Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Belton during CMS and state inspections, most recent first.
A resident with dementia, severely impaired cognition, CHF, and diabetes required total assist with a mechanical lift and two staff for transfers, but a CNA transferred the resident to the toilet without the lift or required assistance. The resident slid off the toilet, was guided to the floor, and later was found to have a fractured right ankle/foot with an open wound and exposed bone. The report also noted improper transfer status handling for three other residents whose care plans and Kardexes required mechanical lift or total-assist transfers.
Failure to Monitor Resident Weights and Nutritional Status: The facility did not obtain and monitor weights as required for a resident with CVA, dysphagia, CHF, and dependence for eating, and it also failed to track weight trends for five other residents with serious chronic conditions including dementia, malnutrition, COPD, CKD, diabetes, and cancer. Records showed limited weight documentation, no scheduled weight orders, and interviews confirmed staff were aware of weight loss concerns but weights were not consistently obtained or reviewed.
Failure to Resolve Grievances and Provide Written Responses: The facility did not provide written grievance findings or actions to 4 residents. The record also showed repeated late administration of ordered meds and missed showers for multiple residents, including residents with dementia, seizure disorder, atrial fibrillation, heart failure, and other chronic conditions. Residents and a family member reported that meds were given late and showers were not being provided regularly.
Missed showers for multiple residents: Three residents with ADL assistance needs had care plans calling for regular bathing/showering, but shower logs showed repeated missed showers and the residents reported not receiving showers regularly. One resident with DM2, morbid obesity, respiratory failure, and cognitive communication deficit said she asked for showers and did not get them; another resident with AFib, HF, depression, and chronic pain said he had not gotten a shower and believed staffing was insufficient; a third resident with cardiomegaly, muscle weakness, and HF said she had to wipe herself down to avoid skin issues. Staff said residents were supposed to receive showers 3 times per week and that missed showers were due to lack of staff.
A facility failed to provide meds on time for three residents with significant medical needs, including dementia, seizures, and atrial fibrillation. MAR review showed scheduled doses of quetiapine, levetiracetam, and apixaban were given hours late, and residents reported repeated delays with morning meds not being given until the afternoon. Staff stated meds were supposed to be administered within 1 hour of the scheduled time, but they were often late because nurses were busy with resident care and staffing was insufficient.
Delayed Medication Documentation for Three Residents: RN D did not document medications at the time they were given for three residents. One resident with a seizure disorder reported morning meds were sometimes delayed until the afternoon, while two other residents with cardiac and psychotropic medication needs had MAR entries showing meds were given hours before they were documented. The DON and ADM stated meds should be documented when given, and the facility policy required immediate documentation after administration.
Unattended medication carts were found unlocked and accessible to staff and residents. An LVN left one cart unattended while stepping away, another cart was observed unlocked near the nurses' station, and both carts contained residents' prescription drugs, OTC medications, and narcotics in a locked box. The LVNs stated they were trained on medication storage and acknowledged the carts should be locked when not in use; the DON and ADM also stated carts were to always be locked when unattended.
A resident with multiple traumatic fractures, minimal cognitive impairment, and a need for max assist with toileting and showering reported waiting hours for help after activating the call light and not receiving a shower for almost two weeks. On observation, the resident’s call light remained on for about 45 minutes while staff sat at the nurse’s station, despite the call light panel beeping and showing active calls. Staff interviews confirmed they had been trained that all staff are responsible for answering call lights and that residents should wait only a few minutes, with expectations generally under 10–15 minutes. A prior grievance documented concerns about call lights not being answered timely, and facility policy stated that residents must have a means to call for assistance from bed and toileting/bathing areas and that calls must be answered timely.
Two residents who required max assist for ADLs, including toileting and showering, did not receive scheduled showers as outlined on the facility’s shower list, despite a policy requiring showers three times weekly and documentation of any refusals. One resident with multiple fractures and minimal cognitive impairment reported not receiving a shower for almost two weeks and appeared disheveled and unkempt, while another resident with anxiety, muscle weakness, and a lumbar compression fracture reported not often receiving showers and that her last shower was more than five days earlier. CNAs, an RN, the ADM, and the DON all confirmed that staff are responsible for providing showers three times weekly, that refusals must be documented, and that there was no acceptable reason for residents to go such extended periods without showers, in the context of existing grievances about untimely care.
Surveyors found that the facility failed to create and implement comprehensive, person-centered care plans with measurable goals and timeframes to address fall and safety risks for three residents. One resident with Alzheimer’s disease, severe cognitive impairment, muscle weakness, and unsteadiness had multiple documented falls, yet his care plan contained only generic fall-risk statements without individualized fall interventions. Another cognitively intact resident with reduced mobility and a history of numerous falls had a care plan that did not include a person-centered fall-prevention plan. A third resident with repeated falls, obesity, muscle weakness, and moderate cognitive impairment experienced dozens of falls over a year, but her care plan remained limited to general fall-risk factors and assistance needs, without tailored, measurable strategies to reduce falls.
A facility failed to keep complete controlled-drug count documentation for a medication cart when an on-coming MA did not sign the narcotic count sheet, and staff stated the count process was required to prevent diversion. The facility also failed to give one resident’s ordered 8 PM nighttime meds within the allowed time window on multiple occasions, with doses documented as late as 10:56 PM and 10:34 PM. The resident reported the late meds kept her awake until after administration and contributed to early waking and daytime sleepiness. The DON stated meds should be given as close to the ordered time as possible and that she was not aware the nighttime meds were being given late.
