Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Avir At Arden Wood during CMS and state inspections, most recent first.
A resident with paraplegia, chronic pain, impaired cognition, and anticoagulant use fell from bed during wound care preparation and complained of pain in her right knee, hand, and elbow. X-rays later showed a nondisplaced distal femur fracture, but the result was texted to the NP instead of being phoned to the on-call provider after hours, no new orders were obtained before the nurse left, and the resident was not sent to the ER until the next day.
Unsafe Bed Positioning and Unsecured Wheels During Wound Care Prep: A resident with hemiplegia, moderate cognitive impairment, pressure ulcers, and 2-person care needs was left on her side in a high bed during wound care prep while CNAs stepped away. The bed was moved away from the wall and the wheels were not safely secured, and when the resident turned her head she slid off the bed and fell between the bed and wall, later found to have a nondisplaced distal femur/right knee fracture.
A resident with multiple comorbidities and limited mobility fell from bed and had an x-ray that showed a nondisplaced distal femur fracture. The LPN received the result but did not call the on-call MD after hours, instead sending the image to the NP without confirmation or response. The result was not handed off to the next shift, the resident remained in pain, and the NP did not learn of the fracture until the next day, when the resident was sent to the hospital.
Failure to update PASRR screening for a resident with MDD and schizophrenia. The resident had a prior negative PL1, but later records documented MDD with psychotic features, schizophrenia, dementia, and impaired cognition. The MDS nurse said she was responsible for monitoring PL1 accuracy and acknowledged the resident should have had a positive PL1 because of the mental illness diagnoses, but the change was missed until an RRC audit identified the error.
Care Plan Not Updated for Schizophrenia: A resident with PVD, dementia, Parkinson’s disease, anxiety, depression, and paranoid schizophrenia had a care plan that addressed behavior, mood, cognition, and anti-anxiety meds, but did not include schizophrenia. The quarterly MDS showed severe cognitive impairment and ongoing mood and care refusal concerns, while the psychiatric eval documented a history of schizophrenic disorder. The DON and MDS nurse stated care plans must include all diagnoses and related interventions, but the schizophrenia diagnosis was not reflected in the care plan.
Expired collection tubes were found stored in the medication room, including 13 unopened eSwab tubes that had expired. The ADON said she checked the room twice weekly but missed them, the LVN said she did not check those supplies, and the Treatment Nurse said she did not monitor the tubes stored in the medication room. The DON stated he expected the ADON, Treatment Nurse, and floor nurses to check for expiration dates, and record review showed the facility had no policy on storing medical supplies.
Air Mattress Function Interrupted by Fitted Sheet: A resident with DM, morbid obesity, impaired cognition, limited mobility, and a history of a healed stage 3 pressure ulcer was observed on an alternating air mattress with a fitted sheet covering it. The resident said she had no current wounds and could not feel the mattress moving, while the Wound Care Nurse and DON stated the fitted sheet disrupted the mattress's pressure-relieving function and should not have been used.
An open tube of Lidocaine and Prilocaine 2.5%/2.5% was found on a resident’s bedside table instead of being stored in a locked medication area. The resident had diabetes, a stroke history with weakness and paralysis, obesity, MDD, anxiety, and a partial left midfoot amputation with wound care needs. The resident said the cream had been at bedside since returning from the hospital, while the Wound Care Nurse stated there was no order for it and the wound care doctor had refused to prescribe it. The facility policy required medications and biologicals to be stored in locked compartments with access limited to authorized personnel.
Daily staffing information was not posted in a prominent, readily accessible location and the posting was incomplete. Surveyors found the staffing sheet placed by the 200 hall entrance, where people going only to the 100 hall would not see it, and the form listed shift times, census, and counts of CNAs, LPNs, and RNs but omitted the facility name and the total hours worked by direct care staff. The Staffing Coordinator confirmed the posting should include the facility name, census, date, staff type, and hours worked.
