Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Bryan during CMS and state inspections, most recent first.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors observed lettuce in a steam table pan loosely covered and exposed, another bag of lettuce without a pull or use-by date, a frozen ham thawing on a wire shelf without a drip-proof container or pull date, and a refrigerator tray with spilled residue. In dry storage, hamburger buns were in a bag with a large hole, a sugar bin had a scoop left inside, and storage bins and the refrigerator were soiled. CK A, the DM, and the ADM stated food was expected to be labeled, dated, sealed, and stored in clean areas to prevent contamination.
Failure to inform residents of their rights: Record review showed resident rights were not discussed in multiple resident council meetings, and some meeting minutes were missing. In confidential interviews, 10 residents said staff had not reviewed their rights with them, and 7 were unsure of their rights. The AD said she did not know she was supposed to review and explain resident rights and was unaware of the Ombudsman, while the SW and ADM described differing expectations for how resident rights information was being shared.
Insufficient Resident Activity Program: A facility failed to provide an ongoing activity program that met resident preferences and abilities. One resident with depression and psychotic disorder said only BINGO was offered, events were not communicated, and resident council did not occur; another resident with Parkinson’s disease said there were not enough activities besides BINGO; and a blind resident stated he could not participate in the mostly BINGO-based program. Staff also reported limited activities for bedbound residents and inconsistent resident engagement.
Unlocked Medication Carts Observed Unattended: The facility failed to keep 3 of 9 med carts locked and secured when not in use. The ADON left two carts unlocked and unattended, and an RN left another cart unlocked and unattended during the initial walk-through. Interviews showed both nurses knew the carts were supposed to be locked, and the facility policy stated meds and biologicals must be stored in locked compartments and carts not left unattended if open.
Antibiotic stewardship was not followed for three residents. The facility’s antibiotic review tracker lacked required data such as MRN, symptom onset, pathogen, infection site, culture date, outcome, and adverse events, and infection surveillance evaluations were not completed for all antibiotic orders. The DON, ADON, and ADM all acknowledged the tracker did not meet policy requirements, and one resident had an antibiotic order without a corresponding infection screening evaluation.
Unclean Resident Wheelchairs: The facility failed to keep resident wheelchairs clean and free of dirt and debris. A resident reported broken wheelchair locks and filthy chairs, while several other residents said their chairs had not been cleaned, including one after a toileting accident. Surveyors observed 6 of 8 wheelchairs with significant dust, hair, and debris on the frames, cushions, and wheels. The ADM, an LVN, and a hospitality aide gave differing accounts of who cleaned the wheelchairs, and the ADM stated staff had slacked in following the facility process.
Failure to preserve dignity and privacy: A resident with severe cognitive impairment was repeatedly observed in bed wearing a hospital gown, including one instance with feces on the gown, while staff and family reported he was often kept in bed because he entered other residents’ rooms and because of staffing limits. Staff also failed to assist him with regular clothing despite clean clothes being available. In a separate incident, an aide entered another resident’s room without knocking, even though the resident stated staff never knocked and that she felt violated when they did not.
Public Survey Binder Contained Resident PHI: A facility left a public survey binder in the foyer containing a resident identifier sheet with names and numbered identifiers plus the matching survey/investigation with PHI, exposing two residents' confidential information. One resident had dementia with a BIMS score of 04, and the other had Ogilvie syndrome and hemiplegia/hemiparesis following a cerebral infarction with a BIMS score of 14. The DON and ADM stated the binder should not have contained residents' names and acknowledged the confidentiality concern.
PASRR Review Not Updated for New Mental Health Diagnosis: A resident with anxiety, psychosis, and moderate cognitive impairment developed a new dx of major depressive disorder during the stay, but the facility did not complete a new Form 1012 or refer the resident for PASRR review. Staff stated the new mental health dx had been missed, an older PASRR II was outdated, and the DON was unsure of the referral process for newly acquired mental health conditions.
Incorrect PASRR Level I Entry for Resident with Mental Health Diagnosis: A resident with stroke, anxiety disorder, depression, and significantly impaired cognition had a PASRR Level I from the referring facility that indicated mental illness, but the facility’s MDS RN entered a different PL1 into SimpleLTC that did not show mental illness. The MDS Coordinator and MDS RN acknowledged the entry was incorrect and that the diagnosis was missed, while the DON stated MDS nurses were responsible for PASRR referrals when a mental health diagnosis was identified.
Medication Left With Resident Without Self-Administration Assessment: A resident with seizures, anxiety, depression, headaches, cancer, and HTN had medication left in his room even though no self-administration assessment had been completed and his care plan did not indicate he could self-administer. The resident said staff sometimes left his meds with him after breakfast, while the DON and ADM stated staff were supposed to watch residents take meds and not leave them with residents.
Hand hygiene was not maintained during breakfast tray pass in the dining room when two CNAs were observed passing trays without washing or sanitizing their hands between residents. Both CNAs stated they had been trained on hand hygiene and knew staff were expected to sanitize between trays, and the DON and ADM confirmed that staff assisting with tray pass were expected to perform hand hygiene and were monitored by observation. The facility policy stated hand hygiene is the primary means to prevent the spread of healthcare-associated infections.
The facility did not follow its grievance policy by failing to complete investigations and provide written decisions to residents who filed grievances. Review of the grievance log for one month showed 17 grievances with no documented dates of written decisions and incomplete "Findings of Investigation" on most forms. An ADON reported she had not been trained on the grievance process, was unsure if residents received written decisions, and that in-services related to grievances were not documented. The SSD stated she routed grievances to department heads but did not verify completion of investigations or notification to the complainant and was unsure if written communication was provided. The DON acknowledged that department heads typically notified residents verbally and that written responses were not being sent, and the ADM confirmed, after reviewing the policy and grievance forms, that required written follow-up and complete documentation were not being carried out.
A resident with HTN, CKD, and AF had a standing order for a weekly clonidine 0.3 mg/24 hr transdermal patch, but during one month the MAR showed multiple scheduled doses marked as "medication not available" instead of administered. The resident reported not receiving his blood pressure patch and was observed without a patch, while a box of his clonidine patches was later found in a medication cart. Medication aides and LVNs gave differing accounts about when the drug was unavailable, who was notified, and whether the provider or pharmacy were contacted, and leadership (DON and ADM) stated they were not informed of the missing medication despite facility policy requiring timely administration, error reporting, and specific actions when medications are unavailable.
A resident with Ogilvie syndrome and a care plan for altered GI status did not consistently receive ordered bowel medications, including bisacodyl suppositories, lactobacillus, and polyethylene glycol. MARs and nursing notes showed multiple missed doses documented as "on order" or "on reorder," while the resident and the resident’s representative reported ongoing problems with medications running out. A medication aide described a weekly OTC ordering process that could delay obtaining needed OTC drugs, and the DON acknowledged that the resident’s suppositories were not on the current order list despite policies requiring accurate ordering, reordering, and timely administration of medications as prescribed.
A resident with dementia, diabetes, and hypertension, who required significant ADL assistance and had impaired coping, was financially exploited when a CNA took the resident’s debit card and made numerous unauthorized purchases at various stores and gas stations. The resident’s POA discovered the suspicious charges on the card statements, reported them to law enforcement, and did not initially inform facility staff, stating police advised against it and that the facility did not receive the statements. The CNA, whose pre-employment criminal history check showed no disqualifying offenses, was later terminated for no call/no show and subsequently arrested. The facility’s policy stated residents’ rights to be free from abuse, exploitation, and misappropriation and required protocols to prevent and identify theft and to screen employees for abuse- or misappropriation-related findings.
A resident with cognitive intactness and multiple medical conditions, including hemiplegia and a history of cerebral infarction, had a care plan for inadequate nourishment that included therapeutic supplements and a physician order for Ensure Clear with the noon meal. Despite this, the resident reported not receiving the supplement, and surveyor observation of a lunch tray confirmed its absence. The resident’s representative stated she had repeatedly raised the issue at care plan meetings, and the SW recalled being told about the need for Ensure Clear but did not verify follow‑through. The DON was unaware the supplement was not being given, even though facility policy requires medications and ordered items to be administered as prescribed.
