Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Bradburn during CMS and state inspections, most recent first.
The facility failed to accurately complete MDS assessments for three residents. One resident who smoked and had COPD was not coded for tobacco use, and two residents with mental health or intellectual disability-related PASRR findings were incorrectly coded in Section A1500. The DON and regional nurse consultant acknowledged the MDS entries were inaccurate.
RN coverage was not maintained for 8 consecutive hours 7 days a week across multiple weekends and other days in two reviewed quarters. Record review showed gaps in RN coverage on numerous dates, and the DON stated the facility had only one RN charge nurse who sometimes worked weekends, with some weekends having no RN onsite while staff were told to call her if needed. The Regional Nurse Consultant acknowledged the staffing did not meet the RN coverage requirement, and the Administrator said she was not aware of the issue.
A resident with schizophrenia, insomnia, and major depressive disorder with psychotic features was started on Ativan for anxiety, but the chart did not contain a psychoactive medication consent and there was no documentation that the resident’s representative was notified of the new order. The DON could not locate the consent, LVN A could not find proof of notification, and the ADM stated nursing staff were responsible for obtaining consent when a new medication order was received.
Delayed PASRR Level I Screening Before Admission: A resident with bipolar disorder and schizophrenia was admitted without a completed PASRR Level I screening. The screening was not completed until over a month after admission, and the Level II evaluation was completed later. The Regional Consultant said the delay was not timely, and the DON said the admission MDS should have identified the missing screening; the facility policy stated the Admissions Coordinator or designee ensures the PL1 is provided upon admission.
Failure to complete and accurately code baseline care plans affected two residents. One resident with COPD, CHF, dementia, diabetes, and atrial fibrillation did not have a baseline care plan completed within 48 hours of admission, and another resident with bipolar disorder, schizophrenia, stroke history, diabetes, CHF, COPD, and a smoking history was incorrectly coded as not being a smoker and had no smoking supervision instructions. RN-D stated baseline care plans should be completed within 48 hours and include resident-specific directions, and the DON said she did not know why the plans were incomplete or inaccurate.
Failure to Include Smoking and Fluid Restriction Needs in Care Plan: A resident with COPD and CHF had a baseline care plan noting smoking and supervision needs, but the comprehensive care plan did not address smoking or a 1500 cc/day fluid restriction order. An LVN and the DON stated the resident smoked occasionally, was supervised when smoking, and was not compliant with fluid restrictions, yet these needs were not included in the care plan as required by facility policy.
Failure to assess smoking safety for two residents: one resident with dementia and COPD and another resident with bipolar disorder, schizophrenia, and COPD were both identified as smokers, but neither had smoking-related physician orders or a documented safe-smoking assessment. One resident’s care plan did not address smoking status or safety needs, and the other resident’s care plan only included education about smoking policy and procedures. Staff were present during smoking observations and controlled cigarettes and lighters, but the required smoking safety assessments were not documented.
Resident rooms failed to meet required square footage standards for 2 of 10 rooms reviewed. One room certified for 4 residents measured 74 sq ft per resident, and a private room measured 81 sq ft instead of 100 sq ft. Surveyors observed no residents in the rooms, and the ADM said she was unaware of current room waivers, noted one room was being used as a staff break room, and could not find paperwork showing a waiver had been filed.
A resident with intact cognition and diagnoses including sepsis, DM, AFib, pneumonia, and bilateral heel DTIs was not included with his representatives in baseline, comprehensive, or discharge care plan development. The baseline, comprehensive, and discharge care plan signature pages were blank, there was no documentation the plans were reviewed with the resident or his representative, and a representative said she requested care plan and discharge meetings but was never notified.
Failure to submit timely abuse investigation report: A resident with intact cognition and multiple medical diagnoses alleged that the Administrator used racial slurs while she was in the ER for pneumonia. The DON and Regional Nurse Consultant investigated and found the allegation unsubstantiated, but no Provider Investigation Report was filed in TULIP within the required timeframe, and the Administrator stated she did not submit the report because she was the alleged perpetrator.