Surveyors found that required Enhanced Barrier Precautions (EBP) signage and PPE were missing outside the rooms of three residents with significant medical conditions, despite care plans and facility policy mandating their presence. Staff interviews revealed reliance on such signage to determine appropriate PPE use, and the infection preventionist confirmed ongoing issues with missing signs, leading to lapses in infection control practices.
Surveyors found a bottled water buried in the kitchen ice machine, which the DM removed using an ice scooper. The DM confirmed that personal items should not be stored in the ice to prevent contamination and was unsure who placed the bottle there. Staff had been previously in-serviced on proper ice machine use, and policies were in place for safe food and beverage storage, but these were not followed, resulting in a deficiency.
A resident with multiple complex medical conditions did not receive a required specialized pressure-reducing mattress because the facility failed to submit the PASRR Nursing Facility Specialized Services (NFSS) request within the mandated timeframe, due to identification issues and delays in obtaining supplier documentation.
A resident with diabetes and chronic kidney disease did not have physician-ordered blood sugar reporting parameters in place, leading to multiple high blood glucose readings not being reported to the physician as required by facility policy. Staff interviews revealed inconsistent understanding of when to notify the physician, and documentation showed no evidence of timely communication regarding abnormal blood sugar levels.
A nurse failed to administer a prescribed dose of Lorazepam to a resident with severe cognitive impairment and behavioral issues, despite signing out the medication on the narcotic sheet. The medication was not removed from the blister pack, resulting in inaccurate controlled substance records and the resident not receiving the ordered medication. Interviews and record reviews confirmed the medication error and documentation discrepancy.
Surveyors found that two medication carts contained narcotic pill cards with torn protective seals, including one instance where a Lorazepam tablet compartment was taped closed. Nurses acknowledged the improper handling and stated that damaged tablets should be wasted, not taped. The DON confirmed that such incidents should be reported and that facility policy requires proper storage and inventory of controlled substances.
A facility failed to protect residents from neglect, resulting in an altercation between two residents in the memory care unit. An 84-year-old male resident with a history of aggressive behavior was involved in an incident with a 92-year-old female resident who wandered into his room. The altercation led to injuries for the female resident. The facility's care plans were not adequately updated to address these behaviors, contributing to the incident.
The facility failed to implement comprehensive care plans for two residents, leading to unaddressed aggressive behaviors in one resident and unmitigated fall risks in another. The care plans lacked necessary updates and interventions, resulting in serious incidents and highlighting systemic issues in care plan management.
A resident with schizoaffective disorder and cognitive impairment exhibited aggressive and territorial behaviors, which were documented in progress notes but not reflected in the care plan. Despite incidents of aggression and physical altercations, the care plan was not updated to address these behaviors. Interviews with staff revealed a lack of awareness and action regarding the resident's behavioral issues, contributing to the deficiency in care.
Delayed Physician Notification of Fracture Result After Resident Fall
Penalty
Summary
The facility failed to ensure treatment and care were provided in accordance with professional standards of practice for a resident who had multiple diagnoses including paraplegia, chronic pain, COPD, obesity, a history of DVT/embolism, and impaired cognition. After a witnessed fall from bed while staff were preparing her for wound care, the resident reported pain to her right knee, right hand, and right elbow. X-rays were ordered for the injured areas, and the right knee imaging later showed a mildly comminuted nondisplaced fracture of the distal femur near the knee joint. The radiology report showing the fracture was reported at about 2:55 p.m., but the resident was not transferred to the hospital until the next day, approximately 27 hours after the fall. The record reflects that the nurse who received the x-ray results took pictures of the reports and texted them to the NP, who responded, "Nothing there," after only seeing part of the images. The nurse did not contact the on-call physician after hours, did not obtain new orders before leaving the shift, and placed the printed x-ray reports on the 24-hour report for the oncoming nurse. The change of condition documentation was not completed at the time of the event, and the oncoming nurse was not aware of the fracture results when she came on duty. Interviews confirmed that staff understood critical x-ray results, including fractures, were to be communicated by phone to the physician team or on-call provider after hours. The DON, MD, NP, ADON, and nursing staff all described that the fracture result should have been reported directly and that the resident should have been sent for higher-level evaluation when the fracture was identified. The resident stated she remained in pain for hours while waiting for x-ray results and said she was not sent to the ER until the next day, when she learned the x-ray showed a hairline fracture to her right leg.