A resident with a PICC line did not have her dressing changed according to physician orders and facility policy, despite documentation by an LVN indicating the task was completed. The DON confirmed the dressing was not changed as required, and the discrepancy was identified through observation and record review.
Expired bottles of Melatonin 1mg and Aspirin 325mg were found on a medication cart during a survey. An LVN acknowledged responsibility for removing expired medications in the absence of a medication aide, and the DON confirmed staff are expected to check for expired drugs before administration. The facility's policy requires nursing staff to maintain medication storage and remove outdated medications, but these expired drugs remained on the cart.
A medication cart was found with a bottle of lactulose that was sticky and adhered to the drawer, indicating improper storage and lack of cleanliness. An LVN acknowledged the issue, and the DON stated that staff are responsible for ensuring medications are stored properly, as outlined in facility policy.
A resident with a stasis ulcer did not receive wound care in accordance with infection control protocols when an LVN failed to perform hand hygiene before and between glove changes, used gloves stored in a scrub pocket, and did not clean the overbed table before placing supplies. Both the LVN and DON confirmed these actions did not follow facility policy.
A deficiency was cited when a resident was found to have been prescribed or administered unnecessary drugs, with no adequate clinical justification documented in the medical record.
The facility did not ensure that laboratory services or tests were provided in a timely and quality manner to meet resident needs, as identified by surveyors.
Nurse staffing information, including the number and hours worked by RNs, LPNs, and CNAs, as well as the facility name, date, and resident census, was not posted as required. Staff schedules were available in a lobby binder but did not meet regulatory requirements, and staff interviews revealed confusion about the posting process and responsibilities.
A resident prescribed Modafinil for sleep apnea did not receive the medication after it was delivered and signed for by nursing staff. The medication and its count sheet went missing after two nurses failed to perform the required shift change narcotic count, with both nurses admitting to not following facility policy for controlled substance accountability. The medication was never found, and the required procedures for receiving, recording, and securing controlled substances were not followed.
Several residents with complex medical needs did not have complete or accurate documentation of medication, treatment, and wound care administration. MARs, TARs, WARs, and Controlled Drug Records were missing or inconsistent, and staff interviews revealed confusion and lapses in following documentation procedures. The facility's narcotic record logs were also disorganized, with missing records for discontinued medications and discharged residents.
Three residents did not have comprehensive, individualized care plans addressing their specific needs, including refusal of monthly weights, refusal to sit upright during meals, and use of respiratory equipment. Care plans lacked documentation of refusals, individualized interventions, and necessary physician orders, resulting in unmet care needs.
Three dependent residents did not receive scheduled showers as required by their care plans, with missing or inaccurate documentation in both EHR and paper records. Staff interviews revealed inconsistent documentation practices and short staffing, leading to missed bathing care and resident dissatisfaction.
Multiple nourishment room refrigerators were found without required temperature logs, contained expired food items, and showed evidence of poor sanitation, including stains, a human hair, and pest activity. Staff interviews revealed confusion over responsibilities for cleaning and monitoring, and a review of the facility's contract confirmed divided duties between the facility and the contracted kitchen.
Two residents did not have their comprehensive admission MDS assessments completed within the required 14-day period. Both assessments were overdue, with one resident's assessment 2 days late and the other 9 days late. Staffing challenges and workload issues among MDS coordinators contributed to the delay, and the facility did not provide a policy on timely MDS completion when requested.
A resident with dementia and moderate cognitive impairment was not properly assisted or positioned to eat her meal in bed, leaving her unable to reach or see her food. Staff were unclear about who placed the tray, and the resident's care plan required assistance with eating, which was not provided according to facility policy.
A medication aide failed to confirm that a resident with impaired cognition and swallowing difficulties consumed her nighttime medications, resulting in unconsumed pills being found in the resident's room. The aide was unaware of a physician's order to crush medications, and staff were not informed of the resident's difficulty swallowing, leading to a lapse in medication administration according to professional standards.
A resident with multiple chronic conditions was using a CPAP machine nightly and a nebulizer as needed, but there were no physician's orders or care plan interventions documented for either device. Nursing staff confirmed the use of these devices without proper documentation, and there was no record of equipment maintenance or cleaning schedules.
A resident with multiple medical conditions did not receive prescribed Thiamine and Ergocalciferol because these medications were not available at the time of administration. Staff interviews revealed inconsistent communication and unclear procedures regarding reporting and obtaining unavailable medications, and no policy on medication availability was provided during the survey.
A medication error rate above 5% was identified when a resident with complex medical needs did not receive prescribed Thiamine and Ergocalciferol because the medications were not available. The medication aide reported the issue to a nurse, but the nurse was unaware of the shortage, leading to missed doses and a failure to follow facility policy for medication administration and communication.
A medication aide left a medication cart unlocked and unattended in a hallway, with over-the-counter medications left out on top of the cart while administering medications in a resident's room. The aide acknowledged that the cart should not be left unlocked or with medications exposed, and the DON confirmed that staff are expected to keep carts locked unless in use, as per facility policy.
A medication aide did not perform hand hygiene or wear gloves before and after administering prescribed eye drops to a resident with multiple medical conditions, including sepsis and glaucoma. This lapse was observed by surveyors, and the aide later acknowledged the failure to follow infection control procedures, which are required by facility policy and staff training.
The facility failed to assess and obtain informed consent for bed rail use for three residents, leading to potential risks of entrapment and injury. Observations showed residents with side rails up, but records lacked documentation of care plans, physician orders, and risk assessments. Interviews revealed that bed rails were used as enablers without proper consent or assessment, contrary to facility policy.
The facility failed to notify residents of a change in their attending physician after terminating the Medical Director's agreement. This affected several residents, who were not informed about the change, leading to a lack of choice in their medical care. The administration admitted the oversight, but there was no evidence of proper notification being distributed.
A resident's medications were left unsecured on a medication cart, and a loose pill was improperly disposed of in a trash can. The facility's policies require medications to be locked or attended by staff and disposed of in a sharps container. Staff interviews confirmed these expectations, but additional policies were not provided during the survey.
A resident was found with a bleeding head wound less than 24 hours after admission, but the facility failed to report the incident to the state agency within the required 24-hour timeframe. The delay occurred because the administrator waited for corporate approval before reporting.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During an initial tour of the kitchen, surveyors observed a stainless-steel steam table pan containing lettuce with a sheet of clear plastic wrap loosely covering it and falling into the lettuce, leaving the contents exposed to open air. An additional clear bag of lettuce was observed wrapped in plastic wrap with no pull date or use-by date. A large frozen ham was observed thawing on the bottom wire shelf without being placed in a drip-proof container and without a pull date for defrosting. The bottom of the refrigerator also contained a tray with a white milky spilled substance that covered part of the tray and the bottom of the refrigerator. In the dry storage room, surveyors observed a shelf of bread containing a clear bag of hamburger buns with a baseball-size hole that exposed the bread to open air. Four dry storage bins with blue lids were also observed; one contained sugar with the plastic scoop left buried inside the sugar, and the bins were soiled on top with white powder residue. The report also noted soiled interior surfaces of the reach-in refrigerator. These observations were made during the kitchen sanitation review and were documented as failures to maintain food storage in a manner that prevented contamination and to maintain a sanitary environment. During interviews, the CK A, DM, and ADM each stated that stored foods were expected to be labeled and dated, sealed or covered to prevent contamination, and kept in clean kitchen and storage areas. CK A stated that items without a pulled date or use-by date could be unknown in age and could have gone bad. The DM stated that lettuce should have been completely sealed, bread should have been tied or closed, scoops should not be left in dry storage bins, and kitchen areas including refrigerators and bins should be cleaned after every meal service. The ADM stated that items in the refrigerator should be labeled and dated, salad or lettuce mix should be covered and have a use-by date, dry storage scoops should be stored separately, bread should be sealed, and the kitchen should be cleaned daily and as needed after each meal.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure residents were informed orally of their rights and provided ongoing communication about those rights during their stay. Record review showed resident council minutes did not document resident rights being reviewed or discussed at meetings dated 05/22/2025, 07/16/2025, 08/19/2025, 09/16/2025, 12/08/2025, 01/08/2026, 02/12/2026, 03/11/2026, or 04/08/2026, and the October and November 2025 minutes were not included in the records. A bulletin board observation on 05/12/2026 at 7:33 AM showed the resident rights posting on the wall. During confidential interviews, 10 residents stated staff had not discussed or reviewed their rights with them, and 7 of those residents said they were unsure which rights they had as residents of the facility. The AD stated on 05/14/2026 at 11:20 AM that she was not aware she should have been reviewing and explaining residents' rights until that morning and was unaware of the Ombudsman position or the facility Ombudsman. The SW stated she reviewed resident rights with residents and family members when grievances could not be resolved and assumed the AD reviewed resident rights in Resident Council meetings. The ADM stated he trained all staff on resident rights and expected the AD to review resident rights with residents and provide ongoing information on the Ombudsman.
