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 Childress during CMS and state inspections, most recent first.
RN coverage was not maintained for at least 8 consecutive hours a day, 7 days a week on two days reviewed. Time sheets showed missed RN coverage despite the facility having three RNs employed, and the ADM acknowledged the missed coverage and stated an RN was needed to ensure quality of care and perform duties only an RN could do.
Unclean Environment With Flies and Maintenance Deficiencies: The facility failed to maintain a clean, comfortable, and homelike environment. Observations showed dried residue and cobwebs on Hall 2, residue and peeling paint in a Hall 3 bathroom, and dead insects in fluorescent light fixtures on multiple halls and in the dining area. Flies were present throughout the facility, interfered with two residents during lunch, and one resident had a fly become entangled in her hair. The MS said he was the only maintenance employee and had been absent due to illness, leaving multiple work orders outstanding, while the DON, HK Supervisor, HK G, and ADM identified housekeeping and maintenance responsibilities for cleaning and repairs.
The facility failed to provide a consistent activity program that matched resident preferences and the posted calendar. Residents reported that scheduled exercise, coloring, puzzles, games, and other activities were often not done, and several said there were few choices, no supplies left out, and little to do during the day. The AD stated he had not completed some scheduled activities, did not document room visits until recently, and did not see bedridden residents who could not talk to him.
Unpalatable and Undercooked Lunch Trays: Surveyors observed bland meatloaf, bland/tasteless mashed potatoes, and bland, not fully cooked hummingbird cake on the regular tray, with similar issues on the mechanical soft and alternative trays. Multiple residents reported the food did not taste good or was tasteless, and one resident said he had to buy snacks because of the food. The DM said she was the only dietary employee working due to call-ins, forgot to add pineapple to the cake, and was unsure whether the potatoes were seasoned or whether food tasting was consistently done before service.
Kitchen Food Storage and Hand Hygiene Failures: A kitchen observation found a bin of loose rice stored open to air with a scoop in the rice and two opened bags of rice placed on top, plus a box of taquitos left open to air in the freezer. An employee was also observed touching kitchen surfaces, utensils, and cake with gloved hands while plating dessert for a resident without washing hands or changing gloves between tasks.
A resident with moderate cognitive impairment and diagnoses including delirium and alcohol-induced persisting dementia was allowed to keep smokeless tobacco in his room, with the can observed on his bedside table during surveyor observations. The resident stated he was permitted to have it there, an LVN reported the issue, and the ADM admitted she allowed it without reading the facility policy. The resident’s chart did not contain a smokeless tobacco assessment, despite the facility policy requiring evaluation on admission and re-evaluation for tobacco users.
A resident who was always incontinent of bladder and bowel and needed partial/moderate help with toilet hygiene received incontinent care that was not performed correctly. During observation, a CNA wiped part of the buttocks toward the vaginal area once and did not wipe the anus, despite staff stating they were trained to wipe front to back and the DON and ADM expecting proper perineal care to be completed.
Unlocked Medication Cart Left Unattended: Med Cart A was observed unlocked and unattended by the nursing station, with no staff within eyesight and two residents nearby. MA A stated she forgot to lock the cart after walking away with her hands full, and the DON stated staff were expected to lock medication carts when unattended. The facility policy required medication carts and other compartments containing medications and biologicals to be locked when not in use.
A resident’s personal refrigerator contained uncovered, unlabeled, and undated food items, along with expired lunch meat and dried food, while staff could not identify who was responsible for monitoring or cleaning the refrigerator. The resident had moderate cognitive impairment and diagnoses including dementia and delirium, and interviews showed no department or staff member had been assigned responsibility for routine refrigerator checks despite a facility policy requiring labeled, properly stored food.
Failure to Perform Hand Hygiene During Incontinence Care: During observed incontinence care, a CNA removed and replaced gloves without performing hand hygiene between glove changes while caring for a resident with UTI, cellulitis, and total bladder and bowel incontinence. The resident required assistance with toilet hygiene, and staff interviews confirmed hand hygiene was expected between glove changes.
Food service safety standards were not followed in the kitchen pantry, freezer, and refrigerator. Surveyors found multiple dry goods and seasonings open to air, several containers of food with no labels or dates, and storage tubs that were grimy, sticky, or had residue on them, including cereal, flour-like and rice-like substances, sugar cubes, breadcrumbs, peanut butter, ice cream, and a cup of red liquid. Staff interviews showed shared responsibility for labeling, dating, and cleaning, and the DFDNS stated she was responsible for clean storage containers and that cleaning schedules were not rehung after a bulletin board fell.