Unsafe Bed Positioning and Unsecured Wheels During Wound Care Prep
Penalty
Summary
The facility failed to ensure Resident #8’s environment remained free of accident hazards when the resident was left positioned on her side in bed during preparation for wound care and the bed wheels were not safely secured. Resident #8 had multiple diagnoses including hemiplegia/hemiparesis after cerebral infarction, spinal stenosis, COPD, obesity, anticoagulant use, and pressure ulcers of the sacral region and right buttock. Her MDS reflected moderate cognitive impairment, and her care plan identified that she required 2-person assistance for transfers and repositioning, was at risk for falls, and required furniture to be kept in locked position. On the morning of the incident, CNA A and another CNA changed the resident’s brief and positioned her on her left side in preparation for wound care. The bed had been moved away from the wall to allow staff access on both sides, and the resident was left without staff in the room while the CNAs left to pass meal trays. When the wound care nurse and NP entered the room, the resident was still on her side with the bed in a high position and her right hand on the quarter rail. As the resident spoke and turned her head, she began sliding off the left side of the bed toward the floor, and the bed moved as she fell between the bed and the wall. After the fall, staff assisted the resident from the floor back to bed and documented pain to the right elbow, right hand, and right knee. X-rays later showed a mildly comminuted nondisplaced fracture of the distal femur/right knee area. The resident was sent to the hospital for further evaluation and returned with a right leg immobilizer and pain medication. Interviews with the resident and staff reflected that the resident required hands-on assistance while on her side, that the bed wheels should have been locked, and that the resident should not have been left unattended in that position during wound care preparation.
Delayed Notification of Femur Fracture Result
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of a radiology result that showed a right distal femur fracture for a resident who had fallen from bed and reported significant pain. The resident had multiple diagnoses including heart failure, depression, pressure ulcers, bone infection, muscle weakness and paralysis following a stroke, deep vein thrombosis, and an unspecified femur fracture. She was cognitively impaired, used a wheelchair, and required total assistance for transfers and bed mobility. After the resident fell while awaiting wound care, an x-ray of the right knee was ordered. The radiology report identified a mildly comminuted, nondisplaced fracture across the distal femur with soft tissue swelling and effusion. The radiology provider reported that the fracture result was communicated to LVN K by phone at 9:39 PM, but LVN K did not call the on-call physician and instead sent a picture of the result to the NP. LVN K stated she did not speak to the NP and no orders were received before she left at 10 PM. The resident remained in pain, with pain assessments documented at 4/10, 3/10, and 5/10 over the following hours. Multiple staff interviews showed the fracture was not communicated through the facility's approved notification process and was not handed off to the next shift. The night nurse stated she was not told about the fall, pending radiology results, or fracture, and therefore did not assess the resident or notify the on-call physician. The NP stated she was not aware of the fracture until the next day, and the resident was then sent to the hospital. Facility policy required the attending physician to be promptly notified of diagnostic test results, required the charge nurse or DON to notify the physician, and required immediate notification for suspected fractures and after-hours critical findings.
