Above 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 Bellville during CMS and state inspections, most recent first.
A staff member prepared pureed casserole and bread by adding hot water instead of broth or gravy, and the DM and DON stated this made the food bland and did not follow the puree recipe. The affected residents had dysphagia, dementia, malnutrition, weight loss, and altered-texture diet orders, and the facility recipe stated water should not be used to puree foods.
Unlabeled fruit cups and a personal water bottle were found in a refrigerator, while a cooking pot, a container lid, and a used flyswatter were stored on the floor or under the serving table. The Dietary Aide said the fruit cups were leftovers from the prior meal, and the DM and DON stated pots, pans, personal drinks, and unlabeled foods were not to be stored that way per facility policy.
Dumpster Lid Left Open: During a kitchen tour, 1 of 2 outside trash bins was observed open and was then closed by [NAME] A. [NAME] A stated some CNAs were too short to close the dumpster after opening it, while the DON and ADM stated the expectation was that dumpster doors remain closed at all times and that staff who open the lid should close it or get help if needed. The facility policy required garbage and refuse to be properly contained in dumpsters with lids.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, for 25 days between October 2024 and March 2025. This deficiency was confirmed through interviews and record reviews, revealing no RN hours recorded on specific dates. The absence of RN coverage could risk residents not having their nursing and medical needs met.
The facility failed to provide adequate pharmaceutical services, resulting in expired medications found in a resident's room and the medication room, and a medication error for a resident. An expired Ketoconazole cream was found on a resident's nightstand without a physician's order, and a medication aide administered Cyclosporine eye drops incorrectly based on the resident's preference without updating the physician's order. Expired medications and COVID-19 tests were also found in the medication room, indicating lapses in medication management and communication.
The facility failed to label opened food items in the kitchen's refrigerator and freezer, as observed during a survey. Items such as a gallon of milk and bags of rolls and French toast were found open and undated, contrary to the facility's policy and FDA guidelines. This oversight could risk food-borne illness for residents.
The facility failed to maintain an effective training program for new and existing staff, affecting 9 out of 20 employees reviewed. Key training areas such as QAPI, infection control, and behavioral health were not provided upon hire or annually. Disruptions due to a change in the online training system and a company buyout contributed to this deficiency, potentially impacting resident care quality.
The facility failed to provide mandatory QAPI training to several staff members, including RNs, CNAs, and the DON, as required by policy. Interviews and record reviews revealed that these employees did not receive the necessary training annually or upon hire, potentially risking resident care quality. The Administrator, BOM, and DON acknowledged the importance of training but failed to ensure its completion.
The facility failed to provide mandatory annual ethics training to a housekeeper and two LVNs, as required by its compliance and ethics program. Despite being responsible for ensuring training completion, the Administrator and BOM did not ensure that these employees received the necessary training, as confirmed by personnel records and interviews. This oversight could potentially impact resident care.
The facility failed to provide annual behavioral health training to three employees, including an Activity Manager, RN, and LVN, as required by facility policy. Despite the availability of training through CEU360, the training logs showed no evidence of completion, potentially affecting resident care quality. The Administrator, BOM, and DON acknowledged their responsibility in ensuring staff training compliance.
Two residents in an LTC facility were subject to inaccurate assessments, potentially leading to inadequate care. One resident was incorrectly documented as receiving insulin instead of Trulicity, while another was inaccurately noted as continent despite having a suprapubic catheter. These errors were confirmed by staff and highlight the need for accurate MDS documentation.
A facility failed to include oxygen therapy in a resident's care plan, despite the resident's need for oxygen when saturation levels fell below 92%. The resident, with moderate cognitive impairment and multiple health issues, did not have a care plan reflecting her oxygen status. The MDS nurse acknowledged the oversight, which could lead to improper care.
A facility failed to provide proper incontinence care for a resident, risking urinary tract infections. A CNA did not clean the suprapubic area of a resident with multiple health issues, despite having received training. The DON confirmed the oversight and noted the CNA's skills check-off was pending. Facility policy requires cleaning from front to back, which was not followed.
A facility failed to ensure proper treatment for a resident with a gastrostomy tube by not checking gastric residual before medication administration. An RN conducted only a visual inspection, contrary to the physician's order, which required aspiration of gastric content. The resident, with severe cognitive impairment and dependent on tube feeding, was at risk for complications, although no harm occurred. The facility's policy also emphasized the need for checking residual volume.