A resident with severe cognitive impairment and multiple medical conditions was moved to a different room for contact isolation without prior verbal or written notice to the responsible party, despite facility policy requiring such notification. An LVN documented the room change but did not notify the family and later acknowledged it was her responsibility. The resident’s representative reported learning of the move only upon visiting and finding the resident in a different room. The DON and Interim ADM confirmed that nurses are trained and expected to notify residents or their representatives of room changes but could not explain why notification did not occur in this case.
A resident with Guillain-Barre syndrome and functional limitations had an annual MDS coded with no oral/dental issues in Section L, despite later observation of brown/discolored teeth and the resident’s report of needing a dentist due to mouth pain. The MDS nurse reported the resident would not allow an oral exam and acknowledged she should have coded "unable to examine" instead of indicating no issues, which would have triggered further care planning. The care plan contained no dental focus, and the facility, which follows CMS RAI guidelines and lacks its own MDS policy, later acknowledged the oral/dental status had been coded incorrectly.
A CNA provided catheter care to a resident with a urinary catheter and history of UTI without wearing a gown as required by Enhanced Barrier Precautions (EBP), despite posted instructions and available PPE. The CNA acknowledged the oversight, and interviews with the DON and ADON confirmed that both gloves and gowns are expected for such care activities to prevent cross-contamination.
A resident's medical information, including wound pictures, was shared with a surgeon through an LVN's personal email account, compromising confidentiality. The LVN believed privacy was maintained as the pictures lacked identifying marks, but the email's subject line included the resident's full name. The ADON and Administrator were unaware of this breach until it was noted in progress records, highlighting a failure to use secure facility email accounts for such communications.
A facility failed to communicate a surgeon's recommendation for a resident with a history of cellulitis and diabetes-related complications. The LVN did not inform the administration of the surgeon's advice to send the resident to the ER for possible surgical debridement, leading to a delay in care. The facility's policy required prompt notification of changes in a resident's condition, which was not followed, resulting in a deficiency in communication and adherence to professional standards.
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The kitchen staff were preparing food without food handler's cards or proper training, and the facility did not have a Dietary Manager since his dismissal. The Administrator confirmed the lack of food handler's cards and the dietitian's limited involvement.
The facility failed to store and distribute food in accordance with professional standards, with multiple instances of improperly labeled and dated food items in the refrigerator, freezer, and dry pantry. Staff interviews confirmed non-compliance with the facility's Food Storage Policy, posing a significant health risk to residents.
The facility failed to ensure a safe, clean, and comfortable environment for several residents, with observations revealing dirty floors, unsanitary bathrooms, and unclean hallways. Interviews with staff and residents confirmed that housekeeping was inadequate, leading to potential risks of falls and infections.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, on multiple occasions. The DON acknowledged the lack of coverage, attributing it to scheduling issues and an RN on maternity leave. Staff had mixed opinions on the impact of this deficiency, with some emphasizing the importance of RN presence for specific tasks and higher-level training.
The facility failed to ensure residents received meals and snacks at regular times, with significant delays in meal service and a lack of scheduled snacks. Staff and residents confirmed these issues, and the Administrator admitted there was no specific policy for meal and snack service.
The facility failed to conduct criminal history background checks for two employees, Cook C and DA E, prior to or at the time of hire, potentially placing residents at risk of abuse, neglect, exploitation, or misappropriation of their property. Staff interviews confirmed the oversight and acknowledged the associated risks.
A facility failed to include necessary oxygen therapy in a resident's baseline care plan, despite the resident's need for it due to a history of pneumonia. Observations and interviews revealed that the resident was receiving oxygen at 2-3 lpm, but this was not documented in the care plan or active orders, leading to potential gaps in care.