Failure to Update PASRR Screening for Resident With Mental Illness Diagnoses
Penalty
Summary
The facility failed to coordinate a PASRR assessment for one resident with newly evident mental illness diagnoses. Resident #4 had a PASRR Level 1 screening dated 04/02/20 that indicated there was no evidence or indicator of mental illness, and the EMR on 05/19/26 showed no documented PE and only one PL1 completed after 04/20/20. However, the resident’s record later documented psychiatric diagnoses including MDD with severe psychotic symptoms and paranoid schizophrenia, with onset dates recorded in the chart, and the facility did not update the PL1 when those diagnoses became evident. Resident #4’s record showed a face sheet with diagnoses including anxiety disorder, MDD recurrent severe with psychotic symptoms, and paranoid schizophrenia. The quarterly MDS documented severely impaired cognition with a BIMS score of 6 out of 15, depressed mood several days in the last two weeks, rejection of care, and active diagnoses of PVD, dementia, Parkinson’s disease, anxiety disorder, depression, and schizophrenia. The care plan addressed behavior problems, mood problems, impaired cognition/thought related to dementia, and use of anti-anxiety medications, but there was no documented focus area for schizophrenia. A psychiatric evaluation dated 04/29/21 documented MDD and a history of mood symptoms, anxiety symptoms, and medication non-adherence, and a later psychiatric periodic evaluation dated 09/13/21 documented dementia with behavioral disturbances, schizophrenic disorder, MDD with psychotic features, and generalized anxiety. The facility’s PASRR Level 1 Screening created on 05/21/26 identified mental illness as present, and the Mental Illness/Dementia Resident Review form indicated schizophrenia and mood disorder were present and that a new positive PL1 was required. In interview, the MDS Nurse stated she was responsible for reviewing PL1 accuracy and monitoring for diagnosis changes, and acknowledged that Resident #4 should have had a positive PL1 because of the MDD and schizophrenia diagnoses, but she did not know why the new diagnoses were missed. The RRC stated she identified the PL1 as incorrect during an audit and completed the form 1012, which led to submission of a new positive PL1.
Care Plan Not Updated for Schizophrenia
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after assessments, including the comprehensive and quarterly review assessments, for 1 of 8 residents reviewed. Resident #4’s care plan was not updated to reflect a diagnosis of paranoid schizophrenia that dated back to 09/13/21. The report states that this deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. Resident #4’s face sheet listed diagnoses including PVD, vitamin deficiency, asthma, anxiety disorder, MDD recurrent severe with psychotic symptoms, and paranoid schizophrenia. The quarterly MDS showed severely impaired cognition with a BIMS score of 6 out of 15, reports of feeling down, depressed, or hopeless several days in the last 2 weeks, rejection of care 1-3 days, and active diagnoses of PVD, dementia, Parkinson’s disease, anxiety disorder, depression, and schizophrenia. The care plan printed on 05/21/26 included focus areas for behavior problems, mood problems related to disease process, impaired cognition/thought related to dementia, and use of anti-anxiety medications, but it did not include a documented focus area for schizophrenia. The psychiatric periodic evaluation dated 09/13/21 identified a past psychiatric history of dementia with behavioral disturbances, schizophrenic disorder, MDD with psychotic features, and generalized anxiety. During observation on 05/19/26, Resident #4 was well groomed, well-dressed, seated in a wheelchair in the activity room, and said she had no issues or concerns with the facility, though she appeared confused when asked questions about her mental status. In interviews, the DON stated the care plan must include all diagnoses, goals, and specific interventions, and the MDS Nurse stated the care plan should address behaviors, medications, and diagnoses, but she could not explain why Resident #4’s care plan did not address schizophrenia.
Expired Collection Tubes Stored in Medication Room
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring the medication room was free from expired medical supplies. During an observation of the 200 hall medication cart, staff were found storing unopened expired eSwab collection tubes, with a count of 13, all expired on 07/12/2025. The expired collection tubes were located in the medication room during the surveyor observation on 05/22/2026. During interviews, the ADON stated she checked the medication room for expired medications and supplies two times each week but overlooked the collection tubes and said she should have noticed and discarded them. The LVN stated she did not check medication room supplies, including collection tubes, for expired items. The Treatment Nurse stated she stored collection tubes in her office and treatment cart, while nurses stored tubes in the medication room, and she did not check the medication room supply. The DON stated he expected the ADON to check the medication room a couple of times a week and expected the Treatment Nurse and floor nurses to check collection tubes for expiration dates every shift and before use. Record review showed the facility did not have a policy on storing medical supplies.