The facility failed to ensure CNAs demonstrated necessary competencies in perineal care, as CNA-C and CNA-D did not have their annual skill check-offs completed. CNA-C was observed providing inadequate perineal care to a resident, missing the cleaning of the suprapubic area. The DON acknowledged the oversight, noting the previous DON did not perform these evaluations.
The facility reported an 8% medication error rate, exceeding the acceptable 5% threshold. Errors included a medication aide administering the wrong fiber laxative to a resident and another aide giving incorrect dosages of Cyclosporine eye drops based on a resident's preference without physician approval. The DON acknowledged these as medication errors due to a lack of adherence to physician orders and communication failures.
A facility failed to store medications securely, as evidenced by an expired Ketoconazole cream found on a resident's nightstand without a physician's order and an unattended, unlocked nursing cart. The resident had moderate cognitive impairment, and the RN admitted to forgetting to lock the cart, acknowledging the risk of drug diversion. The DON confirmed the responsibility of nursing staff to ensure medications are stored in locked compartments.
A facility failed to implement a policy for the safe storage of foods brought by family and visitors, leading to a deficiency. An elderly resident with severe cognitive impairment had an unknown, unlabeled food item in her personal refrigerator, which was not checked daily by night nurses as required. The facility's policy mandates proper labeling and storage of such foods, but this was not adhered to, posing a risk of foodborne illness.
A CNA in an LTC facility failed to change gloves after cleaning a resident's buttock area, using the same dirty gloves to handle a new brief. The resident, with a history of cerebral infarction and other conditions, was at risk for cross-contamination. The CNA admitted to the oversight, citing nervousness despite prior infection control training.
The facility failed to maintain a clean and safe environment by not changing the air filter on B-hall, which was found to be very dirty with thickened dust. The maintenance staff admitted to forgetting to change the filter, which should have been done monthly according to the facility's policy. This oversight was confirmed by the DON and the Administrator.
The facility failed to provide mandatory annual communication training to two employees, Housekeeper G and LVN K, as required. Record reviews showed no evidence of such training, and interviews with the Administrator, BOM, and DON confirmed the responsibility for ensuring training completion. This deficiency could impact the quality of care provided to residents.
The facility failed to provide mandatory annual infection prevention and control training to a registered nurse (RN E), as required by its infection prevention and control program. Despite being hired in April 2023, RN E had no documented evidence of receiving this training within the past year. Interviews with the facility's leadership revealed shared responsibility for ensuring staff training, but the oversight was acknowledged as potentially impacting resident care.
The facility failed to provide mandatory annual dementia training for a CNA, as required by policy. Personnel records showed no evidence of such training for the CNA hired in July 2023. Interviews with the Administrator, BOM, and DON confirmed the importance of this training for resident care, but the training log did not reflect compliance, potentially affecting resident quality of life.
Pureed meals prepared with water instead of broth
Penalty
Summary
The facility failed to ensure pureed foods were prepared by methods that conserved nutritive value and flavor and were served in a palatable manner for five residents who received altered-texture diets. During observation in the kitchen, a staff member prepared pureed tater-tot casserole and bread by adding approximately 1.5 cups of hot water to the food processor for the casserole and approximately 1.5 cups of hot water to puree five slices of bread. The staff member stated the pureed casserole and bread were bland compared with the regular diet items because water had been used to thin the food, and she stated she would normally have used chicken broth but the kitchen was out of broth. The dietary manager observed the preparation and stated broth or gravy was to be used to puree and thin the casserole and bread, but water had been used instead. She stated beef broth and gravy were available and could have been used, and she also stated seasoning could have been added before the trays left the kitchen. The dietary manager further stated she was responsible for ensuring staff followed the puree recipes and that the staff member had been using water too often when broth was unavailable. The director of nursing stated that residents receiving altered-texture meals were already receiving fewer calories than residents on regular diets, that adding water provided no caloric nutrition and made foods less flavorful, and that broth provided additional calories and flavor. The affected residents included residents with diagnoses and care plans reflecting dysphagia, dementia, malnutrition, weight loss, and need for altered-texture diets or supplements. One resident had significant recent weight loss and was on a puree diet with pleasure feeds and staff assistance at meals. Another resident had a puree diet with regular liquids and a history of weight loss and swallowing problems. Additional residents had care plans for malnutrition risk, swallowing problems, and puree diets. The facility record also included a puree recipe stating that liquid such as broth, milk, gravy, or sauce could be used to assist with pureeing and that water should not be used as a liquid to puree foods.