A resident with a history of respiratory issues was administered oxygen without a physician's order. Staff confirmed that oxygen should only be given based on physician's orders, but no such orders were found in the resident's records.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week during April 2026, with two days identified as lacking the required RN coverage. Record review showed the facility had three RNs employed in April 2026, and time sheets reviewed for April 1, 2026 through June 28, 2026 showed that 04/05/2026 and 04/26/2026 did not have RN coverage for at least 8 hours. During an interview on 7/8/26 at 1:40 pm, the ADM stated the facility had missed a couple of days of RN coverage and acknowledged that an RN was needed to ensure quality of care for residents and that there were things only an RN could do. The facility policy titled Staffing, Sufficient and Competent Staff, dated August 2022, stated the facility must use the services of an RN for at least 8 consecutive hours a day, 7 days a week.
Unclean Environment With Flies and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment. During observations, dried splashed residue was seen on the wall near the handrail at the entrance of Hall 2, and the handrail had a layer of dust with cobwebs extending from it to the wall. A bathroom on Hall 3 had residue at the base of the toilet, peeling paint above the sink, and exposed patch material that had not been painted. Fluorescent light fixtures in the dining area and on Halls 2, 3, and 5 contained accumulations of dead insects, with some insects appearing to still be alive. Flies were observed throughout the facility and interfered with residents during lunch service, causing two residents to swat at the insects while eating. An anonymous resident was also observed with a fly repeatedly circling and becoming entangled in her hair after she had recently had her hair styled. The MS stated he was the only maintenance employee and had been absent due to illness, and that multiple work orders remained outstanding, including painting and other maintenance repairs. The DON, HK Supervisor, HK G, and ADM all stated housekeeping was responsible for cleaning and maintenance was responsible for repairs, and the ADM stated she was ultimately responsible for ensuring staff fulfilled their duties.
Activity Program Not Followed and Resident Needs Not Met
Penalty
Summary
The facility failed to provide an ongoing activity program that supported residents’ choices and met their physical, mental, and psychosocial needs. The activity calendar listed scheduled group activities such as stretching, coloring, puzzles, games, and faith-based programming, but observations and interviews showed those activities were not occurring as scheduled. On 7/6/26, residents were observed sitting outside the front door and lined up in the lobby while no activities were in progress, and residents stated there had been no activities that day, including no exercise, coloring, or puzzle time. During interviews, multiple residents stated there were usually no activities, that the program was boring, and that they wanted more choices such as dominoes, cards, chess, singing, music, dancing, exercise, and table games. Several residents said the listed activities did not occur, that supplies such as dominoes and puzzles were not made available, and that they were not offered opportunities to participate. One resident stated he wanted to go to the exercise room but could not do so without staff, and another stated she would like to color but the activity did not occur. A group interview also reflected resident comments that there were very few activities and that they wanted more exercise-based activities. The activity director stated he had not done the scheduled morning exercises or coloring activity and said he had not been aware he needed to document room visits until recently. He stated that room visits sometimes consisted only of talking, listening to music, or watching videos on his phone, and that he did not see bedridden residents who could not talk to him. Observation on 7/7/26 showed the activity director sitting outside with residents for 10 minutes with no resident interaction and no game supplies present. Record review showed room visit paperwork for two residents documenting a puzzle and coloring activity, but both residents denied that those room visits or activities occurred.
Unpalatable and Undercooked Lunch Trays
Penalty
Summary
The facility failed to ensure food served at lunch was palatable and attractive for the regular, mechanical soft, and alternative diets. On 07/06/2026, surveyors observed the lunch test trays in the conference room and sampled the regular, mechanical soft, and alternative trays. The regular tray meatloaf and mashed potatoes were described as bland, with the mashed potatoes also noted as tasteless, and the hummingbird cake was bland and not fully cooked. The mechanical soft and alternative trays had fish with no issues, but the mashed potatoes were bland and the hummingbird cake was bland and not fully cooked. During interviews, multiple residents voiced concerns that the food did not taste good and was tasteless, and one resident stated he had to buy snacks to keep in his room because the food did not taste good. The DM apologized for the bland and undercooked cake and later stated she had been the only dietary employee working that day due to staff call-ins. She said the cake lacked flavor because she forgot to put pineapple in it, and the potatoes were instant potatoes that should have been seasoned, but she could not remember whether seasoning had been added because she was understaffed and trying to get the food out in a timely manner. The DM also stated she was unsure whether cooks consistently tasted food before serving it, and the policy required the director of food and nutrition services to perform routine meal rounds and observe meals for preference, portion sizes, temperature, flavor, and accuracy.