A resident with PTSD, vascular dementia, anxiety, and cognitive communication deficit had a PASRR Level I screening that marked mental illness as “no” despite the PTSD diagnosis being present at admission. Her MDS showed moderately impaired cognition and dependence for several ADLs, and staff interviews confirmed the facility’s PASRR process relied on accurate identification and referral of residents with mental illness or related conditions.
Failure to Complete Baseline Care Plan Within 48 Hours: A resident admitted with traumatic subdural hemorrhage, skull base fracture, and pressure-related skin injury had severe cognitive impairment and was dependent on staff for toileting, bathing, and personal hygiene. Although a care plan addressed impaired cognition, no baseline care plan was completed within the required timeframe, and the DON and ADON acknowledged the care plan was not done timely.
A resident with significant mobility and cognitive impairments, requiring two-person assistance and a gait belt for transfers, was moved by a CNA and RN without a gait belt, contrary to her care plan. During the attempted transfer, the staff were unable to safely complete the move and lowered the resident to the floor, resulting in a displaced femoral fracture that required hospitalization and surgery. Staff interviews confirmed the omission of the gait belt and failure to follow established transfer protocols.
A resident with Alzheimer's Disease reported being treated roughly by a CNA during grooming, which violated her rights to dignity and respect. The resident, who required assistance with daily activities, alleged that the CNA grabbed her roughly and pulled her hair, leading to distress and fear. The facility's investigation confirmed the resident's claims, highlighting a failure to adhere to policies on resident rights and abuse prevention.
A resident with Alzheimer's Disease reported being roughly handled by a CNA, who allegedly dug a comb into her scalp, causing distress and fear. The resident required assistance with daily activities, and her care plan emphasized gentle handling. The incident was reported to the DON and Administrator, who initiated an investigation. The facility's failure to follow abuse prevention policies led to the resident experiencing fear and potential harm.
The facility's kitchen failed to meet professional food safety standards, with issues such as uncovered tea dispensers, expired and improperly sealed foods, and staff not wearing hairnets. Observations included undated and unlabeled food items, cracked lids on storage bins, and unsanitary conditions, posing risks of contamination. The Dietary Manager and Administrator acknowledged these deficiencies and the potential for food-borne illnesses.
The facility failed to maintain a clean and sanitary environment in five resident rooms, with observations showing dark orange stains in bathrooms. Housekeeping staff acknowledged the issue, and the administrator was unaware until shown evidence. The facility's policy emphasized regular cleaning, which was not followed.
A survey revealed that a LTC facility failed to properly store respiratory equipment for several residents, including nasal cannulas, nebulizer masks, and CPAP masks. Observations showed these items were left exposed, contrary to facility policy and staff interviews, which emphasized the importance of storing them in bags to prevent contamination.
A resident with hemiplegia was unable to reach the call light in her room, which was positioned six feet away from her recliner. Despite being cognitively intact, the resident expressed difficulty in accessing the call light, which is crucial for her safety and assistance needs. Facility staff acknowledged the importance of having the call light within reach, as per the facility's policy, but this was not implemented, leading to a deficiency in accommodating the resident's needs.
A facility failed to maintain an effective infection control program when a CNA did not perform hand hygiene after removing soiled gloves during incontinent care for a resident with atrial fibrillation, myocardial infarction, and arthritis. The CNA admitted to forgetting the protocol due to nervousness, and both the DON and ADON confirmed the importance of hand hygiene to prevent cross-contamination. The facility did not provide a policy for infection control or hand hygiene before the surveyors' exit.
A resident with a catheter was observed in a communal area with an uncovered catheter bag, leading to embarrassment and a potential dignity issue. The facility's care plan included maintaining the catheter, but the bag was not covered as expected. Interviews with the DON and an LVN confirmed that privacy bags should be used when catheter bags are visible, and the oversight was acknowledged as not meeting facility expectations.
A resident with severe cognitive impairment and multiple health issues received incontinence care from CNAs who failed to follow proper infection control practices. CNA A did not perform hand hygiene between glove changes and reused disposable wipes, while CNA B kept gloves in her pocket, potentially compromising infection control. Despite training, these actions did not align with the facility's policies, as acknowledged by the ADM and DON.
A CNA failed to properly sanitize hands during catheter care, risking infection spread, while an LVN left food and drink on a medication cart, violating infection control policies. These actions were against the facility's established protocols for maintaining a sanitary environment.
Improper Transfer and Fall Resulting in Fractured Ankle
Penalty
Summary
The facility failed to ensure the environment remained free from accident hazards and failed to provide adequate supervision and assistance to prevent accidents for a resident who had severely impaired cognition, dementia, CHF, diabetes, and required total dependence for transfers using a mechanical lift. The resident’s admission MDS reflected a BIMS score of 03, and the care plan and care profile stated the resident required substantial to maximal assistance for toileting and total dependence on two staff members for transfers using a mechanical lift. On the day of the incident, a CNA transferred the resident to the bathroom without using the mechanical lift and without the required two-person assistance. The CNA stated the resident did not have a sling under her, stood up from the wheelchair, pivoted to the toilet, and then began sliding off the toilet. The CNA stated she tried to help the resident back onto the toilet, but when she could not do so safely, she guided the resident to the floor. Staff later found blood on the floor near the resident’s feet, and the resident’s right ankle/foot was wrapped and bleeding. After the fall, nursing staff assessed the resident and noted the wound was more than a skin tear and that the foot appeared abnormal in position. The resident was sent to the hospital, where EMS and hospital staff reported a fractured right ankle/foot with an open injury and exposed bone. Interviews with multiple staff members reflected that they knew residents requiring mechanical lift transfers should always have two staff present and should not be transferred without the lift. The report also identified that three other residents reviewed had transfer plans requiring total assistance and mechanical lift use, including two-person assistance for one resident and one-to-two staff assistance for another, yet the facility failed to properly transfer those residents as well.