Unlabeled food and improper kitchen storage
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards during the initial kitchen tour on 05/05/2026. Surveyors observed a tray containing 5 cups of applesauce and 1 cup of pears in a refrigerator without labels, along with a 16.9 oz personal water bottle that was also unlabeled. In the same observation, a cooking pot and a container lid were found on the floor under a dish storage shelf, and a red flyswatter was found under the serving table. During interviews, the Dietary Aide stated the fruit cups were leftovers from the previous dinner meal and did not know who placed them in the refrigerator. The DM stated cooking pots and container lids were to be stored off the floor, that the flyswatter should not be stored under the serving table, and that all foods were to be labeled before storage. The DON stated personal water bottles were prohibited in the refrigerator cooler, pots and pans were to be stored off the floor, and foods stored without labels were to be discarded. Record review showed the facility's Food Storage Policy required food to be stored in a clean, dry area free from contaminants and dated as required, and the Sanitization policy stated kitchen and dining areas were to be kept clean and free from garbage and debris.
Dumpster Lid Left Open
Penalty
Summary
The facility failed to ensure a dumpster door was secured on 1 of 2 dumpster bins during the initial kitchen tour on 05/05/2026. During observation and interview at 05:56 a.m., 1 of the 2 outside trash bins was observed open, and [NAME] A was seen closing the trash lid. [NAME] A stated that there were short CNAs who could not close the trash once it was opened, could not provide the staff names, and stated that the dumpsters were filled by all staff. She also stated that it was the kitchen staff's responsibility to ensure the dumpster was closed and that keeping the lid closed was important for infection control purposes. During later interviews, the DON stated it was her expectation that trash dumpster doors remain closed at all times to maintain odor control, prevent trash contamination, and address infection control and pest control issues. She stated she was not aware of who left the trash open and said staff who were unable to close the lid should ask for assistance from a staff member who could. The ADM stated it was the expectation that dietary staff ensure the dumpster was closed at all times per regulation and that any staff member who opened the trash lid should close it. Record review showed an in-service titled Keeping the dumpster lid closed, and the facility policy stated that garbage and refuse are to be properly contained in dumpsters with lids and that areas used for garbage disposal are to be maintained to prevent pests.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 25 days during the review period from October 2024 to March 2025. This deficiency was identified through interviews and record reviews, which revealed that the facility did not have RN coverage on specific dates in October, November, and December 2024. The absence of RN coverage was confirmed by the facility's Administrator, who acknowledged the inability to find RNs for those days, resulting in no recorded RN hours. The lack of RN coverage could place residents at risk of not having their nursing and medical needs met and receiving improper care. The facility's policy, revised in August 2022, mandates that a registered nurse provides services for at least eight consecutive hours every 24 hours, seven days a week. However, the facility's failure to adhere to this policy was evident in the CMS PBJ staffing reports and the facility's RN schedule, which showed no RN hours recorded for the specified dates.
Pharmaceutical Service Deficiencies in Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents and in the medication room. For Resident #5, an expired medication, Ketoconazole cream, was found on the resident's nightstand. The resident had no physician order for this medication, nor did he have a fungal or yeast infection. The expired medication was likely brought by a family member, but it remained the responsibility of the nursing staff to ensure its removal. Both the LVN and the DON acknowledged the oversight and the potential for adverse effects due to the expired medication. For Resident #97, a medication error occurred when a medication aide administered two drops of Cyclosporine 0.05% eye drops into each eye, contrary to the physician's order of one drop per eye. The medication aide acted on the resident's preference without a physician's updated order, and the charge nurse failed to communicate this preference to the primary care physician. The DON was unaware of the resident's preference until informed by the surveyor, indicating a lapse in communication and adherence to professional standards. In the medication room, expired medications and COVID-19 tests were found, including Hydrocortisone cream and Intell-Swab COVID-19 rapid home tests. The DON admitted to not knowing why these expired items were still present and emphasized that it was the nurses' responsibility to remove them. The presence of expired items could lead to inaccurate drug administration and ineffective therapeutic outcomes, as noted by the DON.