Air Mattress Function Interrupted by Fitted Sheet
Penalty
Summary
The facility failed to ensure Resident #25 received care consistent with professional standards of practice to prevent pressure ulcers when her air mattress was interrupted by a fitted sheet on 05/19/26. Resident #25 was a [AGE]-year-old female admitted with diagnoses including type 2 diabetes and morbid obesity due to excess calories. Her quarterly MDS showed severely impaired cognition with a BIMS score of 06 out of 15, lower extremity range-of-motion limitations, substantial assistance needs for bed mobility, total dependence for standing and transfers, risk for pressure ulcers/injuries, and an unhealed stage 3 pressure ulcer. Her care plan addressed impaired physical mobility, and a wound assessment dated 05/11/26 documented that a facility-acquired stage 3 pressure ulcer to the right buttock, identified on 11/18/25, had resolved. On 05/19/26 at 10:46 AM, the resident was observed in bed on an air mattress set at 450 lbs., with a 25-minute cycle time and alternating pressure, but with a fitted sheet on the mattress. The resident stated she had no current wounds, did not ask for the fitted sheet, and could not feel the mattress moving up and down to redistribute pressure. At 1:44 PM, the Wound Care Nurse observed the mattress and stated the resident's bed should not have a fitted sheet because it disrupted the air mattress's ability to relieve pressure and placed residents at risk of skin breakdown. The DON later stated there should never be a fitted sheet on the air mattress because it disrupted the alternating pressure function meant to prevent pressure ulcers, and that staff rounds should have ensured the correct sheets were used, although no task was assigned in the EMR to track it. The facility's policy stated that redistributing support surfaces are to provide pressure relief or reduction and that residents at risk for pressure ulcers should be placed on a redistribution support surface when lying in bed.
Unsecured topical medication left at bedside
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments under proper temperature controls and accessible only to authorized personnel when an open tube of Lidocaine and Prilocaine 2.5%/2.5% was found unattended on a resident’s bedside table. The resident was a female with type 2 diabetes, paralysis of both legs, left-sided weakness after a stroke, obesity, MDD, anxiety disorder, and a partial amputation of the left midfoot. Her MDS showed moderately impaired cognition with a BIMS score of 12 out of 15, and her care plan included wound management and treatment for the left forefoot surgical site. Record review showed the resident had orders for wound care and IV ertapenem, but there was no prescription for Lidocaine and Prilocaine 2.5%/2.5%. During observation, the open and in-use tube was on the bedside table while the resident was in bed and in no immediate distress. The resident stated the cream had been there since she returned from the hospital and that it had been applied by the nurse to her foot. The Wound Care Nurse stated the resident did not have a prescription for the cream and that staff had not administered it, explaining that the resident had asked for it and the wound care doctor refused to prescribe it. The facility policy stated all medications and biologicals are to be stored in locked compartments under proper controls and only authorized personnel may have access to the keys.
Daily Staffing Posting Missing Required Information and Not Posted in a Visible Location
Penalty
Summary
The facility failed to ensure that the daily staffing posting was posted in a location visible and readily accessible to residents, visitors, vendors, and emergency personnel. On 05/19/26, 05/20/26, 05/21/26, and 05/22/26, surveyors observed the Daily Staffing Posting attached to the wall leading to the 200 hall, rather than in a prominent location accessible to all. The posting was located in a common area/dining area immediately after the lobby, with one hall leading to the 100 hall and another leading to the 200 hall, and the posting was positioned on the wall by the 200 hall entrance. During each observation, the posting identified the date, shift times, census of 130, and the number of CNAs, LPNs, and RNs on each shift, but it did not include the name of the facility or the total number of hours worked by direct care staff for each shift. The observations documented the same omission across all four dates reviewed. The Staffing Coordinator stated that the posting should include the type of staff, hours worked, census, date, and the name of the facility, and acknowledged that the current template had omitted the facility name. The facility policy titled 'Posting Direct Care Daily Staffing Numbers,' revised 08/2022, stated that staffing data must be posted daily in a prominent location accessible to residents and visitors and that the form must include the name of the facility and the current date, along with the resident census at the beginning of the shift. The record review showed that the posted information did not fully match the policy requirements because it lacked the facility name and the total number or actual hours worked for each type of direct care staff.