Failure to document change-of-shift narcotic counts on the Nurses Cart involved a resident receiving Hydrocodone-Acetaminophen for chronic pain conditions, including spinal stenosis and radiculopathy. Nursing staff reported that narcotics were supposed to be counted and signed off at every shift change, but the narcotic inventory sheet had missing signatures and staff acknowledged that some counts were not completed or documented. The DON confirmed the missing signatures and the missing Hydrocodone card, and the facility policy required controlled substances to be counted together by the on-coming and off-going nurses.
A Treatment Nurse did not perform required hand hygiene or change gloves at appropriate times while providing wound care to a resident, including after removing soiled dressings and when moving between different wounds. This was observed during a wound care procedure, and interviews confirmed the nurse did not routinely perform hand hygiene between glove changes, contrary to facility policy and training.
A resident who returned from the hospital after sepsis and ureteral stent placement did not receive a prescribed oral antibiotic for six days due to an LPN entering an incorrect start date in the medication order. The error was discovered after a VA case manager requested clarification, and the DON confirmed the delay was caused by the transcription mistake. During the missed doses, the resident showed no signs of infection or discomfort, and the catheter remained intact.
Two residents with surgical wounds did not receive wound care as ordered by the Wound Care NP, with orders not implemented or documented and staff unaware of proper procedures. One resident was hospitalized for a non-healing, infected amputation site, and the other experienced delays in wound care due to inaccessible provider notes. The facility's failure to follow and document wound care orders resulted in actual harm and Immediate Jeopardy.
A resident with a recent surgical amputation and wound infection did not receive timely antibiotic therapy because nursing staff lacked access to the Pyxis medication dispensing system and were unaware that the medication had been delivered and was available. This resulted in missed doses, worsening infection, and subsequent hospitalization for advanced treatment.
Surveyors found that kitchen staff did not consistently label or date opened containers of thickened beverages and other food items, as required by facility policy and product instructions. Items such as orange juice, sweet tea, icing, and fudge were found open and either undated or past their use-by dates, with the dietary manager confirming the lack of proper labeling and dating practices.
Two rooms were found to be below the required square footage for resident occupancy, with one four-bed room providing only 74 sq ft per resident and a private room measuring just 81 sq ft instead of the required 100 sq ft. At the time of the survey, neither room was occupied by residents, and one was used as a staff break room. The Administrator confirmed the deficiencies and stated that waivers were still pending.
The facility failed to ensure resident rooms met the required square footage per resident. One room certified for 4 residents provided only 74 square feet per resident, and a private room measured 81 square feet instead of the required 100 square feet. The Administrator confirmed these deficiencies during an interview.
Inaccurate MDS Coding for Tobacco Use and PASRR Status
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for 3 of 16 residents reviewed. Resident #6’s annual MDS did not code tobacco use in Section J1300, even though the facility’s smoking list identified him as a smoker, his baseline care plan stated he smoked with supervision, and he told staff he smoked sometimes. He had COPD and a BIMS score of 15, indicating intact cognition. Resident #27’s admission MDS incorrectly completed Section A1500 for PASRR. The assessment indicated the resident was considered by the state level II PASRR process to not have serious mental illness and/or intellectual disability or a related condition, but the PASRR Level I screening was not completed until after the MDS, and the PASRR Level II screening was also completed later. The resident’s diagnoses included bipolar disorder and schizophrenia. Resident #29’s admission MDS also had inaccurate PASRR coding in Section A1500. Her record showed a PASRR Level 1 screening completed before admission that found mental illness and intellectual disabilities, and a PASRR evaluation later found intellectual and developmental disabilities. Despite this, the MDS marked PASRR as No. Her diagnoses included bipolar disorder, anxiety, mood disorder, and cerebral palsy, and the record noted she was receiving PASRR specialized services.
