment. Despite this, the reported incidents show residents being subjected to loud, rude, or coercive interactions by an LPN, residents becoming upset, crying, or emotionally distressed, and staff failing to promptly report suspected abuse as required by resident care plans and facility policy.
Failure to Recognize and Report Suspected Verbal Abuse Toward Cognitively Impaired Residents
Penalty
Summary
Facility staff failed to identify and immediately report staff-to-resident verbal abuse involving three residents with cognitive impairments. One resident with malignant neoplasm of the left breast, cerebral infarction, depression, generalized anxiety, unspecified mood disorder, and mild cognitive impairment had a BIMS score of 5, indicating severe cognitive impairment, and adequate hearing. Her care plan identified risk for abuse/neglect with an intervention to report any suspected abuse/neglect to the administrator immediately. The Director of Physical Therapy stated she witnessed an LPN turn to this resident, who was repeatedly asking for her mother, and yell that her mother was dead, after which the resident became very upset and cried. The Director of Physical Therapy described the LPN’s behavior as verbally and mentally abusive but did not report this incident to the administrator or DON, despite facility policy requiring immediate internal reporting of suspected abuse. Another resident with Alzheimer’s disease, unspecified dementia, major depressive disorder, and insomnia also had a BIMS score of 5 and adequate hearing, and a care plan identifying risk for abuse/neglect with instructions to promptly address complaints and report suspected abuse to the administrator. A RN reported that a newer LPN was verbally mean to most residents and had yelled at this resident, who liked to sleep in, from the hallway, telling her she needed to get out of bed and that she was getting up, which the RN considered verbal and mental abuse. The RN admitted she did not report this behavior because she felt it would “put a target on your back.” Another LPN reported that on a weekend the same LPN yelled very loudly and rudely at this resident while she sat near the nurse’s station, upsetting her, and that on another occasion the resident cried when she was not allowed to call her son. This LPN also did not report these incidents to the administrator or DON. A third resident with cerebral palsy, paraplegia, vascular dementia, bipolar disorder, major depressive disorder, anxiety disorder, and unspecified intellectual disabilities had a BIMS score of 11, indicating moderately impaired cognition, and adequate hearing. Her care plan did not include a focus area for abuse. She reported that an LPN told her in a loud voice that she had to get up and take a shower, despite her usual practice of receiving bed baths due to back and spine problems and fear of mechanical lifts after a prior fall from a lift sling at another facility. She stated that staff, at the LPN’s direction, got her up with a mechanical lift for a shower, during which she cried and was very upset. Another LPN corroborated that the LPN insisted staff get this resident up for a “real shower” despite her refusals and fear of the lift, and that the resident was crying and screaming, but this was never reported to the administrator or DON. A CNA confirmed she gave the resident a shower at the LPN’s direction despite the resident’s refusal to get out of bed, and another CNA reported hearing the resident yelling and screaming during the shower, noting it was the first time she had seen the resident get up for a shower. These events, along with staff statements that they did not report the LPN’s conduct, demonstrate a failure to recognize, internally report, and escalate suspected verbal abuse as required by the facility’s Abuse Prevention Program policy. The facility’s Abuse Prevention Program policy requires employees to immediately report any incident, allegation, or suspicion of potential abuse, neglect, or misappropriation of property they observe, hear about, or suspect to the administrator, with specified time frames for reporting based on seriousness, and directs that employees immediately inform the administrator of all such reports so that an investigation can be initiated. Multiple staff, including the Director of Physical Therapy, a RN, and an LPN, acknowledged witnessing or being aware of verbally abusive or coercive interactions by the LPN toward these residents but did not report these concerns to the administrator or DON at the time they occurred. The failure of these staff members to follow the internal reporting requirements resulted in suspected verbal and mental abuse not being promptly identified or reported to facility leadership as required by policy.