Insufficient Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities that supported residents’ choices and met their physical, mental, and psychosocial needs for 3 of 17 residents reviewed. The deficiency involved Resident #19, Resident #51, and Resident #61, whose records showed activity care plan focus areas, but whose interviews reflected limited access to meaningful activities and a heavy reliance on BINGO as the primary activity offered. Resident #19 had diagnoses including major depressive disorder, psychotic disorder with hallucinations, and generalized weakness, and was cognitively intact with a BIMS score of 13. Her care plan included encouragement to participate in activities, socialization, and activities suited to her abilities, but she stated she only participated in BINGO because there were no other activities, the Activity Director did not tell residents what was going on, and residents were not invited to activities. She said the Mother’s Day event never happened, residents did not know about the Cinco de Mayo event because the calendar was not posted in time, and the resident council meeting did not occur. She also stated the lack of activities made her feel bad, bored, and left out. Staff interviews reflected that BINGO was offered daily except Sunday, that there were small activities such as coloring, and that bedbound residents had little to do. Resident #51 had Parkinson’s disease, dysphagia, and generalized weakness, with a BIMS score of 10 indicating moderate cognitive impairment. His care plan stated he was dependent on staff for activities and needed cognitive stimulation and social interaction related to mobility. He stated he had lived at the facility for almost 2 years, joined activities, but there were not enough activities, and he wanted something different besides BINGO. Resident #61 had end stage renal disease, legal blindness, diabetic retinopathy, and generalized muscle weakness, with a BIMS score of 15 and intact cognition. His care plan called for activities that met his physical and mental abilities and for staff to invite and encourage his preferences, but he stated the facility mostly offered BINGO and he did not attend because he was blind and unable to participate; he also stated a previous social worker had ordered blind-friendly activity materials.
Unlocked Medication Carts Observed Unattended
Penalty
Summary
The facility failed to ensure that drugs were stored in locked compartments and that only authorized persons had access to medication carts for 3 of 9 carts reviewed, including MC #1, MC #2, and MC #3. During the initial walk-through on 05/12/2026, the ADON left MC #1 and MC #2 unlocked and unattended at 5:54 a.m., and RN H left MC #3 unlocked and unattended at 6:01 a.m. The carts were observed unsecured and accessible during these observations. During interviews, the ADON said she had been trained on medication storage and stated the carts were supposed to always be locked, but she left the cart unlocked because she got distracted. RN H said she had been trained on resident rights and stated the cart should be locked any time staff walked away from it, but she forgot to lock the carts because she had a lot going on at one time. The DON and ADM both stated that medication carts should always be locked when not in use and that nurses were responsible for locking them. Record review of the facility’s Medication Labeling and Storage Policy dated 02/2023 stated that medications and biologicals are stored in locked compartments and that compartments containing medications and biologicals are locked when not in use.
Antibiotic Stewardship Tracking and Surveillance Deficiencies
Penalty
Summary
The facility failed to establish and follow an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use for three residents reviewed. The facility’s Infection Control and Antibiotic Review tracker did not include all information required by the facility’s antibiotic stewardship policy, including the resident medical record number, date symptoms appeared, pathogen identified, site of infection, date of culture, outcome, and adverse events. The DON and ADON both stated the tracker was not compliant with the policy. For one resident, the record reflected an order for ertapenem for metabolic encephalopathy, but no infection screening evaluation was completed on or around the start of the antibiotic. The resident’s care plan also did not include a care plan related to metabolic encephalopathy or the antibiotic treatment. For another resident, the record reflected cefepime for a scalp infection, and an infection screening evaluation was completed earlier in the month showing McGeer’s Criteria met for cellulitis/soft tissue or wound infection, but no other infection screening evaluations were completed for that month. For the third resident, the record reflected orders for cefazolin for sepsis and clindamycin for pneumonia, and an infection screening evaluation was completed for suspected lower respiratory tract infection with a recent chest x-ray showing new infiltrates consistent with pneumonia, but no other infection screening evaluations were completed for that month. During interviews, the DON stated she was responsible for monitoring antibiotic stewardship and that if an infection did not meet criteria she would contact the provider to discuss antibiotic use. She stated the infection surveillance evaluation for the resident with ertapenem should have been in the assessments and that if it was not there, the charge nurse or ADON should have completed it. The ADON stated she was responsible for the antibiotic stewardship program, that she reviewed antibiotic orders and entered information on the tracker, and that the tracker provided was not compliant with the facility policy. The ADM also stated the tracker did not meet the facility policy requirements and acknowledged that inappropriate antibiotic use could lead to multidrug resistant organisms and other infections.
Unclean Resident Wheelchairs
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for 6 of 8 confidential residents reviewed for homelike environment because resident wheelchairs were not kept clean and free from dirt and debris. During a confidential interview, one resident stated the wheelchair locks do not work, the chairs are filthy, and staff never clean them. Seven additional residents stated their chairs had not been cleaned, and one resident reported having a toileting accident in the chair that was not cleaned afterward. On observation, 8 wheelchairs were reviewed and 6 were found unclean, with significant accumulation of dust, hair, and other debris on the frames, between the seat cushions, and on the wheels. In interviews, the ADM stated CNAs typically clean the wheelchairs and later stated night shift CNAs were assigned that responsibility, but also said staff had slacked in following the facility process. An LVN stated some wheelchairs were clean and some were not, and a hospitality aide stated she cleaned wheelchairs at night on certain units. The facility policy stated residents are to be provided a safe, clean, comfortable, and homelike environment, including a clean, sanitary, and orderly environment.
Failure to Preserve Resident Dignity and Privacy
Penalty
Summary
The facility failed to treat each resident with respect and dignity and to care for residents in a manner and environment that promotes quality of life for 2 of 25 residents reviewed. One deficiency involved Resident #29, a male with severe cognitive impairment, transient cerebral ischemic attack, non-Alzheimer's dementia, muscle weakness, and hypertension. His MDS assessment dated 03/17/2026 showed a BIMS score of 03. On 05/12/2026 and 05/13/2026, he was observed in bed wearing a hospital gown. On 05/13/2026 at 3:13 PM, he was observed in bed with feces on his gown, and the surveyor notified staff. The DON then went to the room with another nursing staff member to assist the resident with being changed. On 05/14/2026, he was again observed in bed wearing a hospital-type gown, and when asked if he wanted to put on clothes, he responded yes. His closet contained clean clothes. Interviews and record review showed staff did not consistently assist Resident #29 with dressing in regular clothing. The family member stated the resident was not getting out of bed regularly and that staff told her they did not place him in his wheelchair because he rolled into other residents' rooms and they did not have enough staff to keep up with him. LVN B stated CNAs were responsible for dressing him and that he required assistance from two to three staff members. CNA D stated the resident required assistance from two to three staff members for transfers and changes and said it was acceptable for him to remain in a gown as long as he was covered. CNA E stated there was no particular reason he was not assisted out of bed, but staff often kept him in bed because he entered other residents' rooms and because staffing was limited. She also stated it was easier to leave him in a gown when his shirts were dirty. The DON stated it was not acceptable for a resident to remain in a gown every day and that keeping him in bed to prevent him from entering other residents' rooms was not an acceptable reason. A second deficiency involved Resident #63, a female with type 2 diabetes mellitus, muscle weakness, difficulty walking, lack of coordination, cognitive communication deficit, hyperlipidemia, and hypertension. Her quarterly MDS showed a BIMS score of 4, indicating severe cognitive impairment. On 05/12/2026 at 7:47 AM, CNA D was observed entering Resident #63's room on the 300-hall without knocking first. During interviews, the DON, CNA D, and the ADM all stated staff were expected to knock before entering residents' rooms and wait for a response. CNA D stated she did not knock because she was moving fast sometimes. Resident #63 stated staff never knocked before entering and that she wanted staff to knock all the time because she felt violated when they did not.