RN Coverage Not Maintained for Required 8 Consecutive Hours
Penalty
Summary
The facility failed to use the services of a registered nurse for 8 consecutive hours 7 days a week during two reviewed quarters of 2026. Record review of CMS PBJ reports and RN time sheets showed multiple dates in Quarter 2 and Quarter 3 when there was no consecutive 8-hour RN coverage, including weekends and other days in January, February, March, April, May, and June 2026. The report also noted a discrepancy in the documentation, with one entry listing 01/03/2025 in the Quarter 2 2026 RN time sheet review. During interview, the DON stated she had been at the facility since 04/15/2026 and said the facility had one RN working as a day shift charge nurse who occasionally worked weekends. She explained that some weekends the RN worked 6 AM to 6 PM and provided 8 consecutive hours of coverage, while on other weekends the RN worked 6 PM to 6 AM, which did not provide consecutive hours. She also stated that some weekends there was no RN coverage and staff were told to call her if needed, but she was not normally onsite. The DON said she was trying to hire a weekend RN supervisor and had interviewed two RNs, but one declined and the other had not completed onboarding. The Regional Nurse Consultant acknowledged the facility did not have adequate RN coverage meeting the 8 consecutive hour requirement, and the Administrator said she had been at the facility for one week and was not aware of the staffing issue.
Failure to Obtain Consent for New Ativan Order
Penalty
Summary
The facility failed to inform the resident or the resident representative in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, treatment alternatives, or treatment options, and failed to obtain written consent for a psychotropic medication for one resident. Resident #18 was a female admitted on 06/17/2022 with diagnoses including schizophrenia, insomnia, and major depressive disorder with psychotic features. Her most recent Quarterly MDS showed a BIMS score of 5, indicating severe cognitive impairment, and the MDS noted that she was receiving an antianxiety medication. Record review showed a care plan dated 05/06/2026 identifying that Resident #18 used anti-anxiety medications, with interventions to administer medications as ordered and monitor for adverse reactions and target behaviors. The medication orders included Ativan 0.5 mg by mouth three times daily for anxiety, dated 05/06/2026. However, review of the electronic medical record on 07/14/2026 did not show a psychoactive medication consent for Ativan, and there were no progress notes indicating that the resident’s responsible party was notified of the new prescription. During interview, the resident did not respond to questions. The resident’s representative and medical power of attorney stated she thought staff had called to discuss a medication for anxiety and agitation. The DON stated she could not find the consent for Ativan and said some consents were still waiting to be scanned into the record; she also stated the ADON had previously been responsible for completing psychoactive medication consents. LVN A stated she could not find documentation that the responsible party was notified of the new Ativan order, and the ADM stated nursing staff were responsible for obtaining consent when a new order was received.
Delayed PASRR Level I Screening Before Admission
Penalty
Summary
The facility failed to provide evidence of a State Level I PASRR screening before admitting a resident with diagnoses of bipolar disorder and schizophrenia. Record review showed the resident was admitted on 12/11/2025, but the Level I PASRR screening was not completed until 01/14/2026, 34 days after admission. The resident’s Level II PASRR evaluation was later completed on 02/18/2026, 52 days after admission. During interviews, the Regional Consultant stated the Level I screening was not completed timely and said multiple nurses assisting with MDS assessments and the PASRR process may have contributed to the oversight. The DON stated she was not employed at the time of admission and could not explain why the Level I screening had not been completed before admission. She said the person completing the admission MDS should have noticed the missing screening, and that the Marketing Director was currently responsible for obtaining Level I screenings for potential admissions. The facility policy stated the Admissions Coordinator or designee would ensure the referring entity provides a copy of the PL1 upon admission.
Failure to Complete and Accurately Code Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #6 and Resident #27. Resident #6 was a [AGE] year-old male admitted with diagnoses including COPD, CHF, dementia, diabetes, and atrial fibrillation. His baseline care plan, dated 06/30/2026, was completed 6 days after admission and identified him as a smoker. Resident #27 was a [AGE] year-old male admitted with diagnoses including bipolar disorder, schizophrenia, cerebral infarction, diabetes, CHF, and COPD, and he also had a history of smoking. His baseline care plan, dated 12/11/2025, indicated he was not a smoker and did not include interventions for smoking supervision. During interview, RN-D stated baseline care plans were to be completed within 48 hours of admission and should include resident-specific directions such as monitoring blood sugars or supervising residents who smoke. The DON stated she did not know why Resident #6's baseline care plan was not completed in a timely manner or why Resident #27 had no smoking interventions, and said the baseline care plan was intended as an initial guide for care based on individual needs.