Failure to Monitor Resident Weights and Nutritional Status
Penalty
Summary
The facility failed to ensure residents maintained acceptable nutritional status and electrolyte balance by not obtaining and monitoring weights as required and by not addressing weight loss for six residents. Resident #4 had multiple diagnoses including CVA, diabetes, spastic hemiplegia, aphasia, encephalopathy, CHF, and impaired attention and concentration. He was dependent on staff for eating, had a care plan goal to maintain current weight and prevent weight loss, and had documented weights of 154 lbs. on 3/27/26 and 5/7/26, with no other weights documented. An observation on 5/14/26 showed him being weighed at 136.6 lbs., but the record contained no scheduled weight orders and no consistent monitoring of his weight trend. Resident #4’s record also reflected dysphagia and a mechanical soft diet, and the Nutrition Risk Assessment noted a prior weight of 154 lbs. with hospital records showing 160 lbs. Interviews showed the ADON was aware of the weight loss and stated the resident had been brought to the dining room previously but was now being fed in his room because of behaviors. The ADON stated the facility had probably not been getting weights because of low staffing and that weights were supposed to be obtained and entered before the 7th day of the month. The MD stated he was made aware of the weight loss earlier that week and expected weekly weights for new admissions and regular intervals. The RP stated she was not aware of the significant weight loss and had been told the resident was eating. The same failure occurred for five additional residents. Resident #5 had stroke-related diagnoses, epilepsy, dysphagia, severe cognitive impairment, and required set up or clean up assistance for eating; weights documented were 102.4 lbs. on 4/30/26 and 105 lbs. on 5/12/26, with no scheduled weight orders. Resident #6 had stroke, dementia, sepsis, CHF, COPD, diabetes, and other chronic conditions; weights documented were 216 lbs. on 4/29/26 and 179 lbs. on 5/13/26, with no scheduled weight orders. Resident #7 had traumatic subdural hemorrhage, anemia, protein-calorie malnutrition, dementia, heart failure, CKD stage 4, and required setup or clean up assistance for eating; weights documented were 145.2 lbs. on 4/24/26 and 143.6 lbs. on 5/3/26, with no scheduled weight orders. Resident #8 had moderate protein-calorie malnutrition, diabetes, dementia, and Alzheimer’s disease; weights documented were 126.2 lbs. on 3/5/26 and 130 lbs. on 5/12/26, with no scheduled weight orders. Resident #9 had CHF, brain cancer, anemia, hypothyroidism, Alzheimer’s disease, CKD stage 2, and required assistance with all ADLs including eating; weights documented were 147.6 lbs. on 4/5/26 and 150 lbs. on 5/12/26, with no scheduled weight orders. The facility policy stated residents are weighed on admission or readmission, weekly for four weeks as determined by the IDT, and monthly thereafter, with monthly weights obtained by the 7th of each month.
Failure to Resolve Grievances and Provide Written Responses
Penalty
Summary
The facility failed to ensure prompt resolution of grievances and failed to notify residents in writing of the findings and actions related to grievances filed by 4 of 4 residents reviewed. The report states that the facility did not provide written decisions to residents regarding the resolution of their grievances, affecting the residents’ right to a written decision about their complaints. Resident #1 was a female with vascular dementia, Alzheimer’s disease, type 2 diabetes, morbid obesity, and heart failure, and her MDS reflected severe cognitive impairment. Her record showed quetiapine 25 mg ordered for sundowning at bedtime, but the MAR documented that the medication scheduled for 8:00 p.m. was not given until 10:03 p.m. on 02/27/2026. Her family member reported that the facility was not giving the sundowning medication on time and that it sometimes was not administered until 10:00 p.m. or 11:00 p.m. Resident #2 had type 2 diabetes, morbid obesity, respiratory failure, hypertension, cognitive communication deficit, and difficulty walking, and her MDS showed she could not complete the BIMS interview. Her MAR showed levetiracetam 2000 mg scheduled for 8:00 a.m. was not given until 12:56 p.m. on 04/26/2026, and her shower log showed multiple missed showers in April 2026. Resident #2 stated that her seizure medication was often late, that she was not getting showers regularly, and that she had asked staff for a shower without receiving one. Resident #3 had atrial fibrillation, obesity, heart failure, respiratory failure, depression, chronic pain, sleep apnea, and lack of coordination, with intact cognition on MDS. His MAR showed levetiracetam 2000 mg was not given until 1:03 p.m. on 04/15/2026 and apixaban 5 mg scheduled for 4:00 p.m. was not given until 6:41 p.m. that day, and his shower log showed multiple missed showers in April 2026. He reported that staff did not give medications on time, that he had told the administrator, and that he still had not gotten a shower. Resident #4 had cardiomegaly, hypomagnesemia, muscle weakness, lack of coordination, and heart failure, with intact cognition on MDS. Her shower log showed multiple missed showers in April 2026, and she reported that her last shower had been on a prior date and that she had not been getting showers regularly.