Kitchen Food Storage and Hand Hygiene Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an observation of the pantry, a large plastic storage bin contained loose dry rice with a scoop sitting in the rice, and two opened 25-pound bags of rice were placed on top of the loose rice; the lid to the rice bin was left open to air. During a later observation, one box of taquitos in the freezer was open to air. During a kitchen observation, [NAME] E was seen wearing gloves while touching various kitchen surfaces, picking up food pans and dishes, getting a Styrofoam cup for a resident, handling serving utensils, cutting cake into squares, and plating cake into bowls. She used her hand to steady the cake pieces while placing them into bowls and did not wash her hands or change her gloves between tasks. [NAME] E later stated she should have washed her hands and changed her gloves and should not have used her hands to put the cake in the bowls. The DM also observed her touching the cake with gloved hands and stated the rice bin should have been closed and the taquitos should have been closed to air.
Unsafe Tobacco Storage and Missing Tobacco Assessment
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision to prevent accidents for one resident. Resident #35, a [AGE]-year-old male admitted on [DATE], had diagnoses including delirium due to a known physiological condition, alcohol-induced persisting dementia, generalized anxiety disorder, and an acute gastric ulcer with hemorrhage. His quarterly MDS showed a BIMS score of 11, indicating moderate cognitive impairment. His care plan noted that he enjoyed using smokeless tobacco and included a goal to adhere to the facility’s tobacco policies, but the clinical file did not contain a smokeless tobacco assessment or evaluation. During observation, Resident #35 was lying in bed with a can of smokeless tobacco on his bedside table and stated he was allowed to keep it in his room. On another observation, the tobacco remained on the bedside table while the resident was out of the room. An LVN stated she had seen the tobacco in the room and reported it, but was told the ADM was allowing it. The ADM stated she allowed the resident to have smokeless tobacco in his room, admitted she had not read the facility policy, and acknowledged she was wrong. The DON also stated the resident did not have a smokeless tobacco assessment and said she had learned something new about implementing one. The facility’s Smoking Policy required residents who use tobacco to be evaluated on admission, re-evaluated quarterly and with significant change, and stated residents may not have or keep smoking articles except when under direct supervision.
Incontinent Care Performed Incorrectly
Penalty
Summary
The facility failed to ensure appropriate incontinent care for a resident who was always incontinent of bladder and bowel and required partial/moderate assistance with toilet hygiene. The resident had been admitted and readmitted with diagnoses including UTI, cellulitis, and need for assistance with personal care. The care plan identified bowel and bladder incontinence related to impaired mobility and included cleaning the peri-area with each incontinence episode. During an observation of incontinent care, CNA B washed hands, cleansed the resident's groin, turned the resident on her side, and changed gloves using ABHR between the glove change. CNA B wiped the left buttocks toward the vaginal area with one wipe, then wiped the left and right buttocks away from the vaginal area, and wiped the upper buttocks area in the middle away from the vaginal area but did not wipe the anus. CNA B stated she wiped toward the vaginal area once because she was at an odd angle. CNA B and CNA C stated they were trained to wipe the buttocks area from front to back, and the DON and ADM stated they expected staff to wipe away from the vaginal area and clean all areas of the buttocks.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure that Med Cart A was locked when unattended. During an observation on 07/06/26 at 11:45 AM, Med Cart A was seen by the nursing station between the 500 and 600 Hallways unlocked and unattended. No staff members were within eyesight of the cart, and two female residents were sitting in the common area within eyesight of the medication cart. During an interview on 07/06/26 at 11:50 AM, MA A stated she had been trained to lock her medication cart when she walked away from it, but she had her hands full and forgot to lock it. MA A stated she thought she was last trained in March 2026 regarding medication cart security. The DON stated she expected MA's or nurses to lock their carts when they walked away from them and said the pharmacist had reviewed medication storage in June 2026, though MA A was not working that day and missed the training. The facility policy stated that compartments containing medications and biologicals are locked when not in use and carts are not left unattended if open or otherwise potentially available to others.