Failure to Label Opened Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service in its kitchen. During an observation, it was noted that items in the reach-in refrigerator and chest freezer were not labeled with the date they were opened or a use-by date. Specifically, a gallon of milk in the refrigerator and bags of rolls and French toast in the freezer were found open and undated. This lack of labeling could potentially expose residents to food-borne illnesses and food contamination. An interview with the Dietary Manager confirmed that the facility's policy requires all opened items in the refrigerator and freezer to be labeled with the date they were opened and a use-by date. The Dietary Manager acknowledged that failing to label these items could put residents at risk of food-borne illness. A review of the facility's policy and the U.S. FDA Food Code supports the requirement for proper labeling of ready-to-eat, time/temperature control for safety food, indicating the importance of this practice for maintaining food safety.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for both new and existing staff members, affecting 9 out of 20 employees reviewed. The deficiency was identified through interviews and record reviews, revealing that several staff members, including a Registered Nurse (RN), Dietary Aide, Housekeeper, Certified Nursing Assistant (CNA), Activity Manager, Licensed Vocational Nurses (LVNs), and the Director of Nursing (DON), did not receive required training upon hire or annually. This lack of training included critical areas such as Quality Assurance and Performance Improvement (QAPI), infection control, behavioral health, resident rights, fall prevention, restraint use, emergency preparedness, communication, and ethics. The personnel records indicated that the RN, hired in April 2023, did not receive annual QAPI, infection control, or behavioral health training. The Dietary Aide, hired in March 2025, did not receive training on resident rights, fall prevention, restraint use, or emergency preparedness upon hire. Similarly, the Housekeeper, hired in June 2022, lacked annual training in communication, QAPI, ethics, and emergency preparedness. The CNA, hired in July 2023, did not receive annual QAPI training, while the Activity Manager, hired in June 2022, missed annual behavioral health training. The LVNs, hired between June 2022 and November 2022, were missing various annual trainings, including QAPI, ethics, communication, and emergency preparedness. The DON, hired in April 2024, did not receive QAPI training upon hire. Interviews with the Administrator, Business Office Manager (BOM), and DON revealed that the facility's training program was disrupted due to a change in the online training system and a company buyout. The Administrator acknowledged that the lack of training could have affected the residents' quality of life and care. The BOM and DON both emphasized the importance of training to ensure residents receive good quality care, but the responsibility for ensuring training completion was not clearly defined, contributing to the deficiency.
Failure to Provide Mandatory QAPI Training to Staff
Penalty
Summary
The facility failed to include mandatory training on its Quality Assurance and Performance Improvement (QAPI) program for several staff members, including RN E, Housekeeper G, CNA H, LVN J, LVN L, and the Director of Nursing (DON). The deficiency was identified through interviews and record reviews, which revealed that these employees did not receive the required QAPI training annually or upon hire, as stipulated by the facility's policy. The absence of this training could potentially place residents at risk of being cared for by inadequately trained staff. Interviews with the Administrator, Business Office Manager (BOM), and DON highlighted a lack of clarity and responsibility regarding the completion of mandatory training. The Administrator acknowledged that training was available through CEU360 and assigned by corporate, but it was the responsibility of the BOM and Administrator to ensure completion. The BOM and DON also indicated that it was crucial for staff to complete their training to ensure quality care for residents. However, the training logs provided by the Administrator showed no evidence of QAPI training being completed for the specified staff members.
Failure to Provide Annual Ethics Training to Staff
Penalty
Summary
The facility failed to provide mandatory annual ethics training to three employees: a housekeeper and two Licensed Vocational Nurses (LVNs). The personnel records for these employees showed no evidence of ethics training being conducted within the last 12 months, despite their hire dates being over a year ago. The absence of this training was confirmed through interviews with the Administrator, Business Office Manager (BOM), and Director of Nursing (DON), who acknowledged the oversight and its potential impact on resident care. The facility's policy requires annual ethics training as part of its compliance and ethics program, especially when operating five or more facilities. The Administrator and BOM were responsible for ensuring that staff received this training, which was available through an online platform. However, the training logs did not reflect completion of the required ethics training for the identified employees, indicating a lapse in the facility's adherence to its own training policies and procedures.