Missed showers for multiple residents
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received the necessary assistance to maintain grooming and personal hygiene. Record review showed that Resident #2, Resident #3, and Resident #4 each had care plans calling for shower assistance and shower logs documenting multiple missed showers during April 2026. The facility’s ADL supporting policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, including bathing and showering in accordance with the plan of care. Resident #2 was a female with diagnoses including type 2 diabetes mellitus, morbid obesity, respiratory failure, hypertension, cognitive communication deficit, and difficulty walking. Her MDS reflected she required supervision or touching assistance for showers, and her care plan directed extensive assistance from one staff member with bathing/showering and showers per schedule and as needed. Her shower log showed missed showers on multiple dates in April 2026. During interview, she stated she was not getting showers regularly, that she asked staff for showers and never got them, and that she did not feel good when she could not take a shower. Resident #3 was a male with diagnoses including paroxysmal atrial fibrillation, obesity, heart failure, respiratory failure, depression, chronic pain, obstructive sleep apnea, and lack of coordination. His MDS reflected intact cognition and required supervision or touching assistance for showers. His care plan identified risk for skin breakdown and stated he required staff assistance with ADLs and showers per schedule and as needed. His shower log showed numerous missed showers in April 2026. During interview, he said he still had not gotten a shower, felt he should not smell bad, and believed there was not enough staff to provide showers regularly; his shirt was observed to be dirty. Resident #4 was a female with diagnoses including cardiomegaly, hypomagnesemia, muscle weakness, lack of coordination, and heart failure. Her MDS reflected intact cognition, and her care plan noted she was wheelchair bound and required substantial to maximum assistance of 1 to 2 staff for transfers, but did not include shower information. Her shower log also showed multiple missed showers in April 2026. During interview, she said she last got a shower on 04/25/2026, that she had to wipe herself down to prevent skin issues, and that it upset her that she could not get showers regularly. Staff interviews stated that all residents were to receive three showers per week and that missed showers were occurring because of lack of staff.
Delayed Medication Administration for Multiple Residents
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring medications were administered in a timely manner for 3 of 3 residents reviewed. Resident #1, a female with vascular dementia, Alzheimer’s disease, type 2 diabetes mellitus with unspecified complications, morbid obesity, and heart failure, had an order for quetiapine fumarate 25 mg at bedtime for sundowning. Her MAR showed the medication was scheduled for 8:00 p.m., but it was not administered until 10:03 p.m. on 2/27/2026. Her care plan directed staff to administer medications as ordered and monitor/document side effects and effectiveness. Resident #2, a female with type 2 diabetes mellitus without complications, morbid obesity, respiratory failure, hypertension, cognitive communication deficit, and difficulty walking, had an order for levetiracetam 2000 mg by mouth twice daily for seizures. Her MAR showed the medication was scheduled for 8:00 a.m., but it was not administered until 12:56 p.m. on 04/26/2026. During interview, she stated she was not getting her seizure medication on time and reported that there were times her morning medication was not given until the afternoon and that staff were always late giving her medication. Resident #3, a male with paroxysmal atrial fibrillation, obesity, heart failure, respiratory failure, depression, chronic pain, obstructive sleep apnea, and lack of coordination, had an order for apixaban 5 mg twice daily for atrial fibrillation. His MAR showed the medication was scheduled for 8:00 a.m. and 4:00 p.m., but it was not administered until 1:03 p.m. and 6:41 p.m. on 04/15/2026. During interview, he stated staff did not give him his medications on time and said he had reported this to the administrator. Staff interviews confirmed that medications were supposed to be given within one hour before or after the scheduled time, that nurses were responsible for timely administration, and that medications were late because staff were busy with resident care and staffing was not sufficient.
Delayed Medication Documentation for Three Residents
Penalty
Summary
The facility failed to ensure medical records were complete and accurately documented for 3 of 3 residents reviewed for record accuracy. The deficiency involved RN D not documenting medications at the time they were administered to Resident #2, Resident #3, and Resident #4, contrary to the facility’s stated documentation practice that medications are to be recorded immediately after administration. Resident #2 was a female with diagnoses including type 2 diabetes mellitus without complications, morbid obesity, respiratory failure, hypertension, cognitive communication deficit, and difficulty walking. Her care plan identified a seizure disorder and directed staff to give seizure medication as ordered and monitor/document side effects and effectiveness. During interview, she stated she was not getting her seizure medication on time and reported that morning medications were sometimes not given until the afternoon. Resident #3 was a male with diagnoses including paroxysmal atrial fibrillation, obesity, heart failure, respiratory failure, depression, chronic pain, obstructive sleep apnea, and lack of coordination. His care plan directed staff to provide medications as ordered and check vital signs prior to giving them. His MAR showed RN D gave furosemide at 5:09 a.m. but did not document it until 6:09 a.m., and he stated staff did not give medications on time and did not document them until hours later. Resident #4 was a female with diagnoses including cardiomegaly, hypomagnesemia, muscle weakness, lack of coordination, and heart failure. Her care plan directed staff to administer psychotropic medications as ordered and monitor/document side effects and effectiveness. Her MAR showed RN D gave fluoxetine at 8:22 a.m. but did not document it until 10:24 a.m., and she stated staff did not give her medications on time and she had asked several times about them.
Unattended Medication Carts Left Unlocked
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and were accessible only to authorized personnel for 2 of 4 medication carts reviewed. During an observation on the hall, LVN B was in a resident room with the door cracked open while the medication cart was left unattended and unlocked. In another observation, MC #1 was left against the hall wall unattended and unlocked while LVN A walked away from the cart, and residents were seen walking past it. MC #1 contained residents' prescription drugs, over-the-counter medications, and narcotics in a locked box. A later observation at the nurses' station showed MC #2 unattended and unlocked while LVN B sat at the nurses' station with her back to the cart, and staff and residents were passing by. In interviews, LVN A and LVN B stated they were trained on medication storage and that carts must be locked when not in use, but both acknowledged leaving the carts unlocked while they stepped away. The DON and ADM also stated that medication carts were to always be locked when unattended and that the assigned nurse or MA was responsible for locking them. The facility policy dated February 2023 stated that compartments containing medications and biologicals are locked when not in use and that carts used to transport such items are not left unattended if open or otherwise potentially available to others.