Public Survey Binder Contained Resident PHI
Penalty
Summary
The facility failed to ensure the resident's right to personal privacy and confidentiality of personal and medical records for 2 of 8 residents reviewed. During observation and record review, the public survey binder in the foyer contained a resident identifier sheet listing resident names and numbered identifiers, along with the corresponding survey/investigation that included protected health information such as medical diagnoses. The binder was left accessible in a public area of the facility. Resident #63 was a [AGE] year old female admitted with dementia, diabetes mellitus, and hypertension, and her quarterly MDS reflected a BIMS score of 04, indicating severe cognitive impairment. Resident #65 was admitted and readmitted with Ogilvie syndrome and hemiplegia/hemiparesis following a cerebral infarction, and his annual MDS reflected a BIMS score of 14, indicating cognitive intactness. The DON stated the survey binder should not have residents' names inside and that confidential information left where the public could review it could lead to legal issues. The ADM stated he was unaware the confidential resident identifier form had been left in the survey binder and acknowledged that accessible confidential information could affect residents' rights to confidentiality.
PASRR Review Not Updated for New Mental Health Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the PASRR program for one resident who developed a new mental health diagnosis during the stay. Resident #38 was admitted on 06/14/2024 with diagnoses including atherosclerotic heart disease, generalized anxiety disorder, unspecified psychosis, and later major depressive disorder with an onset date of 03/06/2025. The resident’s MDS reflected a BIMS score of 11, indicating moderate cognitive impairment. Record review showed the resident’s only PASRR Level I, dated 06/13/2024, indicated no mental illness. The resident also had an older PASRR Level II dated 10/22/2015 that reflected a mood disorder. The facility did not complete a new Form 1012 to update the PASRR Level I after the resident received the new diagnosis of major depressive disorder, and the resident was not referred to the appropriate state-designated mental health authority for review when the diagnosis was identified. During interviews, the MDS RN and MDS LVN stated the outdated PASRR Level II had been missed and that the new mental health diagnosis had not been recognized for PASRR review. The MDS RN stated she completed Form 1012 and submitted it after the issue was identified. The DON stated the MDS nurses were responsible for PASRR referrals and said she was new to the role and unsure of the referral process for residents who acquired a new mental health diagnosis during their stay. The facility policy stated that when a diagnosis changes, the social worker or designee will complete and submit Form 1012 or a new PL1.
Incorrect PASRR Level I Entry for Resident with Mental Health Diagnosis
Penalty
Summary
PASRR screening for mental disorders or intellectual disabilities was not completed correctly for one resident. Resident #7 was a male admitted to the facility with diagnoses including stroke, anxiety disorder, and depression, and his BIMS score was 05, indicating significantly impaired cognitive skills. A PASRR Level I screening completed by the referring facility’s SW reflected that the resident had a mental illness, but the facility’s MDS RN entered a different PASRR Level I into the SimpleLTC portal that did not indicate a mental illness. During interview, the MDS Coordinator stated the resident had a negative PASRR Level I that was not correct based on the resident’s diagnosis and that she missed the diagnosis and did not submit a new PASRR Level I screening. The DON stated the MDS nurses were responsible for PASRR referrals when a resident was identified with a mental health diagnosis. The MDS RN later stated the first PASRR Level I from the referring facility was correct if the resident had a mental health diagnosis, and that it was her fault the diagnosis was not included on the copy entered into SimpleLTC. The facility policy stated that when a PL1 was filled out incorrectly, the MDS Coordinator, SW, or designee would contact the referring facility to correct it, or submit a form 1012 or new PL1 if needed.
Medication Left With Resident Without Self-Administration Assessment
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #23 by leaving medication with the resident when no self-administration assessment had been completed. Resident #23 was a male admitted to the facility with diagnoses including seizures, difficulty walking, anxiety, major depressive disorder, headaches, cancer, and hypertension. His admission MDS showed a BIMS score of 13, indicating intact cognitive response, and his MDS also indicated he did not have swallowing issues with medications. His care plan identified him as being at risk for falls related to unsteady gait, history of falls, muscle weakness, cognitive impairment, medication side effects, poor vision, or incontinence, and it did not state that he could self-administer medications. Record review showed that Resident #23 did not have a self-administration assessment completed. During observation of his room, a medication cup with a white liquid, another medication cup with a green gel capsule, and a prescription nasal spray were found in the room. When interviewed, Resident #23 said staff did not always leave his medication with him, that the facility told him he could not self-administer his medication, and that the medication left for him was supposed to be taken right after breakfast. The DON and ADM both stated that staff were not to leave medication with a resident and were responsible for ensuring the resident took it, but neither knew why medication had been left with Resident #23.
Hand Hygiene Not Performed During Meal Tray Pass
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in the dining room. During breakfast meal service observation, CNA D and CNA E were observed passing meal trays to residents without washing or sanitizing their hands between trays. The report states this occurred in 1 of 1 dining rooms reviewed for infection control. Interviews confirmed that both CNAs had been trained on hand hygiene and understood that staff passing meal trays were expected to sanitize their hands between each tray, and wash with soap and water if hands were physically dirty. The DON and ADM both stated that staff assisting with tray pass were expected to perform hand hygiene and that the nurse or department heads monitored compliance through observation. CNA E stated she did not wash or sanitize her hands because she was moving fast. CNA D later stated she got sanitizer from the nurse to sanitize her hands, but the observation documented that she did not wash or sanitize her hands during the tray pass. The facility's Handwashing/Hand Hygiene Policy dated 01/2025 stated hand hygiene is the primary means to prevent the spread of healthcare-associated infections and that all personnel are expected to adhere to hand hygiene policies and practices.
Failure to Provide Written Grievance Decisions and Complete Investigations
Penalty
Summary
The facility failed to honor residents’ grievance rights by not ensuring prompt resolution and written notification of grievance outcomes for all four confidential residents reviewed. Review of the March 2026 grievance log showed 17 grievances, with the “Date of Written Decision” column left blank for every entry. The log also indicated that 10 of the 17 grievances lacked completion of the “Findings of Investigation” section, leaving the nature and results of the investigations undocumented on the forms. Interviews with key staff revealed a lack of training, unclear responsibility, and inconsistent documentation related to the grievance process. The ADON reported signing 12 of the 17 March grievances but stated she had not been trained on how to complete a grievance or conduct an investigation. She described that when a grievance related to nursing was received, the SSD would pass it to her or the DON, and that in-services and re-education were sometimes provided to staff, including 1:1 sessions, but there was no record of these educational efforts. She also stated she was unsure whether residents were receiving written decisions regarding their grievances. The SSD stated she was responsible for receiving, reviewing, and routing grievances to the appropriate department, and that the investigating department head was responsible for completing the grievance form, including investigation, outcome, and notification. She indicated she did not verify that the forms were completed correctly, that investigations were thorough, or that the person filing the grievance was notified, and she was unsure if written communication was provided to residents. The DON acknowledged she had not recently read the grievance policy and stated that department heads were responsible for completing investigations and notifying the complainant verbally, with no written responses being provided. The ADM, after reviewing the grievance policy and the March grievances, stated the policy was not being followed, noted blank sections on the grievance forms, and confirmed that written follow-up was not being provided to persons filing grievances, despite the policy requiring written responses and written summaries of investigations.