Unmonitored Resident Refrigerator Contained Unlabeled and Expired Food
Penalty
Summary
The facility failed to maintain safe and sanitary storage of a resident’s food items in a personal refrigerator. During observation, the refrigerator in the resident’s room contained multiple perishable items, including uncovered, unlabeled, and undated red and purple substances, as well as a wrapped Taco Bell burrito that had become hardened and dried and packed ham lunch meat with an expiration date of 06/09/2026. The resident stated he did not know who was responsible for cleaning or monitoring the refrigerator and could not say how long the food had been there. Record review showed the resident was admitted with diagnoses including delirium due to a known physiological condition, alcohol-induced persisting dementia, generalized anxiety disorder, and acute gastric ulcer with hemorrhage. His quarterly MDS showed a BIMS score of 11, indicating moderate cognitive impairment, and his care plan included an intervention for good nutrition due to potential for pressure ulcers. Interviews with housekeeping, nursing, and the administrator showed no specific staff member or department had been assigned responsibility for routinely inspecting, cleaning, or monitoring personal refrigerators, and staff were unaware of a policy or procedure for addressing them. The facility policy stated food brought by family or visitors that is left with the resident to consume later is to be labeled and stored in a clearly distinguishable manner, with perishable foods stored in resealable containers with tightly fitted lids in a refrigerator and containers labeled.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Provide and implement an infection prevention and control program. During observation of incontinence care for Resident #33, a CNA washed her hands, put on clean gloves, and provided perineal care. After removing her gloves and washing her hands, she put on clean gloves again and grabbed the dirty brief under the resident with her right hand. She then stated she should not have done that, removed the right-hand glove, and replaced it with a clean glove without performing hand hygiene between the glove change. Another CNA assisted with placing a clean brief under the resident. Resident #33 was a female admitted and readmitted with diagnoses including UTI, cellulitis, and need for assistance with personal care. Her MDS indicated a BIMS score of 13, partial/moderate assistance for toilet hygiene, and that she was always incontinent of bladder and bowel. Her care plan addressed bowel and bladder incontinence related to impaired mobility and included cleaning the peri-area with each incontinence episode. Interviews with the CNAs and leadership confirmed staff were expected to perform hand hygiene between glove changes, and the DON stated the CNA should have removed both gloves, performed hand hygiene, and continued care. Record review also showed CNA B had completed handwashing competency and in-service training on handwashing.
Food Storage Containers and Open Foods Left Unlabeled, Undated, and Unclean
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During an observation of the pantry, surveyors found a bag of macaroni noodles open to air, a plastic storage container of cereal with greyish marks that were grimy and sticky to touch, and multiple lidded tubs containing dry goods with no label or date. These included a white flour-like substance with a scoop lying on top, a rice-like substance, and a tub containing a zipped bag with an open box of sugar cubes inside. An empty tub labeled sugar was also grimy and sticky to touch. The pantry observation also identified a wheeled plastic bin containing breadcrumbs half in and half out of a large bag with no label or date, and multiple seasoning containers left open to air, including freeze dried chives, paprika, garlic herb seasoning, rotisserie chicken seasoning, cloves, garlic bread sprinkle, celery seed, sage, basil, chili powder, cinnamon, and a cardboard container of seasoning. A plastic tub of peanut butter had brownish smears around the lid and sides. In the freezer, two small clear plastic bowls containing what appeared to be vanilla ice cream were open to air with no label or date. In the refrigerator, a small clear plastic cup full of red liquid was covered with plastic wrap but had no label or date. During interviews, kitchen staff stated that all kitchen staff were responsible for labeling and dating food and for keeping the pantry containers clean, while some staff stated cooks were responsible for cleaning the plastic storage containers when they became empty. The director of food and nutrition services stated she was responsible for ensuring the plastic storage containers in the pantry were clean and said she usually had daily, weekly, and monthly cleaning schedules posted, but the bulletin board had fallen and the schedules had not been rehung. Facility policies reviewed stated dry storage areas should be kept clean, canned and dry foods should be labeled with date of receipt, cleaning schedules should be posted and followed, and open package food should be stored in clean airtight containers, labeled, and dated.
Failure to Notify Responsible Party of Resident Room Change
Penalty
Summary
The facility failed to ensure a resident’s responsible party received notice of a room change prior to the move, as required by resident rights and facility policy. A female resident with hemiplegia, peripheral vascular disease, major depressive disorder, and severe cognitive impairment (BIMS score of 4) was moved to another room for contact isolation precautions. A progress note dated 12/11/25 by LVN A documented that the resident was moved to a different room for contact isolation and that the resident was aware, but there was no documentation that the resident’s responsible party was notified. The facility’s policy, revised April 2025, stated that a nurse will notify the resident’s representative when there is a need to change the resident’s room assignment. During interviews, LVN A stated she was the nurse who moved the resident in December 2025 and did not remember contacting the family about the room change. She reported that the DON had said she would contact the family but did not, and acknowledged it was ultimately her responsibility to contact the family. The resident’s responsible party stated she did not receive a call about the room change and only learned of it when family members visited and found the resident in a different room. The DON and Interim Administrator both stated that nurses were trained and expected to notify the resident or responsible party of room changes and could not explain why the family was not contacted prior to the move.