Failure to Timely Respond to Call Lights and Provide Hygiene Care
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences by not answering call lights in a timely manner and not providing regular showers. The resident was an adult male with multiple serious traumatic injuries, including multiple pelvic fractures, unstable burst fractures of T9–T10, rib fracture, dislocation of the left wrist and hand, and displaced trimalleolar fractures of both legs. His MDS dated 02/15/2026 showed a BIMS score of 12, indicating minimal cognitive impairment, and documented that he required maximum assistance for toileting and showering. During observation on 04/07/2026 at 11:00 AM, his call light was illuminated above his door, and at 11:01 AM he was observed lying in bed, appearing disheveled and unkempt, and reported that he hated being at the facility. The resident stated he often had to wait multiple hours, approximately three hours, before receiving assistance after using his call light. He reported that staff would sometimes respond to the call light only to say someone else would come to help, but then no one returned. He stated he had pressed his call light about 10 minutes before the investigator’s interview. Subsequent observations showed that at 11:18 AM his call light remained on, while two staff members, identified as a nurse and a respiratory therapist, were seated at the nurse’s station. At 11:25 AM, the same two staff were still at the nurse’s station, and the call light alert system mounted there was beeping and displaying room numbers, including the resident’s. At 11:30 AM, the same two staff remained at the nurse’s station, and the same four lights, including the resident’s, were still active on the call light alert system. By 11:32 AM, the investigator requested assistance from the administrator regarding the resident’s call light, which had been on for approximately 45 minutes. Interviews with CNAs, an RN, the administrator, and the DON confirmed that all staff were trained and expected to respond to call lights and that call lights were indicated by a light above the resident’s door and alerts at the nurse’s station. CNA A stated residents should not wait a long time for call lights to be answered, and CNA B stated residents should wait no more than about 10 minutes. RN C stated residents should only wait a couple of minutes for a response. The administrator and DON both stated that call lights should be answered in a timely manner and that all staff in the building were responsible for responding. The DON specifically stated residents should not wait 30–45 minutes and that a 10–15 minute response time was expected. A grievance dated 03/17/2026 documented a complaint that call lights were not answered in a timely manner and that a family member had observed multiple call lights on with no staff assisting. Facility inservice records showed prior training on resident rights and call light responsibilities, and the facility’s call system policy stated that residents are provided a means to call staff for assistance from bed and toileting/bathing areas and that calls for assistance are to be answered timely.
Failure to Provide Scheduled Showers and Maintain Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ rights to a dignified existence, self-determination, and communication by not providing scheduled showers to two residents who required maximum assistance with activities of daily living. Resident #1, a male with multiple serious fractures including pelvis, T9–T10 vertebrae, ribs, left wrist and hand, and bilateral trimalleolar fractures, had a BIMS score of 12 indicating minimal cognitive impairment and required maximum assistance for toileting and showering. During an observation and interview, he was noted to appear disheveled and unkempt while lying in bed and reported that staff did not offer him showers or bed baths, stating he had not received a shower in almost two weeks and that this lack of care made him feel dirty and want to leave the facility. Resident #2, a female with anxiety disorder, muscle weakness, a wedge compression fracture of a lumbar vertebra, and reduced mobility, had a BIMS score of 8 indicating moderate cognitive impairment and also required maximum assistance for toileting and showering. The facility’s daily shower list indicated that both residents were scheduled to receive showers on the evening shift on Mondays, Wednesdays, and Fridays, and that all refusals were to be reported to the nurse and documented in the plan of care or electronic record, with only the DON or ADON authorized to make changes. In an interview while she was in bed, Resident #2 stated she did not often receive showers and that her last shower had been more than five days earlier; she did not know how it made her feel to not receive her showers. Staff interviews confirmed that CNAs and nursing staff were responsible for providing showers and that residents were to be offered showers three times a week or every other day, with refusals documented. CNA A and CNA B both stated that residents should not go nearly two weeks without a shower unless they refused, and that refusals should be documented. RN C stated that showers should appear in the Kardex and that failure to provide showers over such a period could be due to resident refusal or low staffing, and that refusals should be documented. The Administrator and DON both stated that residents have the right to be treated with dignity and to be clean, that showers should be provided three times a week or more often as needed, and that there would be no reason for a resident to go about two weeks without a shower. Facility grievance records from March documented resident care complaints about not being changed timely and not receiving care timely due to short staffing. The facility’s undated Shower/Tub Policy stated that the purpose of the procedure was to promote cleanliness, provide comfort, and observe the condition of the resident’s skin.
Failure to Develop Person-Centered Fall Prevention Care Plans
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes to address fall and safety risks for three residents. For a male resident with Alzheimer’s disease, muscle weakness, unsteadiness on his feet, and a severely impaired BIMS score of 6, the MDS identified him as at risk for falls. His care plan, last revised on 1/06/2026, noted fall risk related to unsteady gait, decreased balance, medications, poor safety awareness, use of a mobility device, and need for assistance with transfers, but lacked person-centered fall interventions despite documented falls on 3/23/2024, 7/28/2024, and 1/13/2026. A female resident with cellulitis of the abdominal wall, late-onset Alzheimer’s disease, reduced mobility, and need for assistance with personal care had an MDS BIMS score of 13, indicating intact cognition, and was coded as a fall risk. Her care plan, also last revised on 1/06/2026, similarly identified generic fall risk factors and assistance needs but did not include a person-centered plan to address her falls, despite 17 falls between 8/13/2025 and 12/27/2025. Another female resident with sepsis, repeated falls, obesity, and muscle weakness had an MDS BIMS score of 8, indicating moderate cognitive impairment, and was coded as a fall risk. Her care plan, last revised on 1/06/2026, documented fall risk factors and assistance with transfers but did not provide individualized, measurable fall-prevention strategies, even though she experienced 45 falls over the prior 12 months.