Failure to Ensure Wheelchair Safety and Proper Gait Belt Use Resulting in Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents, both in relation to wheelchair safety and transfer/ambulation assistance. One resident with severe cognitive impairment, dementia, bipolar disorder with psychotic features, schizoaffective disorder, seizure history, and prior falls used a manual wheelchair and required substantial to maximal assistance for wheeling 50–150 feet, along with maximum verbal and tactile cues due to low comprehension and confusion. The resident’s care plan identified risk for falls and injuries related to weakness, dementia, and poor safety awareness, with interventions including use of proper assistive devices and cueing/redirection as needed. The facility’s wheelchair safety policy required staff to ensure proper foot placement on footrests and safe use and supervision of wheelchairs. On one occasion, a CNA was asked to return this resident from a hallway where the resident was known to go in an attempt to get into other residents’ beds. The CNA began pushing the resident in the wheelchair back toward the nurse’s station without foot pedals in place. Multiple staff, including the CNA, LPN, and DON, reported that the resident’s feet were not on footrests and that the resident put her feet down while being pushed, causing a foot to become caught in the wheelchair wheel. This resulted in the resident falling forward out of the wheelchair and striking her head on the floor, reopening a previous forehead laceration and causing additional injury to the elbow. The facility’s event report documented that the resident’s foot became caught in the front wheel while being pushed in the hallway, leading to the forward fall. The second resident had diagnoses including cerebral infarction, COPD, asthma, hypertension, seizure disorder, depression, anxiety, and osteoarthritis, and was cognitively intact with a BIMS score of 14. The MDS and therapy staff documented that this resident required partial/moderate assistance with self-care and mobility and had episodes of being unbalanced and falling backward when ambulating. The resident’s care plan identified a need for assistance with ADLs due to weakness and a risk for falls and injuries, with an intervention to observe for safety. The facility’s gait belt policy required use of gait belts when transferring weight-bearing residents or assisting them with walking. Despite this, a CNA responded to the resident’s call light for toileting assistance and helped the resident ambulate with a walker from a recliner to the bathroom without using a gait belt. During ambulation, the resident became off balance, which the CNA stated happens at times, and the CNA grabbed the resident’s shirt and pants on the left side to guide the resident to the floor. The resident ended up sitting on the bathroom floor with her back against the door and was then assisted by two CNAs to the toilet and back to the recliner. Both the CNA and the resident later confirmed that no gait belt was used during the transfer or ambulation. Several days later, an LPN noted the resident’s complaints of left shoulder pain, bruising, and limited movement, and imaging ordered by the practitioner showed a left shoulder separation and arthritis. The DON and Administrator stated that facility policy and their expectations required use of a gait belt during transfers and ambulation, and the fall management policy defined such an event, including a loss of balance that would have resulted in a fall without staff intervention, as a fall.
Failure to Provide Safe Repositioning Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to provide safe turning and repositioning care for a resident with significant physical impairments and a history of falls. The resident, who was cognitively intact but had one-sided weakness and required substantial assistance with activities of daily living, was at high risk for falls due to conditions including Parkinson's disease and a previous hip dislocation. After receiving a shower, the resident was returned to bed, which was equipped with a low air mattress. Only one certified nursing assistant (CNA) was present, despite facility protocol requiring two staff members for such care. The CNA attempted to turn the resident alone to apply lotion, without placing a blanket underneath as expected for residents on low air mattresses, and the resident subsequently slid off the bed and fell to the floor. Interviews and documentation confirmed that the resident was wet from the shower, making the surface slippery, and that the CNA was aware of the requirement for a second staff member but proceeded alone due to being busy. The Director of Nursing acknowledged that staff are expected to use a blanket to prevent slipping on air mattresses, which was not done in this instance. The facility's fall policy emphasizes the need to recognize and address high fall risk, but these procedures were not followed, resulting in the resident sustaining an abrasion and requiring hospital evaluation.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for a resident diagnosed with orthostatic hypotension. The resident, who requires substantial assistance for transfers, was found with bruises on her face and neck after attempting to use the bedside commode independently. Despite being on blood thinners, which increased her risk of injury from falls, the resident was left unattended on the commode after requesting privacy. This lack of supervision led to her becoming dizzy and falling, resulting in a hematoma to her left eye. The resident's care plan documented her risk for falls due to weakness and included interventions such as a comprehensive medication review and individualized toileting interventions. However, the care plan did not specifically address her orthostatic hypotension or provide clear guidance for staff on how to manage this condition. The resident's fall risk assessment identified her as a moderate risk for falls, yet the facility's fall prevention program did not adequately mitigate this risk. Interviews with facility staff revealed that the resident was known to have orthostatic hypotension, yet staff did not remain with her during toileting despite her condition. The facility's policy aimed to decrease falls by recognizing high-risk residents, but the implementation of this policy was insufficient in this case. The resident's electronic health record did not document a refusal to attend a cardiology appointment, which was necessary for managing her condition.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Aviston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evercare Of Breese | 4.4 mi | ★★★★★ | 3 | 0 |
| Clinton Manor Living Center | 7.3 mi | ★★★★★ | 0 | 0 |
| Highland Health Care Center | 9.1 mi | ★★★★★ | 3 | 1 |
| Cedar Ridge Health & Rehab Ctr | 11.4 mi | ★★★★★ | 8 | 0 |
| Evercare Of Lebanon | 11.6 mi | ★★★★★ | 6 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.