Failure to Ensure Availability and Administration of Ordered Clonidine Patch
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident had prescribed clonidine 0.3 mg/24 hr transdermal patches available and administered as ordered for essential hypertension. The resident was an older male with chronic kidney disease, essential hypertension, and atrial fibrillation, with a BIMS score indicating moderate cognitive impairment. His physician’s order, in place since January, directed application of one clonidine patch weekly on Saturdays. Review of the March MAR showed the resident was scheduled to receive the clonidine patch on four specific dates in March, but on each of those dates the MAR was marked with a “9,” which the MAR key defined as “medications not available,” instead of being signed as administered. Blood pressure records for March showed multiple readings throughout the month, including several elevated values. The resident reported to surveyors that the facility had recently changed pharmacies and that he had not received his blood pressure patch in over a week; he believed his blood pressure was elevated due to the missed patch and stated he did not have a patch on at the time of the interview. On observation of the unit 3 medication cart, surveyors found a box of clonidine 0.3 mg/24 hr patches labeled with the resident’s name, dated earlier in March, stored in the cart drawer. The DON later confirmed that the clonidine patches were in the unit 3 medication cart and that a skin assessment revealed no clonidine patch on the resident. Multiple staff interviews showed inconsistent awareness and follow-through regarding the missing medication. Medication aides stated that on several March dates they could not locate the clonidine patches at medication pass, marked the MAR with a “9,” and reported the issue to the charge nurse, but they were unsure whether the provider was notified each time or whether the medication was obtained from the pharmacy or emergency sources. One MA reported that the patches were later found in the nurses’ medication cart by an LVN, but she did not know if a patch was then applied. Several LVNs, including the charge nurse, stated they were not informed that the resident was out of clonidine patches, did not recall seeing the patches on the resident in March, or only became aware when the resident himself mentioned missing doses. The DON and ADM both stated they were not notified in March that the resident was out of clonidine patches, despite facility policy requiring safe, timely administration of medications, documentation and review of medication errors, and specific steps when medications are withheld or unavailable. The attending MD stated that missing clonidine patches for a month could cause the resident’s blood pressure to go up and that he had not been aware the medication had not been administered for March until after reviewing the record. He noted the resident’s blood pressure had been stable with occasional spikes and reported that the NP told him she had been notified by staff via text message about the missing medication. The facility’s written medication administration policy required that medications be administered as prescribed, that medication errors be documented and reviewed by QAPI, and that withheld or refused drugs be properly documented on the MAR. Despite these requirements, the resident’s clonidine patches were repeatedly documented as not available, remained misplaced in medication storage areas, and were not administered as ordered throughout March, leading to the cited deficiency in pharmaceutical services and medication administration.
Failure to Ensure Continuous Availability and Administration of Ordered Medications for Bowel Management
Penalty
Summary
Surveyors identified a failure to provide pharmaceutical services to meet the needs of a resident with Ogilvie syndrome, hemiplegia, and hemiparesis following a cerebral infarction. The resident was cognitively intact per a recent MDS and had a care plan focus on altered gastrointestinal status related to Ogilvie syndrome, with interventions including administering medications as ordered and monitoring side effects and effectiveness. Physician orders included bisacodyl rectal suppository 10 mg daily, lactobacillus two tablets by mouth daily, and polyethylene glycol 17 grams by mouth twice daily. Record review of the MAR showed that the resident did not receive lactobacillus for several consecutive days, did not receive polyethylene glycol on two days, and did not receive the ordered bisacodyl suppository on another day. Nursing progress notes documented that lactobacillus and polyethylene glycol were not administered because they were "on order" and that the bisacodyl suppository was not administered because it was "on reorder." The resident reported he was not getting his constipation medications consistently, stated he had run out of medications, and specifically noted he did not receive his suppository the previous night because staff told him they had run out. The resident’s responsible party reported that running out of the resident’s medications had been an ongoing problem and that he had missed multiple doses of lactobacillus, polyethylene glycol, and bisacodyl suppositories. A medication aide stated that the resident’s polyethylene glycol and probiotic were OTC medications and explained that OTC orders had to be submitted to the DON on a specific day of the week, with delivery occurring later, and that missing the weekly order meant waiting until the next week. The DON stated that OTCs were ordered a week ahead, that the facility had a contract with a local pharmacy that could supply OTCs, and that residents should not run out of medications, while acknowledging that the resident’s suppositories were not on the current week’s delivery list. Facility policies required accurate documentation and management of medication ordering, reordering, dispensing, and receipt through the EHR, and required medications to be administered in a safe and timely manner as prescribed.
Failure to Protect Resident From Financial Exploitation and Misappropriation of Property
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from exploitation and misappropriation of property by a CNA. The resident was an elderly female with dementia, diabetes mellitus, and hypertension, admitted with severe cognitive impairment as evidenced by a BIMS score of six and requiring partial to substantial assistance with all ADLs. Her care plan included interventions for impaired coping, such as encouraging rest and involving the resident or representative in determining next steps in care. Despite these needs and vulnerabilities, a CNA employed at the facility from late October to early December took the resident’s debit card at some point during her employment and used it for personal purchases. Law enforcement records reviewed by surveyors indicated that the CNA allegedly committed financial exploitation of the resident over a period of several months, resulting in at least 36 unauthorized charges on the resident’s debit card at liquor stores, grocery stores, and gas stations in multiple cities. The exact dollar amount was not yet determined because the matter remained under investigation. The CNA’s criminal history check, completed prior to hire, did not reveal any disqualifying offenses, and the facility’s records showed she was terminated for no call/no show, with no documented complaints about her performance while employed. The resident’s responsible party, who held power of attorney and received the debit card statements, discovered numerous charges that the resident could not have made and reported the matter directly to law enforcement without informing the facility, stating that police advised him not to notify the facility until further investigation. He also stated that the facility could not have known about the charges because the statements were sent only to him. The facility became aware of the alleged misappropriation when it received a subpoena from a detective requesting employment and termination records for the CNA. At the time of surveyor observation and interview, the resident did not voice complaints about staff treatment or missing personal items. The facility’s written policy stated that residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation, and that the facility would develop and implement policies and protocols to prevent and identify theft, exploitation, or misappropriation of resident property and conduct background checks to avoid employing individuals with findings related to abuse or misappropriation.
Failure to Provide Physician‑Ordered Nutritional Supplement at Lunch
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered nutritional supplement to a resident with identified nutritional concerns. The resident, who had diagnoses including Ogilvie syndrome, hemiplegia and hemiparesis following a cerebral infarction, had a comprehensive care plan focus area for "state of nourishment, less than body requirement" characterized by weight loss, inadequate intake, and decreased appetite, with interventions that included providing therapeutic supplements. The consolidated physician orders included an order for Ensure Clear with the noon/lunch meal once daily. Despite this, observation of the resident’s lunch tray showed no supplement present, and the resident reported that he was supposed to receive a supplement at lunch but that staff never gave it to him. The resident’s responsible party reported that the resident was not receiving his Ensure Clear as ordered and stated she had raised this concern at the last two care plan meetings, including one documented meeting where the care plan noted the need for clear Ensure. The social worker confirmed remembering the family’s report about the Ensure Clear and stated she believed she had passed the information on to nursing but did not follow up to ensure the supplement was provided. The DON stated she was not aware the resident was not receiving the ordered supplement and indicated there was no reason the supplement should not have been provided if ordered. The facility’s provided policy on administering medication stated that medications are to be administered in a safe and timely manner and as prescribed, but the resident’s ordered supplement was not administered with his lunch as required.