Incomplete narcotic counts and late administration of nighttime medications
Penalty
Summary
The facility failed to maintain a complete record of receipt and disposition of controlled drugs for the Medication Aide Cart for 100, 300, and 500 Halls. Review of the change-of-shift narcotic count sheets showed that the narcotic receipt and reconciliation documentation was missing from MA A for the 6:00 AM to 6:00 PM on-coming shift on 01/04/2026. During interviews, MA A and LVN A stated that the off-going and on-coming staff were required to count the narcotic medications and sign the narcotic count sheet, and both identified the possibility of drug diversion if the count process was not consistently followed. MA A stated she forgot to sign the narcotic count sheet for that shift. The facility also failed to ensure Resident #54 received prescribed nighttime medications within the ordered time frame. Resident #54 was a female resident with diagnoses including cellulitis of the abdominal wall, chronic kidney disease stage 3, spondylosis, bradycardia, and dementia; her MDS reflected a BIMS score of 13, indicating intact cognition. Her physician’s orders and medication audit report showed that nighttime medications were ordered for 8:00 PM daily, with administration acceptable one hour before or after the scheduled time. However, the record showed multiple administrations outside that window, including doses given at 9:21 PM, 9:06 PM, 10:56 PM, 10:34 PM, 9:16 PM, 9:24 PM, 9:08 PM, 9:11 PM, and 10:04 PM. During observation and interview, Resident #54 stated she had been receiving her night medications late, often around 10:30 PM, and said it happened especially when the facility was short-staffed. She stated she stayed up until she received her medication, woke at 5:00 AM daily, and fell asleep at the breakfast table, requiring daytime naps. The DON stated the facility’s medication administration policy was to pass medications as close to the ordered time as possible, one hour before or after the scheduled time, and said she was not aware that night medications were being administered late. The facility’s policy also stated medications are to be administered in a safe and timely manner and in accordance with prescriber orders, including any required time frame.
PASRR Screening Did Not Reflect Resident’s PTSD Diagnosis
Penalty
Summary
The facility failed to ensure the PASRR Level I screening accurately reflected Resident #2’s status. Resident #2 was admitted initially on 02/16/23 and later readmitted, and her diagnoses included post-traumatic stress disorder, vascular dementia without behavioral disturbance, anxiety, and cognitive communication deficit. Her quarterly MDS assessment showed a BIMS score of 09, indicating moderately impaired cognition, and she required staff assistance for toileting, bathing, and personal hygiene. The PASRR Level I screening dated 02/16/23 marked Section C Mental Illness as “no,” indicating that Resident #2 did not have a mental illness, even though PTSD was documented as a diagnosis present on the admission date. The resident’s care plan later identified her as at risk for declining cognition, behavior, and physical condition due to PTSD, with interventions addressing redirection, expression of concerns, physical activity, and monitoring for changes in condition. During interviews, the DON, ADON, Social Worker, and MDS Coordinator described the facility’s PASRR process and stated that the MDS Coordinator or Social Worker was responsible for referrals to the state-designated authority when a resident was identified as having an evident or possible mental disorder, intellectual disability, or related condition. They also stated that if the PASRR was not completed accurately or a referral was missed, residents could miss needed follow-up and services. The facility policy stated that the PASRR program is intended to ensure individuals with mental illness or intellectual disabilities receive appropriate care and services.
Failure to Complete Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #9. Resident #9 was admitted with diagnoses including traumatic subdural hemorrhage with loss of consciousness status unknown, pressure-induced deep tissue damage of another site, and other fracture of the base of skull with routine healing. The MDS assessment dated 12/18/2025 showed a BIMS score of 00, indicating severely impaired cognition, and the resident was dependent on staff for toileting, bathing, and personal hygiene. Record review showed a care plan dated 1/6/26 addressing impaired cognitive function/dementia or impaired thought process related to head injury and traumatic brain injury, with a goal to maintain current cognitive function and an intervention to administer medications as ordered. However, there was no baseline care plan. During observation on 01/06/26 at 11:07 AM, Resident #9 was lying in a hospital bed in the lowest position with a fall mat beside the bed and appeared not to be in distress. In interviews, the DON stated the baseline care plan was not done timely and said it must be initiated by an RN, while the ADON stated she did not know the care plan was not completed timely. The Administrator stated care plan updates were communicated through the DON, Kardex, in-services, one-on-one meetings, PCC, dashboard, and nurse feedback. The facility policy stated that a comprehensive, person-centered care plan is developed and implemented for each resident.
Failure to Use Gait Belt During Resident Transfer Resulting in Fracture
Penalty
Summary
A 91-year-old female resident with multiple diagnoses, including muscle weakness, lack of coordination, restless leg syndrome, acute respiratory failure, and mild cognitive impairment, required two-person physical assistance with transfers using a gait belt, as documented in her care plan and Kardex. On the date of the incident, a CNA and an RN attempted to transfer the resident from her bed to a wheelchair without using a gait belt, contrary to her care plan instructions. During the transfer, the staff found the resident too heavy to move safely and lowered her to the floor, resulting in the resident sitting on the floor with bent knees. Following the transfer, the resident complained of knee pain and was subsequently given pain medication. An x-ray was ordered and revealed a displaced periprosthetic distal femoral fracture. The resident was transferred to the hospital, where she underwent surgery to insert an intramedullary rod in her right femur. The incident was confirmed through staff interviews, which revealed that the staff did not use a gait belt during the transfer, despite being aware that it was required for the resident's safety. Staff interviews further indicated that the failure to use a gait belt was due to a lack of adherence to the resident's care plan and transfer protocols. Both the CNA and RN involved in the transfer acknowledged not using the gait belt and described their attempts to lift the resident under her arms and by holding her brief, which was not in accordance with safe transfer practices. The facility's policy required the use of appropriate techniques and devices, such as gait belts, to ensure resident safety during transfers, but this was not followed in this instance.