Inaccurate MDS Coding of Oral/Dental Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure an accurate MDS assessment for a resident’s oral/dental status. A male resident with Guillain-Barre syndrome, lack of coordination, and need for assistance with personal care was admitted and later readmitted to the facility. His annual MDS assessment documented a BIMS score of 12, indicating he was cognitively intact, and Section L (Oral/Dental Status) was coded as "none of the above were present." The resident’s comprehensive care plan did not contain a focus area for dental care. During an observation and interview, the surveyor noted the resident had brown/discolored teeth, and the resident reported it had been a while since he had seen a dentist and that he likely needed to be placed back on a list to see a dentist due to some mouth pain. In a phone interview, the MDS nurse stated she completed the annual MDS and that the resident told her he did not have any mouth pain and did not need anything, but he would not allow her to look in his mouth. The MDS nurse acknowledged she must have been in a hurry and should have coded Section L as "unable to examine," which, per her statement, would have triggered a care plan decision in Section V. Initially, the Interim Administrator stated he did not think the MDS nurse had marked the dental status incorrectly, explaining that he understood she did not see any issues and therefore marked no issues. After further discussion, the Interim Administrator stated he did think the MDS nurse had marked the dental status incorrectly and confirmed the facility did not have its own MDS policy and followed the CMS RAI guidelines. The RAI User’s Manual excerpt cited in the report specifies that "unable to examine" should be checked if the resident’s mouth cannot be examined.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow infection prevention and control protocols while providing catheter care to a male resident with a history of urinary tract infection and benign prostatic hyperplasia. During the observed care, the CNA did not don a gown as required by the facility's Enhanced Barrier Precautions (EBP) policy, despite a posted sign indicating the need for EBP and a PPE station present in the room. The CNA wore gloves but omitted the gown, completed the catheter care, and performed hand hygiene afterward. The CNA later acknowledged missing the sign and not using the gown, attributing the oversight to being accustomed to PPE stations outside the room and recent management changes. Interviews with facility staff, including the CNA, DON, and ADON, confirmed that the expectation is for staff to wear both gloves and gowns during high-contact care activities such as catheter care, in accordance with the facility's EBP policy. The CNA reported prior training on EBP but was uncertain about the current infection control officer due to recent staff turnover. The DON and ADON reiterated the importance of proper PPE use to prevent cross-contamination, and facility documentation confirmed that device care requires both gloves and gowns under EBP.
Resident's Medical Information Shared via Personal Email
Penalty
Summary
The facility failed to maintain the confidentiality of a resident's personal and medical records, specifically for a resident who was admitted with multiple diagnoses including cellulitis, type 2 diabetes with complications, and amputations. The resident's medical information, including pictures of a wound, was shared with a surgeon via a nurse's personal email account. This action was taken by an LVN who believed she was not violating privacy because the pictures did not have identifying marks, although the subject line of the email contained the resident's full name. The Assistant Director of Nursing (ADON) and the Administrator were unaware of the email being sent through a personal account until it was discovered in the progress notes. The ADON stated that it was not the LVN's responsibility to send such information, and it should have been handled by Administration personnel through secure facility email accounts. The Administrator and the Registered Nurse (RN) both acknowledged that using an unsecure personal email account could lead to unauthorized access to the resident's information, compromising their privacy and confidentiality.