Failure to Maintain EBP Signage and PPE for Infection Control
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding Enhanced Barrier Precautions (EBP) for three residents reviewed for infection control. Observations on multiple occasions revealed that required EBP signage was missing from the doors of rooms where EBP was indicated, and there was no equipment placed outside these rooms to alert staff of the necessary personal protective equipment (PPE) to be used. This was contrary to the facility's own policy and care plans, which specified that signage should be posted to inform staff of required precautions during high-contact care activities. Record reviews showed that the affected residents had significant medical conditions, including obstructive and reflux uropathy, malignant neoplasm of the kidney, sepsis, slow transit constipation, anemia, and heart failure. Their care plans required staff to use gowns and gloves during high-contact care and specified that EBP signage should be posted outside their rooms. However, during the survey, these signs were not present, and staff interviews confirmed reliance on such signage to determine appropriate PPE use before entering rooms. Staff interviews indicated that while in-service training on EBP and PPE had been conducted recently, staff depended on the presence of signage or equipment outside the room to guide their infection control practices. When signage was missing, staff reported they would consult with the nurse or infection preventionist. The infection preventionist acknowledged that EBP signs had been disappearing and required frequent replacement, but at the time of the survey, the necessary signage was not consistently in place for residents requiring EBP.
Improper Storage of Personal Beverage in Kitchen Ice Machine
Penalty
Summary
A deficiency was identified when surveyors observed a bottled water buried within the stored ice of the facility's kitchen ice machine. During the initial kitchen tour, the Dietary Manager (DM) used an ice scooper to remove the 8oz bottled water from the ice. The DM acknowledged that bottled water should not have been placed in the ice and was unaware of who was responsible. He explained that items should not be stored in the ice to prevent contamination. The kitchen had a cart with various beverages containing ice for the morning meal, and the DM noted that there was no designated area in the kitchen for staff to store personal food or beverages, though an employee breakroom was available for this purpose. Further interviews confirmed that both the DM and Corporate DM had previously conducted in-services instructing staff to keep the ice machine free from personal items, including drinks. The DM reiterated that kitchen staff were informed to store personal food and drinks in the breakroom or lockers, and that drinks for hydration could be kept in the DM's office. The Administrator stated that all individuals were expected to follow proper storage protocols to prevent items from coming into contact with the ice, which would render the ice unusable. Policy reviews indicated procedures for safe food handling and storage, but the incident demonstrated a failure to adhere to these standards.
Failure to Submit PASRR NFSS Request for Specialized Mattress
Penalty
Summary
The facility failed to coordinate an assessment with the Preadmission Screening and Resident Review (PASRR) program for a resident who required specialized services under Medicaid. Specifically, the facility did not submit a Nursing Facility Specialized Services (NFSS) request for a specialized pressure-reducing support surface mattress within the required 20 business days following the Interdisciplinary Team (IDT) meeting. The delay was attributed to issues with the resident having two social security numbers, which necessitated repeating the PASRR process, and the inability to obtain a medical equipment supplier quote in time. As a result, the NFSS was not submitted, and the mattress was never ordered before the resident was discharged. Record reviews confirmed that the resident had multiple complex medical diagnoses, including diabetes, severe intellectual disabilities, heart failure, and a pressure ulcer. Interviews with staff revealed that the tracking system for NFSS submissions was in place, but the process was disrupted due to the resident's identification issues and delays in obtaining necessary documentation. Additionally, the facility did not provide a written policy outlining its PASRR process, only supplying state guidance documents upon request.