Resident Rights Violation Due to Rough Handling by CNA
Penalty
Summary
The facility failed to ensure that a resident was treated with respect, dignity, and care, which compromised the resident's right to a dignified existence and self-determination. The incident involved a resident with Alzheimer's Disease and a need for assistance with personal care, who reported being treated roughly by a CNA during grooming and dressing. The resident alleged that the CNA grabbed her roughly out of bed and yanked and pulled her hair while combing it, leading to feelings of fear and insecurity. The resident's care plan indicated that she required assistance with all activities of daily living, including personal hygiene and dressing, and emphasized the need for encouragement, verbal cues, and gentle assistance. However, the actions of the CNA contradicted these care plan directives, as the resident reported being rudely awakened and handled roughly, which was corroborated by observations from other staff members who found the resident in distress. The facility's investigation confirmed the resident's allegations, with staff members observing the resident crying and expressing fear of being left alone. The resident's statements and behavior indicated a breach of her rights to dignity and respect, as outlined in the Texas Health and Human Services guidelines. The incident highlighted a failure in adhering to the facility's policies on resident rights and abuse prevention, as the resident felt unsafe and mistreated by the CNA involved.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) and a resident diagnosed with Alzheimer's Disease. The resident, who required assistance with all activities of daily living, reported being awakened abruptly and treated roughly by CNA A. The resident alleged that the CNA dug a comb into her scalp while combing her hair, causing her to cry and feel unsafe. This incident was observed and reported by another CNA, who found the resident in distress. The resident's care plan indicated that she needed assistance with personal hygiene and transfers, and it emphasized the importance of providing reassurance and not rushing the resident. Despite these guidelines, the resident reported being handled roughly, which contradicted the care plan's instructions. The incident was reported to the Director of Nursing (DON) and the Administrator, who initiated an investigation into the allegations. The investigation included interviews with the involved CNA, other staff members, and the resident. The resident expressed fear and reported feeling unsafe, while other staff members confirmed the resident's distress. The facility's policy on abuse prevention and reporting was reviewed, highlighting the requirement for immediate safety measures and investigation upon receiving an abuse allegation. The report indicates that the facility's failure to adhere to these policies resulted in the resident experiencing fear and potential physical and psychosocial harm.
Food Safety and Storage Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Several deficiencies were noted, including the failure to cover a tea dispenser, which was left exposed to air-borne contaminants. Additionally, expired foods were not discarded according to guidelines, and various food items in the refrigerator and freezer were not properly sealed or labeled, leaving them vulnerable to contamination. These lapses in food storage and preparation practices were observed during a breakfast service, where a cook was also noted to be without a hairnet, further compromising food safety. The survey revealed multiple instances of improper food storage, with items such as chicken patties, cookies, and various frozen goods either undated, unlabeled, or improperly sealed. This included bags of meat, vegetables, and other food items that were covered in frost or exposed to air contaminants. In the dry food storage area, bins containing sugar, flour, and powdered onion were found with cracked lids and dirt stains, indicating a lack of proper sanitation and maintenance. Interviews with the Dietary Manager (DM) and the Administrator confirmed awareness of these issues. The DM acknowledged the failure to cover the tea dispenser and the ongoing issue of staff not wearing hairnets. The DM also admitted responsibility for ensuring compliance with food storage and sanitation guidelines. The Administrator recognized the potential risk of food contamination and illness due to these deficiencies, emphasizing the need for resolution.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for residents in five of the twelve rooms reviewed. Observations revealed that the bathrooms in these rooms had dark orange stains circling the toilets and on the floors, indicating a lack of thorough cleaning and sanitization. Interviews with the housekeeping staff and supervisor confirmed that these areas were supposed to be cleaned regularly, but the stains persisted despite their efforts. The housekeeping supervisor acknowledged the issue and mentioned that a floor tech had been hired to assist with cleaning the heavily stained bathroom floors. The facility's administrator was not fully aware of the cleanliness concerns until they were shown pictures of the affected areas. The administrator expressed that the expectation was for housekeeping to ensure thorough cleaning of resident rooms to prevent infections and maintain resident dignity. The facility's policy on Internal Environmental Services emphasized the importance of keeping the residence clean and well-maintained through regular cleaning schedules and preventive maintenance, which was not adhered to in this case.
Improper Storage of Respiratory Equipment in LTC Facility
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as observed during a survey. Specifically, the facility did not ensure that respiratory equipment such as nasal cannulas, nebulizer masks, and CPAP masks were stored properly when not in use. This failure was noted for seven residents who required respiratory care, potentially placing them at risk for respiratory infections and unmet respiratory needs. For Resident #24, the nasal cannula was observed hanging over the back of the wheelchair instead of being stored properly. Resident #25's nebulizer mask was found hanging from the bed controller on the bedside table. Similarly, Resident #12's CPAP face mask was left on the bedside table, and Resident #31's nebulizer mask was on the table next to the bed. These observations indicate a consistent pattern of improper storage of respiratory equipment across multiple residents. Interviews with facility staff, including a CNA, an LVN, and the DON, confirmed that the equipment should have been stored in bags to prevent contamination. The facility's policy on breathing therapy devices also reflected the need to wash, rinse, air-dry, and store reusable equipment in a clean plastic bag. Despite these guidelines, the facility did not adhere to proper storage practices, leading to the identified deficiencies.