Failure to Provide Annual Behavioral Health Training
Penalty
Summary
The facility failed to provide annual behavioral health training to three employees: the Activity Manager, RN E, and LVN L. Personnel records revealed that the Activity Manager and LVN L were hired on 06/01/2022, and RN E was hired on 04/24/2023. However, a review of the training logs for the past 12 months showed no evidence of behavioral health training being provided to these employees. This lack of training was confirmed through interviews with the Administrator, BOM, and DON, who acknowledged the responsibility of ensuring that staff receive both new employee and annual behavioral health training. The facility's policy on in-service training, dated 2001, outlines required training topics, including behavioral health, and mandates documentation of completed training. Despite this policy, the facility did not ensure compliance, potentially affecting the quality of life and care for residents due to uninformed staff. The Administrator and BOM stated that training was available through CEU360 and assigned by corporate, but it was their responsibility to ensure completion. The DON emphasized the importance of training for maintaining good quality care for residents.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to potential risks for inadequate care. Resident #11's significant change Minimum Data Set (MDS) inaccurately indicated that the resident was receiving insulin, while in reality, the resident was prescribed Trulicity, a medication that stimulates insulin secretion but is not insulin itself. This error was confirmed through interviews with a pharmacist surveyor and the MDS nurse, who acknowledged the mistake and its potential to cause incorrect care. Similarly, Resident #96's admission MDS inaccurately documented the resident as always continent for urinary bladder, despite the presence of a suprapubic catheter, which is a type of indwelling urinary catheter. This discrepancy was observed during catheter care and confirmed by the MDS nurse, who admitted the error in coding. The facility's policy requires all individuals completing any portion of the MDS to attest to the accuracy of the information, highlighting the importance of accurate documentation to ensure appropriate care.
Failure to Include Oxygen Therapy in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental needs. Specifically, the care plan did not reflect the resident's oxygen status or include instructions on how to manage the resident's oxygen therapy. This oversight was identified during a review of the resident's records and interviews with staff, revealing that the resident was receiving oxygen therapy as needed when her oxygen saturation levels fell below 92%. The resident, who had moderate cognitive impairment, was diagnosed with chronic kidney disease, venous insufficiency, heart failure, muscle weakness, and hypertension. Despite these conditions and the need for oxygen therapy, the care plan did not address the oxygen therapy requirements. Interviews with the MDS nurse confirmed that the omission was an oversight, potentially leading to improper care for the resident. The facility's policy on comprehensive person-centered care plans requires that services be described to maintain the resident's highest practicable well-being, which was not adhered to in this case.
Inadequate Incontinence Care Leads to Potential UTI Risk
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident, leading to a potential risk of urinary tract infections. During an observation, a CNA did not clean the suprapubic area of a resident who was incontinent of the bladder. The resident, a male with a history of cerebral infarction, hypertension, hypokalemia, muscle weakness, type 2 diabetes mellitus, and muscle wasting, was dependent on staff for incontinence care. The CNA admitted to forgetting to clean the area due to nervousness, despite having received peri-care training three months prior. The Director of Nursing (DON) acknowledged that the CNA should have cleaned the suprapubic area during peri-care. The DON had not yet conducted a skills check-off for the CNA, which was scheduled for a later date. The facility's policy on perineal care, revised in 2018, requires cleaning from front to back, but this was not followed in this instance. This oversight could place residents at risk for cross-contamination and the development of urinary tract infections.
Failure to Check Gastric Residual in Enteral Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition through a gastrostomy tube was provided with appropriate treatment and services to prevent complications. Specifically, a registered nurse (RN-E) did not check the gastric residual by aspiration of gastric content before administering medication to the resident. This action was contrary to the physician's order, which required checking the residual volume before feeding or medication administration. The resident, a male with severe cognitive impairment and multiple diagnoses including moderate protein-calorie malnutrition and dysphagia, was dependent on tube feeding for nutrition and hydration. During an observation, RN-E conducted a visual inspection of the gastrostomy tube placement but failed to aspirate gastric content to check for residual volume, as required by the physician's order. The RN admitted to forgetting this step due to nervousness. Interviews with the resident's primary care physician and the Director of Nursing (DON) confirmed that while no harm occurred from this incident, the failure to check the residual could potentially lead to complications. The facility's policy on administering medications through an enteral tube also emphasized the importance of confirming tube placement and checking gastric residual volume.