Failure to Change PICC Line Dressing per Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that parenteral fluids were administered in accordance with professional standards of practice and physician orders for one resident. The resident, a cognitively intact female with a history of Staphylococcal arthritis, sepsis, and methicillin-susceptible staphylococcus aureus infection, was admitted with orders for IV medication and a peripherally inserted central catheter (PICC) line. The care plan required weekly monitoring and dressing changes for the PICC line, and physician orders specified that the dressing should be changed every week and as needed. Upon review, it was found that the resident's PICC line dressing was dated eight days prior to the observation, despite documentation indicating that the dressing had been changed as scheduled. The dressing was signed off as changed by an LVN, but direct observation and the date on the dressing indicated that the change had not actually occurred. The DON confirmed that the dressing had not been changed as required and that it was inappropriate for staff to document completion of a task that was not performed. Facility policy also required dressing changes at least every seven days to prevent complications, but this was not followed in this instance.
Expired Medications Found on Medication Cart
Penalty
Summary
Expired medications were found on the station one medication cart during an observation, specifically one bottle of Melatonin 1mg and one bottle of Aspirin 325mg, both expired as of 08/2025. The facility's policy requires nursing staff to maintain medication storage areas and ensure that discontinued, outdated, or deteriorated medications are removed and handled according to pharmacy instructions. However, these expired medications remained on the cart past their expiration date. During interviews, an LVN stated that it was the medication aide's responsibility to ensure expired medications were not present, but since there was no medication aide at the time, the LVN acknowledged it was his responsibility while passing medications. The DON confirmed that both medications were expired and stated that staff are expected to check medications prior to administration to ensure they are not expired. The presence of expired medications on the cart indicated a failure to follow established procedures for medication management.
Failure to Maintain Clean and Orderly Medication Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure proper storage and cleanliness of drugs and biologicals on one of four medication carts reviewed. Specifically, a bottle of lactulose was found in the medication cart drawer with sticky residue on its sides, and the bottle was stuck to the bottom of the drawer. During interviews, an LVN acknowledged that the bottle was sticky and should have been cleaned, and the DON confirmed that staff are expected to check medications prior to administration to ensure proper storage. Review of the facility's medication labeling and storage policy indicated that medications should be stored in an orderly manner and that nursing staff are responsible for maintaining medication storage areas in a clean, safe, and sanitary condition. The observed failure to maintain cleanliness and orderliness in the medication cart drawer directly contradicted the facility's policy and could affect the integrity of medications stored within.
Failure to Follow Infection Control Protocols During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with a right lower extremity (RLE) stasis ulcer. During wound care, an LVN did not perform hand hygiene prior to the procedure, between glove changes, or after glove removal. The LVN also used gloves that had been stored in the pocket of his scrub pants, which were considered contaminated, and did not clean the overbed table before placing treatment supplies on it. These actions were observed during a wound care procedure, and the LVN acknowledged not following proper hand hygiene protocols and not ensuring a clean field for the supplies. The resident involved was an older female with diagnoses including alcohol dependence, major depression, and muscle wasting, and had a care plan for potential impaired skin integrity. Physician orders required specific wound care procedures, including cleansing and dressing changes. Facility policies on hand hygiene and wound care were reviewed, which outlined the need for handwashing before resident contact, between glove changes, and after glove removal, as well as the use of a clean field for supplies. The LVN and DON both confirmed that the observed practices did not align with facility policy.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated or were excessive in dose or duration, without adequate justification documented in the medical record.
Failure to Provide Timely, Quality Laboratory Services
Penalty
Summary
The facility failed to provide timely and quality laboratory services or tests to meet the needs of residents. This deficiency was identified through surveyor observation and review of facility practices, indicating that laboratory services were not delivered in a manner that met the required standards for resident care. No additional details regarding specific residents, their medical history, or the exact nature of the laboratory service delays or deficiencies are provided in the report.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was properly posted as required. On the day reviewed, there was no posted nurse staffing information in the building, including in the lobby, nurse's stations, or hallways. Although a binder containing staff schedules was present in the front lobby, it did not include the required details such as the total number and actual hours worked by registered nurses, licensed practical/vocational nurses, and certified nurse aides for each shift, nor did it include the facility name, current date, or resident census. Multiple locations were checked, and the required posting was not found. Interviews with facility staff revealed a lack of understanding and awareness regarding the nurse staffing posting requirements. The DON believed the schedule binder met the requirement and was unaware of the specific posting obligations or how to generate the necessary report from the electronic system. The RNC was aware of the requirement but did not realize the facility was not in compliance, and confirmed that the schedule binder did not meet the requirement. The facility's policy stated that nurse staffing information should be posted daily in a clear and accessible format, but this was not followed.
Failure to Account for and Secure Controlled Substance Due to Missed Shift Change Narcotic Count
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for a resident. Specifically, a resident with diagnoses including sleep apnea, morbid obesity, and epilepsy was prescribed Modafinil 100 mg tablets for sleepiness related to sleep apnea. The medication, consisting of 30 tablets, was delivered by the pharmacy and signed for by a nurse, but was never administered to the resident and was reported missing the following day. The investigation revealed that the medication was received by one nurse and handed over to another, who reported placing it in the narcotic storage box with the pharmacy's count sheet. However, during the subsequent shift change, the required narcotic count was not performed by the two nurses responsible. Both nurses admitted in interviews that they did not count the narcotics together at shift change, contrary to facility policy. One nurse stated she counted the narcotics alone, while the other left the cart keys in the narcotic book and did not participate in the count. The medication and the count sheet were subsequently discovered missing, and a search of all medication carts and rooms failed to locate the missing Modafinil. Facility records and interviews confirmed that the required procedures for controlled substance accountability were not followed. The facility's policy mandates that controlled substances be signed for by two nurses, immediately recorded, and stored securely, with counts performed at each shift change. The failure of the nurses to conduct the shift change narcotics count and properly secure the medication led to the loss of the resident's Modafinil, with no resolution as to its whereabouts.
Incomplete and Inaccurate Medical Record Documentation for Medications and Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for three residents reviewed for medication, treatment, and wound administration. Specifically, there were multiple instances where Medication Administration Records (MAR), Treatment Administration Records (TAR), Wound Administration Records (WAR), and Controlled Drug Records were either incomplete, missing, or inaccurately documented. For example, one resident's records for Norco, Pregabalin, tramadol, and wound cleanse treatments were not properly completed or accurately reflected in the MAR, TAR, WAR, and Controlled Drug Records. Another resident's MAR for Lorazepam was missing for two consecutive months, and the documented dose did not match the Controlled Drug Record. A third resident's MAR and Controlled Drug Record for Hydrocodone showed discrepancies in the number of doses administered. Interviews with nursing staff, the DON, and other facility personnel revealed a lack of consistent procedures and understanding regarding documentation requirements. Staff reported that medication errors were not always documented or reported as required, and there was confusion about the retention and submission of narcotic logs, especially for discontinued medications and discharged residents. The DON and other staff acknowledged that documentation practices were not being followed correctly, and some staff expressed concerns about the accuracy and completeness of the records. Additionally, there were reports of medical record entries being removed or edited, further contributing to the lack of reliable documentation. The affected residents had significant medical needs, including pain management for conditions such as cellulitis, end-stage renal disease, morbid obesity, schizoaffective disorder, and dementia. Despite active orders for medications and treatments, the facility's failure to document administration accurately and completely meant there was no reliable record to confirm that residents received their prescribed care. The absence of proper documentation also extended to the facility's narcotic record logs, which were found to be disorganized and inconsistent, with multiple forms in use and missing records for some residents.