Failure to Include Smoking and Fluid Restriction Needs in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #6 that included measurable objectives and time frames to meet his medical, nursing, mental, and psychosocial needs. Record review showed Resident #6 was a male admitted with diagnoses including COPD and congestive heart failure, and an annual MDS reflected a BIMS score of 15, indicating intact cognition. His baseline care plan dated 06/30/2025 noted that he smoked and required supervision when smoking, but it did not address fluid restrictions. Physician orders dated 07/15/2026 included a 1500 cc per 24-hour fluid restriction dated 10/10/2025. The comprehensive care plan with a last revision date of 04/27/2026 did not include concerns or interventions related to smoking or the physician's fluid restriction order. During interview, an LVN stated Resident #6 smoked occasionally, was supervised by staff when smoking, and was not compliant with fluid restrictions, though staff encouraged him to limit fluids. The DON stated Resident #6 was not compliant with fluid restriction orders, had not shown evidence of fluid retention, and confirmed that smoking and fluid restrictions should have been addressed in the care plan. The facility policy required a comprehensive, person-centered care plan with measurable objectives and timetables that reflects recognized standards of practice for problem areas and conditions.
Failure to Assess Smoking Safety for Two Residents
Penalty
Summary
The facility failed to ensure adequate supervision and assessment for safe smoking for two residents who were identified as cigarette smokers. Resident #6 had diagnoses including dementia and COPD, had a BIMS score of 15 indicating intact cognition, was ambulatory, and could voice needs, but the record showed no physician orders related to smoking, no smoking information in the comprehensive care plan, and no documented assessment for safe smoking. Although the facility’s list of residents who smoked identified Resident #6 as a smoker, he was not present during observations of residents smoking, and he stated in interview that he smoked sometimes and would go outside with other residents if he wanted to smoke. Resident #27 had diagnoses including bipolar disorder, schizophrenia, and COPD, and a quarterly MDS showed a BIMS score of 9 with moderately impaired cognition and noted tobacco use. The record showed no physician orders related to smoking and no documented assessment for safe smoking. The comprehensive care plan referenced smoking and included education about the facility’s tobacco/smoking policy and smoking times and procedures, but it did not include smoking status information or safety needs to prevent injury. During observations, Resident #27 was seen sitting in a chair smoking a cigarette, holding it safely and using the ashtray appropriately, while facility staff were present and controlled the dispensing of cigarettes and lighters.
Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that resident rooms measured at least 80 square feet per resident in multiple resident rooms and at least 100 square feet in a single resident room for 2 of 10 resident rooms reviewed for square footage. One room certified for 4 residents measured 74 square feet per resident, and one room certified as a private room measured 81 square feet instead of 100 square feet. The report also states that room [ROOM NUMBER] was used as a staff break room, and no residents were residing in the rooms at the time of observation. During observation, surveyors noted that no residents were residing in the rooms in question. During interview, the Administrator said she was not aware the facility had any rooms with room waivers and stated she had been at the facility about a week. She was informed that the rooms had room waivers in previous years and that the rooms still required waivers. She also said she had not found any physical papers indicating a room waiver had been filed last year and stated she had been told by life safety code that she only needed to indicate on the plan of correction that she was requesting the waiver and that there should be no end date so it would continue indefinitely. Record review of the bed classification form dated 07/13/2026 indicated one room was certified for 4 residents and another room was certified for 1 resident.