Inaccessible Call Light System for Resident
Penalty
Summary
The facility failed to ensure that the call light system in a resident's room was accessible, which is a deficiency in accommodating the resident's needs and preferences. The resident, a cognitively intact female with hemiplegia affecting her left side, was unable to reach the call light from her recliner, which was approximately six feet away from the bed where the call light was secured. This inaccessibility was confirmed through observations and interviews, where the resident expressed difficulty in reaching the call light and the need to be cautious when walking to access it. Interviews with facility staff, including a CNA, an LVN, and the ADON, highlighted the importance of having the call light within reach for resident safety and to prevent falls. The facility's policy on the use of call lights emphasizes the need for the call light to be conveniently positioned for resident use, yet this was not adhered to in the case of the resident in question. The failure to position the call light within reach could potentially place the resident at risk of being unable to obtain assistance when needed.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of CNA B during the provision of incontinent care to Resident #50. Resident #50, a cognitively intact female with a BIMS score of 15, was diagnosed with atrial fibrillation, myocardial infarction, and arthritis, and was dependent on staff for transfers and toileting due to incontinence. During the care process, CNA B did not perform hand hygiene after removing soiled gloves and before donning clean gloves, which is a critical step in preventing cross-contamination and infection. Observations revealed that CNA B removed soiled gloves multiple times without washing her hands or using hand sanitizer before putting on a new pair of gloves. This lapse in protocol was acknowledged by CNA B, who admitted to forgetting to perform hand hygiene due to nervousness. Both the DON and ADON confirmed that proper hand hygiene should have been performed to prevent the spread of bacteria and protect both residents and staff. The facility did not provide a policy for infection control or hand hygiene before the exit of the surveyors.
Failure to Maintain Resident Dignity Due to Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity of a resident by not ensuring that his catheter bag was covered while he was in a communal area. The resident, a male with a history of hypertension, obstructive uropathy, hyperlipidemia, seizure disorder, depression, and kidney cancer, was observed sitting in his wheelchair with an uncovered catheter bag in the sunroom. The resident expressed embarrassment and concern about the visibility of the catheter bag and the risk of stepping on the tubing. The facility's comprehensive care plan for the resident included maintaining the catheter, but during the observation, the catheter bag was not covered, which was against the facility's expectations and procedures. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the facility's practice was to use privacy bags for catheter bags whenever they were visible, especially in communal areas. The DON acknowledged that the lack of a privacy bag did not meet her expectations and could be a dignity issue for the resident. The LVN mentioned that catheter assessments were conducted every shift, including checking for privacy bags, and suggested that the resident's recent return from the hospital might have led to the misplacement of the privacy bag. The facility's policies on catheter care did not address the use of privacy bags.
Infection Control Deficiency Due to Improper Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use during incontinence care for a resident. The resident, a female with severe cognitive impairment and multiple diagnoses including dementia and renal insufficiency, required assistance with toileting due to incontinence. During an observation, CNA A did not perform hand hygiene between glove changes and reused disposable wipes multiple times while providing care, which could contribute to the spread of infection. CNA A, despite having received training on infection control and hand hygiene, did not adhere to the facility's handwashing policy. She believed it was acceptable to reuse wipes by folding them and did not think hand hygiene was necessary with every glove change. Additionally, CNA B kept gloves in her pocket, which she later acknowledged could be an infection control issue. Both CNAs' actions during the care of the resident did not align with the facility's infection control policies. Interviews with facility staff, including the ADM and DON, revealed that the expectation was for staff to follow infection control policies, including proper hand hygiene. The DON acknowledged that the observed practices did not meet her expectations and that training and monitoring were responsibilities shared among the DON, ADON, and other staff. Despite recent training and hand hygiene check-offs, the facility's infection control practices were not consistently followed, as demonstrated by the observed deficiencies.
Infection Control Deficiencies in Hand Hygiene and Medication Cart Management
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving staff members. In the first incident, a Certified Nursing Assistant (CNA) did not properly sanitize his hands during the process of providing catheter care to a resident. The CNA was observed using an alcohol-based hand rub (ABHR) but only rubbed the palms of his hands together, neglecting to sanitize the backs of his hands, between his fingers, or under his fingernails. Additionally, he was seen fanning his hand in the air to dry the sanitizer, which is against proper hand hygiene practices. The CNA admitted to not recalling training on proper catheter care and acknowledged the risk of spreading germs and causing infections due to improper hand hygiene. In the second incident, a Licensed Vocational Nurse (LVN) left personal food and drink items on a medication cart, which is against the facility's policy. The LVN admitted to placing a drink cup and a food item on the cart due to being in a hurry and not having access to the usual storage area. This action posed a risk of cross-contamination with resident medications, potentially leading to infection. The Director of Nursing (DON) confirmed that food and drink should not be on medication carts or at the nurse's station, as it is an infection control issue. The facility's policies on hand washing and medication storage emphasize the importance of maintaining cleanliness and preventing the spread of infections. However, the observed actions of the CNA and LVN did not align with these policies, leading to deficiencies in the facility's infection control practices. The DON acknowledged that the staff received training on these procedures, but the incidents indicate a lapse in adherence to the established protocols.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 61 citations issued within 25 miles in the last 12 months — including the 4 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 Belton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Creekside Terrace Rehabilitation | 2.4 mi | ★★★★★ | 3 | 0 |
| Morada Temple | 4.5 mi | ★★★★★ | 5 | 0 |
| Avir At Temple West | 4.5 mi | ★★★★★ | 1 | 0 |
| Avir At Weston | 4.6 mi | ★★★★★ | 3 | 0 |
| Avir At Temple East | 4.7 mi | ★★★★★ | 3 | 0 |
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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.