Failure to Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, resulting in unmet needs related to their physical, mental, and psychosocial well-being. For one resident with a history of muscle wasting, atrophy, and cognitive communication deficit, the care plan did not address the resident's ongoing refusal to be weighed monthly, despite a physician's order and documentation of refusals in progress notes. The care plan only included general interventions for monitoring signs of malnutrition, without specific strategies for addressing the resident's refusal to be weighed or alternative monitoring methods. Another resident with a history of a left arm fracture, diabetes, malnutrition, and dysphagia had a care plan that failed to address repeated refusals to sit up at a 90-degree angle during meals, as ordered by the physician. Despite documentation of multiple refusals and the resident's report of dizziness when sitting upright, the care plan did not include individualized interventions to address these refusals or alternative approaches to ensure safe feeding and aspiration prevention. Staff interviews and documentation indicated that the resident was not consistently offered the opportunity to sit up for meals, and the care plan was not updated to reflect these ongoing issues. A third resident with dementia, diabetes, sleep apnea, and congestive heart failure used both a CPAP machine and a nebulizer, but the care plan did not address the use, maintenance, or monitoring of these devices. There were no physician orders for the CPAP or nebulizer in the electronic health record, and no documentation of cleaning schedules or replacement parts. Staff and family interviews confirmed the resident's long-term use of these devices and the lack of documentation or care planning related to their use. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timetables, but these requirements were not met for the residents involved.
Failure to Provide Scheduled Showers and Accurate Documentation for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living, specifically bathing, to three residents who were dependent on staff for personal hygiene. Documentation review revealed that scheduled showers for these residents were not consistently provided according to their care plans and facility protocols. Electronic health records (EHR) and paper shower sheets were either missing, incomplete, or contained inaccurate entries, with staff admitting to documenting tasks in the EHR to avoid system alerts, regardless of whether the care was actually provided. One resident, a female with multiple diagnoses including non-traumatic brain dysfunction, stroke, and partial paralysis, was physically dependent on staff for bathing and required a mechanical lift for transfers. Despite being scheduled for showers three times a week, there was no evidence in the shower binder or EHR that these showers were provided. Both the resident and her family member reported that she did not refuse showers and felt unclean due to missed bathing. Staff interviews confirmed that documentation practices were inconsistent and sometimes inaccurate, with reliance on paper records that were not always completed or retained. Two other residents, both male with significant medical conditions such as dementia, diabetes, and acute kidney failure, also did not receive scheduled showers. One had only a single, undated shower sheet in the binder, and the other had only two completed shower sheets for the review period, with no EHR documentation. Family members reported delays in bathing and related health issues, such as a yeast infection. Staff interviews indicated that short staffing on certain shifts contributed to missed showers, and that documentation was often incomplete or not performed in real time, contrary to facility policy.
Deficient Food Storage, Sanitation, and Temperature Monitoring in Nourishment Refrigerators
Penalty
Summary
The facility failed to maintain proper food storage, preparation, and distribution practices in accordance with professional standards for food service safety in several nourishment room refrigerators. Observations revealed that temperature logs were not maintained or visible on multiple refrigerators, including those in dining rooms and nourishment rooms. Inside the refrigerators, there were visible stains, a human hair, and expired food items such as sour cream packets and half & half cups. Additionally, a multi-use tub of homemade ice cream was found in a freezer without a resident's name or date. One nourishment refrigerator was found to have sugar ants crawling along the freezer door seal. Interviews with facility staff, including the ADON, DON, and ADM, revealed confusion and inconsistency regarding responsibility for maintaining temperature logs, cleaning, and disposing of expired foods. The facility's contract with the contracted kitchen indicated that the kitchen was responsible for stock and cleanliness, while the facility was responsible for temperature monitoring. Pest control invoices confirmed that pest control services had been provided in the months prior to the observations.
Failure to Complete Timely Admission MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive admission assessments (MDS) within the required 14-day timeframe for two residents. One resident, a male with diagnoses including acute kidney failure, altered mental status, osteoarthritis, low potassium, and hyperosmolality, was admitted but did not have a completed admission MDS assessment within 14 days; the assessment was still in progress and noted as overdue. Another male resident with diagnoses of unspecified dementia, diabetes, sleep apnea, hypertension, atrial fibrillation, congestive heart failure, and GERD also did not have a completed admission MDS assessment within the required timeframe, with the assessment similarly overdue. Interviews with MDS staff revealed that one MDS coordinator had been the only person in the role until recently and had become overwhelmed with new admissions, while the newly hired MDS coordinator was still orienting and attempting to catch up on the workload. The facility did not provide a policy on the timing for completion of MDS assessments when requested. The MDS job description and the Resident Assessment Instrument User's Manual both require that admission MDS assessments be completed within 14 days of admission.
Failure to Assist Resident with Eating Due to Improper Positioning
Penalty
Summary
A deficiency occurred when a female resident with dementia, chronic obstructive pulmonary disease, and anorexia was not provided with the necessary assistance to maintain her ability to perform activities of daily living, specifically eating. The resident's assessment indicated moderate cognitive impairment and a need for setup or clean-up assistance with eating, but no swallowing disorder or weight loss. Her care plan specified that staff assistance was required for eating. During observation, the resident was found in bed with her breakfast tray placed at chin level, unable to see or reach her food, and stated she needed to be repositioned to eat. Interviews with the DON and CNAs revealed uncertainty about who placed the tray and confirmed that the resident was not properly positioned to feed herself. The facility's policy requires that residents receive care and services to maintain their abilities in activities of daily living, including eating, based on their comprehensive assessment. The failure to monitor the resident's assistance needs and ensure proper positioning resulted in the resident being unable to access her meal.
Failure to Ensure Resident Consumed Medications as Ordered
Penalty
Summary
A deficiency occurred when a medication aide (MA) failed to ensure that a resident with multiple diagnoses, including non-traumatic brain dysfunction, stroke, seizure disorder, and dysphagia, consumed her nighttime medications as ordered. The resident, who had moderately impaired cognition, was observed to have spit out her medications and stored them in her bedside table after the MA left the room without confirming ingestion. Family members discovered the unconsumed pills and reported that the MA had rushed the resident, not allowing sufficient time for safe medication administration. The MA was also unaware of a standing physician order permitting medications to be crushed and mixed with food or jelly, which could have facilitated safer administration for the resident with swallowing difficulties. Interviews with facility staff revealed that neither the charge nurse nor the DON were aware of the resident's difficulty swallowing medications or the incident of spitting out pills. The MA stated she believed the resident had swallowed the medications and was not aware of the crush order. The facility's medication administration policy requires medications to be administered as ordered, including crushing medications when specified. The failure to ensure the resident consumed her medications as ordered and in accordance with professional standards led to the identified deficiency.
Lack of Physician Orders and Care Plan for Respiratory Devices
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required the use of a CPAP machine and a nebulizer. The resident, an elderly male with multiple diagnoses including dementia, diabetes, sleep apnea, congestive heart failure, and atrial fibrillation, was observed using a nebulizer mask and had both a CPAP machine and a nebulizer present in his room. Despite this, there were no physician's orders or care plan interventions documented for the use of either device in the resident's electronic health record (EHR). The care plan only addressed monitoring for labored breathing and use of accessory muscles, and the physician's orders included only PRN albuterol for shortness of breath or wheezing, but not the use of the CPAP or nebulizer machines themselves. Interviews with nursing staff confirmed that the resident used the CPAP nightly and the nebulizer as needed, but acknowledged that no orders for these devices were present in the EHR. Staff relied on their knowledge of the resident's routine rather than documented orders or care plans. Additionally, there was no documentation regarding the replacement of parts or cleaning schedules for either respiratory device. The resident's family member also confirmed the long-term use of the CPAP and nebulizer and noted that the facility was in the process of obtaining a new CPAP machine for the resident.