Resident and Representatives Not Included in Care Plan Development
Penalty
Summary
The facility failed to ensure a resident and his representatives participated in the development and implementation of his person-centered care plan. The resident was admitted with diagnoses including sepsis with septic shock, diabetes, atrial fibrillation, and bacterial pneumonia. His admission MDS showed a BIMS score of 13, indicating intact cognition, and he was able to feed himself, used a wheelchair, and was frequently incontinent of urine. His record also showed physician orders for wound care and heel offloading related to bilateral heel deep tissue injuries, along with a pressure-reducing mattress and daily heel treatment. The resident’s baseline care plan listed a preference for care plan updates during normal care plan meetings, but the signature page for the resident, representatives, and staff was blank. The comprehensive care plan addressed full code status, visual impairment, bilateral heel DTI, infection risk, impaired skin integrity risk, physical mobility weakness, and diabetes, but its signature page was also blank and there was no documentation that it had been reviewed with the resident or his representative. The discharge plan was likewise unsigned by the resident or representatives. A representative stated she requested both a care plan meeting and a discharge care plan meeting a few days before discharge but was never notified of one. The DON stated the SW handled scheduling of care plan meetings, the SW said the resident discharged before she could schedule a comprehensive care plan meeting, and the DON stated nurses should complete and print the baseline and discharge care plans, review them with the resident and/or representative, and obtain signatures.
Failure to Submit Timely Abuse Investigation Report
Penalty
Summary
The facility failed to report the results of an investigation of an allegation of abuse to the State Survey Agency within 5 working days of the incident. Resident #2, a [AGE]-year-old female with diagnoses including lupus erythematosus, bipolar disorder, anxiety, factitious disorder imposed on another, diabetes, chronic kidney disease, and pneumonia, had a BIMS score of 15 on the annual MDS, indicating intact cognition. On 05/06/2026, she was sent to the hospital ER for pneumonia and returned with antibiotic orders. While at the hospital, she alleged that the facility Administrator used racial slurs, including the N word, and the DON received the report from the hospital case manager. A facility incident report dated 05/06/2026 showed the Administrator was suspended and sent home after the allegation was received, and the Regional Nurse Consultant reported the incident to the appropriate state agency. The facility investigation dated 05/06/2026 found the allegation of verbal abuse unsubstantiated, and the Administrator was allowed to return to work. However, a review of the TULIP system on 05/20/2026 found that no Provider Investigation Report (Form 3613-A) had been filed. During interview, the Administrator stated she did not submit the report of findings because she was the alleged perpetrator and was not part of the investigation. The facility policy stated that all abuse allegations are investigated and that a follow-up report is to be provided within five business days of the incident.
Failure to Document Change-of-Shift Narcotic Counts
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate acquiring, receiving, dispensing, and administering of controlled medications for one of two medication carts reviewed. The concern involved the Nurses Cart and the handling of narcotics, specifically a card of Hydrocodone-Acetaminophen 10-325 mg tablets for a resident with spinal stenosis, chronic neck and back pain, lumbar and cervical radiculopathy, left shoulder pain, and post spinal cord surgery. The resident’s admission MDS showed a BIMS score of 12, indicating moderately impaired cognition, and he was able to feed himself, ambulate short distances, use a wheelchair, and was continent of bowel and bladder. Record review showed the facility received a bottle of 29 Hydrocodone 10-325 mg tablets from the resident’s home and later received a card of 25 Hydrocodone-Acetaminophen 10-325 mg tablets from the pharmacy. The Controlled Medication Administration Record showed the resident received one tablet on two occasions. During observation and interviews, nursing staff stated that narcotics in the Nurses Cart were to be counted at every change of shift and that the on-coming and off-going nurses were supposed to count and document the narcotics when keys were passed from one person to another. The Nurse Cart’s Narcotic Release and Acceptance of Narcotic Inventory sheet had four missing signature entries on different dates, and staff acknowledged that these blank signature spots made it appear that change-of-shift counts had not been done. Interviews with nursing staff and the DON showed that the narcotic card was present during earlier counts, then later was missing when the resident’s medication was checked again. One nurse said she had written “Use Bottle First” on the count sheet, and another nurse said she did not perform a change-of-shift narcotic count when relieving the off-going nurse and had no reason for not doing so. The DON stated she was aware the card of 25 Hydrocodone-Acetaminophen tablets and the corresponding count record were missing, that several signatures were missing from the narcotic inventory sheet, and that the missing signatures implied the change-of-shift narcotic counts had not been done. The facility policy required controlled substance inventory to be monitored and reconciled, with nursing staff counting controlled medication inventory at the end of each shift and the on-coming and off-going nurses making the count together and documenting discrepancies.