Failure to Ensure Physician Supervision and Blood Sugar Reporting Parameters for Diabetic Resident
Penalty
Summary
The facility failed to ensure that a resident with multiple complex medical conditions, including Type 2 diabetes mellitus, chronic kidney disease, and hemiplegia, was under appropriate medical supervision as required. The resident was admitted with significant care needs and was dependent on staff for most activities of daily living. Despite being on insulin therapy and tube feeding, there were no physician orders specifying blood sugar parameters for when to notify the physician of abnormal glucose levels, as required by facility policy. Over several days, the resident experienced multiple episodes of elevated blood glucose readings, with values consistently above 300 mg/dl. These high readings were not reported to the physician or the resident's guardian until several days after the initial occurrences. Interviews with nursing staff and facility leadership revealed inconsistent understanding and implementation of protocols for reporting high blood sugar levels, with some staff stating they would report values above 200 mg/dl or 300 mg/dl, while the attending physician indicated she only wanted to be notified for blood sugars below 70 mg/dl or above 400 mg/dl. Documentation showed that no calls were made to the physician regarding the high blood sugar readings, and there was no evidence of physician orders for specific reporting parameters in the resident's chart. The facility's diabetes management protocol required the physician to order parameters for monitoring and reporting blood sugar levels, and for staff to incorporate these into the care plan and medication administration record. However, this was not done for the resident in question. Staff interviews further confirmed that there was confusion and lack of clarity regarding when to notify the physician about abnormal blood sugar levels, and that in-service training had occurred but did not result in consistent practice. The failure to obtain and follow physician orders for blood sugar reporting parameters resulted in a lack of appropriate medical supervision for the resident.
Failure to Administer Medication and Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering medications as ordered and by not maintaining accurate records of controlled substances. Specifically, a nurse signed out a dose of Lorazepam 0.5 mg for a resident with severe cognitive impairment, schizophrenia, anxiety, depression, and dementia, but did not actually administer the medication as prescribed by the physician. The medication administration record was later corrected to indicate the dose was not given, and the nurse acknowledged the error, stating she thought she had dispensed the medication but had not. The resident in question had a history of behavioral symptoms, including agitation, wandering, and refusal of care, and was prescribed antipsychotic, antianxiety, and antidepressant medications. The care plan emphasized the importance of administering medications as ordered and monitoring for side effects and effectiveness. On the day in question, the nurse signed out the Lorazepam on the narcotic sheet, reducing the count, but the blister pack still contained the expected number of tablets, confirming the medication was not removed or given. Interviews with the nurse and the Director of Nursing confirmed that the medication was not administered as ordered and that the recordkeeping for the controlled substance was inaccurate. The facility's policies require medications to be administered as prescribed and for accurate inventory of controlled substances to be maintained at all times. The failure to follow these procedures resulted in the resident not receiving the intended dose of Lorazepam and inaccurate documentation of the controlled drug inventory.
Improper Storage and Handling of Controlled Substances in Medication Carts
Penalty
Summary
Surveyors observed that two medication carts, one in the secured unit back hall and one in the station 1 front hall, contained narcotic pill cards with torn protective seals. In the secured unit, a Lorazepam 0.5 mg pill card had a torn seal on one compartment, which was covered with tape. The nurse present stated that the tablet should have been wasted and not taped, and was unsure who applied the tape or why. In the station 1 front hall, pill cards for Tramadol 50 mg and Lorazepam 1 mg were found with torn seals on several compartments. The nurse acknowledged the risk of tablets falling out or being lost due to the torn seals and stated that the affected tablets should be wasted with another nurse present. The Director of Nursing (DON) confirmed that narcotics are counted at the end of every shift, with additional checks by unit managers and charge nurses. The DON stated that tape should not be used to reseal pill cards and that any damage to the packaging should be reported immediately. Facility policy requires controlled substances to be stored and maintained in locked compartments with accurate inventory at all times. Despite the torn seals, the narcotic log sheets showed correct counts for the medications involved.