Failure to Ensure CNA Competency in Perineal Care
Penalty
Summary
The facility failed to ensure that licensed staff demonstrated the necessary competencies and skill sets to care for residents' needs, specifically in perineal care. This deficiency was identified for two nursing staff members, CNA-C and CNA-D, who did not have their annual skill check-offs completed. CNA-C was hired without a skill check-off for perineal care, and CNA-D did not have a skill check-off for perineal care in 2024. During an observation, CNA-C was seen providing inadequate perineal care to a resident by not cleaning the suprapubic area, which she attributed to nervousness and forgetting the step. The Director of Nursing (DON) acknowledged the oversight in conducting the skill check-offs, noting that the previous DON did not perform these evaluations, and the current DON was hired after these lapses occurred. The facility's policy requires all nursing staff to meet specific competency requirements, but this was not adhered to in the cases of CNA-C and CNA-D. The lack of skill check-offs could place residents at risk of receiving care from staff who are not adequately trained or competent in necessary care procedures.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. This was based on two errors out of 25 opportunities involving two residents. The first error involved a medication aide administering the wrong type of fiber laxative to a resident. Instead of the prescribed Metamucil (psyllium husk) capsule, the aide gave a fiber laxative calcium polycarbophil tablet. The aide stated that she was informed by nurses that this substitution was acceptable, but the Director of Nursing (DON) acknowledged it as a medication error, noting that the facility should have contacted the physician for clarification. The second error involved the administration of Cyclosporine eye drops to another resident. The medication aide administered two drops to each eye once a day, contrary to the physician's order of one drop to each eye twice a day. The aide claimed that the resident requested this change, and she had informed a charge nurse, who was supposed to notify the primary care physician. However, the charge nurse did not follow up, and the aide assumed the change was acceptable. The DON confirmed that the agency nurse involved should have contacted the physician and updated the order accordingly. Both errors highlight a lack of adherence to physician orders and communication breakdowns within the facility. The facility's policy requires medications to be administered according to prescriber orders, which was not followed in these instances. The DON recognized these as medication errors, indicating a failure to provide adequate care and medical interventions as prescribed.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by two separate incidents. In the first incident, a medication, Ketoconazole cream, was found on a resident's nightstand without a physician's order. The resident, who had moderate cognitive impairment and required assistance with daily activities, did not have a current fungal or yeast infection. The Licensed Vocational Nurse (LVN) acknowledged the presence of the expired medication and speculated that it might have been brought by the resident's daughter. However, the LVN confirmed that it was the nurses' responsibility to ensure all medications, even those brought by family members, were stored securely. In the second incident, a Registered Nurse (RN) left a nursing cart open and unattended while administering medication to another resident. The RN admitted to forgetting to lock the cart, acknowledging the risk of drug diversion. The Director of Nursing (DON) confirmed that all medications should be stored in locked compartments and that it was the responsibility of the nursing staff to ensure this policy was followed. The facility's policy on medication labeling and storage mandates that all medications and biologicals be stored in locked compartments, accessible only to authorized personnel.
Failure to Implement Food Storage Policy for Resident
Penalty
Summary
The facility failed to implement a policy regarding the use and storage of foods brought to residents by family and other visitors, which resulted in a deficiency. Specifically, the facility did not ensure safe and sanitary storage, handling, and consumption of food for a resident. During an observation, an unknown food item wrapped in paper, without a date or label, was found in the resident's personal refrigerator. This oversight was noted during a survey, and it was revealed that the facility's night nurses were responsible for checking the refrigerator daily, but this was not done effectively. The resident involved was an elderly female with severe cognitive impairment, as indicated by a BIMS score of 4 out of 15, and required assistance with daily activities. The facility's policy, revised in March 2022, stated that food brought by family or visitors should be labeled and stored properly, with perishable items kept in resealable containers with the resident's name, item, and use-by date. However, this policy was not followed, as evidenced by the unlabeled and undated food found in the resident's refrigerator, which could potentially lead to foodborne illness.