Failure to Follow Hand Hygiene and Glove Change Protocols During Wound Care
Penalty
Summary
A deficiency was identified when a Treatment Nurse failed to follow proper infection prevention and control protocols during wound care for a resident. The nurse did not perform hand hygiene at several critical points, including after removing gloves and between glove changes, while providing wound care to the resident's sacral area and right heel. The nurse also failed to change gloves between different steps of the wound care process and when moving from one wound to another. These actions were observed during a wound care procedure, where the nurse handled wound dressings, applied treatments, and interacted with the resident and the environment without adhering to the facility's established hand hygiene and glove change policies. Interviews with the Treatment Nurse revealed a lack of routine hand hygiene between glove changes, despite having received training from the DON. The DON confirmed that staff are expected to perform hand hygiene before, during, and after care, and specifically after glove removal and between steps in wound care. Review of the facility's policies on wound care and hand hygiene further supported these expectations, outlining specific steps for handwashing and glove use to prevent infection and cross-contamination.
Medication Error Due to Incorrect Transcription of Antibiotic Order
Penalty
Summary
A medication error occurred when a resident, who was readmitted to the facility following hospitalization for sepsis and ureteral stent placement, did not receive a prescribed oral antibiotic (Sulfamethoxazole-Trimethoprim) as ordered. The resident's physician had ordered the antibiotic to be administered twice daily for seven days, starting immediately upon the resident's return to the facility. However, the order was incorrectly transcribed by an LPN, who entered an incorrect start date, resulting in a six-day delay in the administration of the antibiotic. The resident's medical records and nurse's notes confirmed that the antibiotic was not given between the dates of readmission and the corrected start date. The error was discovered after a VA case manager noticed a new order for the antibiotic and sought clarification, leading to the realization that the medication had not been started as intended. The DON verified that the staff nurse had entered the wrong date, which caused the delay in treatment. Throughout the period when the antibiotic was not administered, documentation indicated that the resident exhibited no fever, pain, or urinary complaints, and the urinary catheter remained intact with clear, yellow urine. The resident was alert, oriented, and denied any issues related to the catheter or signs of neglect during interviews. The error was attributed to the incorrect transcription of the medication order upon readmission, and the responsible staff member could not be reached for further comment during the investigation.
Failure to Implement and Document Wound Care Orders Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to ensure that residents received wound care treatment and services in accordance with professional standards of practice and their comprehensive care plans. For two residents with surgical wounds, the facility did not implement wound care orders as prescribed by the Wound Care Nurse Practitioner (NP). In one case, a male resident with a recent right below-the-knee amputation and multiple comorbidities, including diabetes and peripheral vascular disease, did not have wound care orders implemented or documented as required. Despite having clear orders to cleanse the wound, apply xeroform, and cover with a dry dressing, there was no evidence in the Treatment Administration Record (TAR) that wound care was performed throughout the month. The Director of Nursing (DON) was unable to explain the lack of documentation or implementation and acknowledged the importance of following wound care orders. The resident was later hospitalized for a non-healing, infected surgical wound, and required further surgical intervention. A second resident, a female with a history of lower leg fracture, congestive heart failure, and diabetes, also did not receive timely implementation of wound care orders. The Wound Care NP had provided specific instructions for wound care, including the use of wound cleanser, xeroform, medical honey, and calcium alginate, but these were not transcribed or carried out as ordered. The DON reported not being able to access the wound care provider's progress notes for a period, which contributed to the delay in implementing the orders. The Wound Care NP was not aware that her orders had not been followed until much later and stated that failure to implement the prescribed wound care could have led to wound deterioration. Interviews with staff revealed a lack of awareness and inconsistent understanding of the wound care orders, with one LVN stating that only bandaging was performed, contrary to the NP's orders. The facility's own wound care policy required documentation of wound care, including the date, initials of the person performing care, and any changes in the resident's condition, but this was not followed. The surveyor identified these failures as resulting in actual harm and Immediate Jeopardy, as residents with surgical wounds did not have their treatments performed as ordered, leading to wound infection and deterioration.