Neglect and Inadequate Supervision in Memory Care Unit
Penalty
Summary
The facility failed to ensure that each resident was free from neglect, as evidenced by an incident involving two residents in the memory care unit. Resident #2, an 84-year-old man with a history of schizoaffective disorder and other conditions, exhibited aggressive and territorial behaviors, particularly when other residents entered his room. Despite these behaviors being documented in progress notes, his care plan did not adequately address these issues. On one occasion, Resident #2 was involved in a physical altercation with another resident, resulting in a traumatic brain injury. Resident #3, a 92-year-old woman with dementia and a tendency to wander, was found injured in Resident #2's room. She had wandered into his room, which led to an altercation where she was struck with a trash can, sustaining multiple injuries. The facility's failure to supervise and manage the behaviors of both residents contributed to this incident. The care plan for Resident #3 noted her wandering behavior but did not effectively prevent her from entering other residents' rooms. Interviews with staff revealed that there were lapses in updating care plans and addressing the behavioral needs of residents. The Unit Manager admitted to not attending care plan meetings in 2024, and the MDS coordinator acknowledged that Resident #2's care plan was incomplete. These deficiencies in care planning and supervision led to the incident, highlighting the facility's failure to protect residents from neglect and ensure their safety.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which led to deficiencies in addressing their mental and psychosocial needs. One resident, an 84-year-old man with schizoaffective disorder and other conditions, exhibited aggressive behaviors that were not adequately addressed in his care plan. Despite a history of aggressive incidents, including verbal and physical altercations with staff and other residents, his care plan lacked focus areas related to these behaviors. This oversight resulted in multiple incidents where the resident's aggressive actions were not properly managed, culminating in a serious physical altercation that led to his hospitalization with a traumatic brain injury. Another resident, a 92-year-old woman with dementia and other diagnoses, was identified as a fall risk, but her care plan did not reflect this critical information. Despite multiple fall risk evaluations indicating her vulnerability, the care plan failed to include necessary interventions to mitigate this risk. This omission left the resident without appropriate measures to prevent falls, as evidenced by several incidents of unknown origin and other incidents recorded in the facility's logs. Interviews with facility staff revealed systemic issues in care plan management, including a lack of regular updates and communication among the interdisciplinary team. The Unit Manager and MDS staff acknowledged that care plans were not completed or updated in a timely manner, partly due to changes in management and staffing gaps. This lack of coordination and oversight contributed to the facility's failure to provide adequate care and services tailored to the residents' needs, as required by regulatory standards.
Failure to Update Care Plan for Resident with Behavioral Issues
Penalty
Summary
The facility failed to review and revise the person-centered care plan for a resident, leading to a deficiency in care. The resident, an 84-year-old man with schizoaffective disorder, generalized anxiety disorder, and hyperlipidemia, exhibited behavioral issues such as aggression and territorial behavior. Despite these behaviors being documented in progress notes, the care plan did not include any focus areas regarding these behaviors. The resident's BIMS score was 3.0, indicating significant cognitive impairment. The resident's progress notes detailed several incidents of aggressive and territorial behavior, including verbal aggression towards staff and other residents. These incidents were documented over several months, yet the care plan was not updated to address these behaviors. The resident was involved in physical altercations with other residents, resulting in injuries to himself and others. Despite these incidents, the care plan remained unchanged, failing to provide staff with guidance on managing the resident's behaviors. Interviews with facility staff revealed a lack of awareness and action regarding the resident's behavioral issues. The Unit Manager, who was responsible for updating care plans, had not attended care plan meetings in 2024 and was unaware of the resident's behavioral triggers. The MDS coordinator acknowledged that care plans were outdated due to staffing gaps and that the resident's care plan had not been updated following his transfer to a behavioral hospital. This lack of timely updates and communication contributed to the deficiency in care for the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 764 citations issued within 25 miles in the last 12 months — including the 70 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Spring Branch Transitional Care Center | 0.9 mi | — | 0 | 0 |
| Memorial City Nursing And Rehabilitation Center | 1.2 mi | ★★★★★ | 10 | 0 |
| The Vosswood Nursing Center | 3 mi | ★★★★★ | 0 | 0 |
| The Buckingham | 4.3 mi | ★★★★★ | 8 | 0 |
| Treemont Health Care Center | 4.5 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.