Failure to Ensure Timely Availability of Prescribed Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring the availability of prescribed medications, specifically Thiamine and Ergocalciferol. The resident, who had diagnoses including sepsis, anxiety, myasthenia gravis, and mild protein calorie malnutrition, was admitted with a care plan that included medication supplements to maintain nutritional status. Record review showed that the resident had active orders for Thiamine and Ergocalciferol, but the Medication Administration Record indicated these medications were not administered because they were on order and not available at the facility. During medication pass, the medication aide prepared the resident's medications except for the unavailable Thiamine and Ergocalciferol, documenting their absence. The aide reported the missing medications to the charge nurse but was unsure why they had not arrived. Interviews with staff revealed inconsistent communication regarding the unavailability of medications, with the charge nurse stating she was not informed and the DON outlining procedures that were not followed. The facility did not provide a policy on medication availability during the survey.
Medication Error Rate Exceeds Threshold Due to Unavailable Medications
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, resulting in a medication error rate of 7.69% based on 2 out of 26 observed opportunities. This deficiency involved a resident with multiple diagnoses, including sepsis, anxiety, myasthenia gravis, and mild protein calorie malnutrition, who did not receive ordered doses of Thiamine and Ergocalciferol because the medications were not available for administration. The resident's care plan included medication supplements to maintain adequate nutritional status, and the medication administration record confirmed the missed doses, noting the medications were on order. During medication pass observation, the medication aide prepared all available medications but omitted the unavailable ones, documenting them as on order. The aide reported the missing medications to the charge nurse, but the nurse later stated she was not informed about the unavailability. The facility's policy required staff to administer medications as ordered and to report unavailable medications to nursing leadership, but this process was not followed, resulting in the resident not receiving prescribed medications as scheduled.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication aide (MA) left a medication cart unlocked and unattended in the hallway outside a resident's room. Over-the-counter medications, including Oscal (a calcium supplement) and a Vitamin D supplement, were left out on top of the cart while the MA administered medications inside the room. This allowed the medications and biologicals to be accessible to other staff, residents, or visitors during the period the cart was unattended. The MA acknowledged in an interview that the cart should never be left unlocked or unattended and that medications should not be left out on top of the cart when unattended. The Director of Nursing (DON) confirmed that all staff are expected to keep the medication cart locked unless it is actively being used, and that staff receive regular reminders and annual competency checks regarding medication pass procedures. The facility's policy requires all medications to be stored securely in accordance with professional standards. The failure to lock the medication cart and secure medications was observed and confirmed through staff interviews and policy review.
Failure to Follow Infection Control Protocol During Medication Administration
Penalty
Summary
A medication aide failed to follow proper infection prevention and control procedures during the administration of eye drops to a resident. Specifically, the aide did not perform hand hygiene or don gloves before administering Timolol Maleate Ophthalmic Solution to the resident, nor did she wash her hands after the procedure. This was directly observed by surveyors during a medication pass. The aide later acknowledged in an interview that she should have washed her hands and worn gloves, attributing her lapse to nervousness and recognizing that not doing so could spread germs and infections. The resident involved had a history of sepsis, anxiety, myasthenia gravis, and glaucoma, and was noted to have severely impaired cognition. Facility records and policies reviewed by surveyors confirmed that staff are required to perform hand hygiene and use personal protective equipment before resident care procedures, including medication administration. The Director of Nursing confirmed that all staff had been educated on these requirements and that hand hygiene is part of annual competency checks.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to use appropriate alternatives before installing bed rails for three residents, and did not assess the residents for the risk of entrapment, review the risks and benefits with them or their representatives, or obtain informed consent prior to installation. This deficiency was identified during observations, interviews, and record reviews. The residents involved had various medical conditions, including polyosteoarthritis, chronic heart failure, and cerebral infarction, which could potentially increase their vulnerability to the risks associated with bed rail use. For Resident #1, there was no mention of bed rails in the care plan, no physician orders for their use, and no informed consent or risk assessment on file. An observation revealed that the resident was asleep with side rails in the up position. Similarly, Resident #2's records showed no care plan mention, physician orders, or informed consent for bed rails, and the resident expressed that she did not consent to their use. She also reported a past incident involving the side rails that made her nervous about sleeping in her bed. Resident #3's records also lacked documentation of bed rail use, including care plan mention, physician orders, informed consent, and risk assessment, yet observations showed the resident asleep with side rails up. Interviews with facility staff, including the VPCO, DON, and ADM, revealed that the bed rails were already on the beds when the facility was acquired and were not removed because they were used as enablers. The staff acknowledged the lack of assessments, orders, and consents, and recognized the potential risks of entrapment and injury associated with the use of bed rails without proper documentation and consent. The facility's policy emphasized the need for a person-centered approach, assessment of alternatives, and informed consent, none of which were followed in these cases.
Failure to Notify Residents of Physician Change
Penalty
Summary
The facility failed to honor the residents' right to choose their attending physician, affecting five residents. This issue arose after the facility terminated the agreement with their Medical Director and changed the attending physician without notifying the residents or their representatives. The change was effective on July 4, 2024, and the lack of communication regarding this change was evident in the interviews and record reviews conducted during the survey. Resident #1, a female with intact cognition, was not informed about the change in her primary physician. She noticed the change when a new doctor visited her, but she was not officially notified. Similarly, Resident #2's responsible party was not informed about the change in the medical director, although they were notified about the facility's change in ownership. Resident #3's responsible party also did not receive any notification about the change in the medical director or the primary physician. The facility's administration acknowledged the oversight in communication. The new administrator and other staff members, including the Director of Operations and the Director of Nursing, admitted that residents and their responsible parties should have been notified 30 days in advance of the change. However, there was no evidence that such notifications were distributed, leading to confusion and a lack of choice for the residents regarding their attending physicians.
Medication Storage and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure that medications for a resident were stored securely and properly, as required by regulations. During an observation, a medication aide was seen leaving a box of Mucinex tablets and a Baclofen tablet unsecured on top of a medication cart while she went to retrieve an additional Baclofen tablet from the medication room. This lapse in protocol left the medications unattended for approximately 4-5 minutes, although no residents were observed in the hallway during this time. The medication aide acknowledged that leaving medications unattended was against the facility's policy. Additionally, the facility did not properly dispose of medications, as evidenced by a loose Docusate sodium tablet found in a trash can in the private dining room. The Director of Nursing (DON) confirmed that medications should be disposed of in a sharps container and not in the trash. The DON also stated that leaving medications unsecured or improperly disposing of them could lead to serious consequences, such as a resident taking medication that was not theirs. Interviews with staff, including the DON and the Administrator, revealed that the facility's policy required medications to be locked in a medication cart or attended by staff. The facility's Preparation for Medication Administration policy outlined the need for lockable medication carts and proper disposal methods. However, additional policies regarding secure storage and disposal of medications were requested but not provided by the time of the survey exit.
Failure to Timely Report Injury of Unknown Source
Penalty
Summary
The facility failed to report an incident of injury of unknown sources to the state agency within 24 hours, as required by regulations. A male resident, who had been admitted less than 24 hours prior, was found on the floor with a bleeding head wound. The incident was documented by an RN, and the resident was sent to a local hospital for treatment. Despite the severity of the incident, the facility did not report it to the state agency within the mandated timeframe. The administrator was informed of the incident shortly after it occurred, but waited for corporate approval before reporting it to the state, which did not happen until the following day. Interviews with facility staff revealed that the corporate nurse was not made aware of the incident until the day after it occurred, leading to a delay in reporting. The facility's policy mandates that all incidents of abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, must be reported to the appropriate agencies within 24 hours. However, this policy was not followed in this case, resulting in a failure to comply with state and federal regulations.
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What surveyors actually found near you
We read the 92 citations issued within 25 miles in the last 12 months — including the 5 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bryan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crestview Retirement Community | 0.1 mi | ★★★★★ | 2 | 0 |
| Lampstand Nursing And Rehabilitation | 0.2 mi | ★★★★★ | 24 | 2 |
| Legacy Nursing And Rehabilitation | 0.5 mi | ★★★★★ | 6 | 0 |
| Five Points Nursing & Rehabilitation Of College St | 5.6 mi | ★★★★★ | 7 | 1 |
| Fortress Nursing And Rehabilitation | 6.4 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 August 2026) and official state health department websites.