Infection Control Breach During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by an incident involving a certified nursing assistant (CNA) providing perineal care to a resident. During the care, the CNA used old and dirty gloves to handle a new and clean brief after cleaning the resident's buttock area. This action was observed during a survey and was confirmed through interviews with the CNA and the Director of Nursing (DON). The CNA admitted to the oversight, attributing it to nervousness despite having received infection control training. The resident involved was a male with a history of cerebral infarction, hypertension, hypokalemia, muscle weakness, type 2 diabetes mellitus, and muscle wasting and atrophy. The resident was cognitively intact, as indicated by a BIMS score of 15 out of 15, and was always incontinent to bladder and bowel, requiring assistance for sit-to-stand transfers. The resident's care plan included interventions for incontinence care and monitoring for signs of urinary tract infection. The deficient practice of not changing gloves before handling a clean brief placed the resident at risk for cross-contamination and infections.
Failure to Maintain Clean Air Filters
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by the condition of the air filter on B-hall. Observations on March 18, 2025, revealed that the air filter was very dirty with gray colored thickened dust and had not been changed since April 2, 2024. Interviews with the maintenance staff, the Director of Nursing (DON), and the Administrator confirmed that the air filter should have been changed monthly according to the facility's maintenance checklist. The maintenance staff admitted to forgetting to change the air filter, which was a responsibility outlined in the facility's policy dated November 2023.
Failure to Provide Mandatory Communication Training
Penalty
Summary
The facility failed to provide mandatory effective communication training to two employees, Housekeeper G and LVN K, as required annually. Record reviews of their personnel files revealed no evidence of such training being completed in the previous 12 months. The Administrator confirmed that communication trainings were available through CEU360 and were assigned by corporate, with new employees receiving in-house training from the BOM before starting work. However, it was the responsibility of the BOM and Administrator to ensure that both new and current employees completed their required trainings. Interviews with the BOM and DON further highlighted the responsibility of the BOM and DON in ensuring the completion of communication trainings by staff annually. The facility's policy on in-service training, dated 2001, mandates effective communication training among other topics. The lack of training documentation for Housekeeper G and LVN K indicates a failure in the facility's training program, which could potentially affect the quality of life and care provided to residents.
Failure to Provide Annual Infection Control Training
Penalty
Summary
The facility failed to provide mandatory annual infection prevention and control training to one of its registered nurses (RN E), as part of its infection prevention and control program. RN E, who was hired on April 24, 2023, did not have any documented evidence of receiving this training within the previous 12 months. This oversight was identified during a review of RN E's personnel records and a training log provided by the Administrator. Interviews with the facility's Administrator, BOM, and DON revealed that the responsibility for ensuring staff received their annual infection control training was shared among them. The Administrator acknowledged that the lack of training could have impacted the quality of life and care for residents. The BOM and DON emphasized the importance of completing these trainings to ensure residents were well taken care of. The facility's policy on in-service training, dated 2001, includes infection prevention and control as a required training topic, but the facility failed to adhere to this policy in RN E's case.
Failure to Provide Annual Dementia Training for CNA
Penalty
Summary
The facility failed to provide mandatory effective in-service training for nurse aides on dementia care, specifically for one of the five nurse aides reviewed, identified as CNA H. The personnel records for CNA H, who was hired on July 13, 2023, showed no evidence of annual dementia training being provided. This lack of training was confirmed through interviews with the Administrator, BOM, and DON, who all acknowledged the importance of such training for ensuring quality care for residents. The facility's policy on in-service training, dated 2001, requires training on several topics, including dementia management and resident abuse prevention. However, the training log for CNA H did not reflect compliance with this policy. The Administrator and BOM stated that it was their responsibility to ensure that staff received the necessary training, but the records indicated a failure in this regard, potentially affecting the quality of life and care for residents.
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 71 citations issued within 25 miles in the last 12 months — including the 6 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 Bellville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Sealy | 13.8 mi | ★★★★★ | 1 | 0 |
| Kruse Village Senior Living Community | 15.5 mi | ★★★★★ | 7 | 0 |
| Brenham Healthcare Center | 16 mi | ★★★★★ | 18 | 5 |
| High Hope Care Center Of Brenham | 17.4 mi | ★★★★★ | 9 | 0 |
| Brenham Nursing And Rehabilitation Center | 17.6 mi | ★★★★★ | 29 | 1 |
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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.