Delayed Antibiotic Administration Due to Medication Access and Communication Failures
Penalty
Summary
The facility failed to provide timely pharmaceutical services for a resident who had recently undergone a right below-the-knee amputation and was at risk for infection. The resident was prescribed Cleocin (Clindamycin) 150mg, two capsules three times daily, by a vascular surgery nurse practitioner to treat a surgical wound infection. Despite the order being placed, the antibiotic was not started as directed. Documentation shows that the medication was available in the facility's Pyxis medication dispensing system, but the nurses on duty did not have access to the Pyxis and therefore could not obtain the medication for administration. The medication was delivered from the pharmacy and was present in the facility, but it was not placed in the correct location for the nurses to find and administer. As a result, the resident missed multiple scheduled doses of the antibiotic over two days. Progress notes and interviews confirm that staff were waiting for the medication to be delivered, unaware that it was already available in the Pyxis or had been delivered and misplaced. The lack of access to the Pyxis and failure to check for the medication's availability led to a delay in starting the antibiotic treatment. Due to the delay in receiving the prescribed antibiotic, the resident's infection worsened, resulting in hospitalization for a non-healing surgical wound and infection. The hospital nurse reported that the resident required intravenous antibiotics and was scheduled for further surgical intervention. The facility's own policy required medications to be administered in a safe and timely manner as prescribed, but this was not followed in this case, leading to actual harm for the resident.
Failure to Label and Date Opened Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to properly label and date food items stored in the kitchen's reach-in cooler and on the prep table. Specifically, several containers of thickened orange juice and sweet tea were found open without labels or open dates, despite packaging instructions stating they should be used within seven days of opening. Additionally, a small bowl of white substance (icing) was found with an outdated label, and a small square container with an unidentified brown substance (fudge) was found without any label or date. The dietary manager confirmed that the date marked on the boxes was for delivery and not for when the items were opened, and acknowledged that items should be marked when opened. The facility's Food Receiving and Storage policy requires all refrigerated and frozen foods to be covered, labeled, and dated, with refrigerated foods monitored for use-by dates, freezing, or discarding as appropriate. The dietary manager also stated that leftovers should be used within three days or discarded. The observed failures to follow these procedures could result in food being kept beyond safe timeframes, as items were not consistently labeled or dated when opened or stored.
Resident Rooms Below Required Square Footage
Penalty
Summary
The facility failed to ensure that resident rooms met the required minimum square footage, as observed during an initial tour and confirmed through interviews and record review. Specifically, one room certified for four residents provided only 74 square feet per resident, falling short of the 80 square feet requirement, while another room certified as a private room measured only 81 square feet instead of the required 100 square feet. At the time of the survey, neither of these rooms was occupied by residents, and one was being used as a staff break room. The Administrator acknowledged that these rooms still required waivers and confirmed the square footage deficiencies during the interview.
Deficiency in Resident Room Square Footage
Penalty
Summary
The facility failed to ensure resident rooms met the required square footage per resident. Specifically, room [ROOM NUMBER] was certified for 4 residents but only provided 74 square feet per resident instead of the required 80 square feet. Additionally, room [ROOM NUMBER], certified as a private room, measured 81 square feet instead of the required 100 square feet. These deficiencies were identified during an initial tour and confirmed through interviews with the Administrator, who acknowledged that the rooms still required waivers. A resident roster review corroborated the certifications and measurements of the rooms in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Grand Saline
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Azalea Trail Nursing And Rehabilitation Center | 0.3 mi | ★★★★★ | 5 | 0 |
| Avir At Grand Saline | 0.8 mi | ★★★★★ | 14 | 0 |
| Van Healthcare | 11.2 mi | ★★★★★ | 10 | 0 |
| Avir At Mineola | 12.4 mi | ★★★★★ | 16 | 1 |
| Mineola Gardens Wellness & Rehabilitation | 12.9 mi | ★★★★★ | 7 | 0 |
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