Failure to Communicate Surgeon Recommendation for Resident's Wound Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and professional standards of practice for a resident with a history of cellulitis, type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, and other significant medical conditions. The resident was admitted for wound care management, and the facility was responsible for following the physician's orders for wound care and medication administration. However, there was a delay in communication regarding the surgeon's recommendation for the resident to be sent to the emergency room for possible surgical debridement. The deficiency occurred when LVN A did not inform the facility administration of the surgeon's recommendation in a timely manner. Although LVN A had communicated with the surgeon's office and sent pictures of the resident's wound, the response from the surgeon's office, which included the recommendation to send the resident to the ER, was not relayed to the administration. LVN A checked her personal email and found the surgeon's recommendation but did not share this information with the administration or other staff members, leading to a delay in the resident receiving the recommended care. Interviews with facility staff, including the MD, ADON, and ADM, revealed that they were unaware of the surgeon's recommendation. The facility's policy required prompt notification of changes in a resident's medical condition, but this was not followed. The failure to communicate the surgeon's recommendation could have resulted in missed care for the resident, as the administration was not informed of the need for an ER evaluation. The facility's inability to provide a quality of care policy further highlights the deficiency in communication and adherence to professional standards of practice.
Failure to Employ Qualified Dietary Manager and Staff
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. During an initial tour of the kitchen, it was revealed that the facility did not have a Dietary Manager since his dismissal on 4/1/24. The kitchen staff, including Cook D and DA I, were preparing food without food handler's cards or proper training. The Administrator confirmed that the facility was relying on dietary aides to prepare meals until a new Dietary Manager could be hired and that the facility did not have food handler's cards on file for the current kitchen staff. Additionally, the facility's dietitian worked only as a consultant and visited the facility once a month to review resident nutrition plans. Interviews with the kitchen staff revealed significant issues due to the lack of a qualified Dietary Manager. DA I and DA J both stated that they had not received any training on how to run the kitchen, and there was no guidance on job assignments, portion sizes, food temperatures, or tray readiness. The kitchen was described as disorganized, with no communication between staff working different shifts, and meals were being served late. The Administrator acknowledged the difficulty in hiring a Dietary Manager in a small community and stated that there was no corporate policy regarding the employment of a Dietary Manager, relying instead on state and federal regulations as guidelines.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to store and distribute food in accordance with professional standards for food service safety. During an initial tour of the kitchen, it was observed that there were no free-standing thermometers in the refrigerator, freezer, or dry pantry. The temperatures being checked and logged were taken from the manufacturer's thermometers on the outside of each appliance, and there was no thermometer or logbook for the dry pantry. This lack of proper temperature monitoring could lead to improper food storage conditions, increasing the risk of food-borne illnesses among residents. Further inspection of the refrigerator revealed multiple instances of improperly labeled and dated food items. These included various juices, milk, tea, and other food items that were open to air and lacked proper labeling and dating. Additionally, there were expired food items such as a package of ham lunch meat. Similar issues were found in the freezer and dry pantry, where numerous food items were not labeled or dated, and some were stored improperly, such as fresh produce in grocery store bags and bulk items in unmarked containers. Interviews with staff, including the Dietary Aide and the Administrator, confirmed that the facility's food storage practices were not in compliance with their own Food Storage Policy. The policy outlined specific procedures for maintaining food safety, including proper labeling, dating, and storage temperatures. The failure to adhere to these procedures could result in residents consuming expired or contaminated food, posing a significant health risk. The staff acknowledged the potential negative outcomes of these deficiencies, including the risk of residents becoming ill from improperly stored or expired food.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for several residents. Observations revealed that the floors in the rooms of multiple residents were dirty, with brown crumb-like substances, stains, and sticky spots. Specifically, Resident #5's room had brown crumbs and stains on the floor, Resident #35's room had dark brown smears on the walls and an overflowing trash can, and Resident #36's room had a large sticky spot on the floor. Additionally, Resident #42's room had a yellow-brown stain under the catheter bag, indicating a spill that had not been cleaned up. The facility also failed to maintain cleanliness in the shared bathroom of Resident #9 and Resident #18. The bathroom was observed to have feces in the toilet, on the toilet seat, and on a shower chair, along with a pot containing urine and toilet paper on the floor. Despite multiple observations over several days, the bathroom remained in an unsanitary condition with a foul odor. Interviews with staff revealed that housekeeping was responsible for cleaning, but the bathroom had been missed, leading to unsanitary conditions. Furthermore, the facility did not maintain cleanliness in hall 600, where a trail of clear liquid was observed running down the hall and later became sticky and dark brown. Residents in a council meeting expressed concerns about the cleanliness of bathrooms and floors, stating that housekeeping staff did not mop bathrooms and that floors were often sticky. Interviews with nursing staff confirmed that dirty or sticky floors could contribute to falls and the spread of infections, highlighting the facility's failure to provide a safe and clean environment for its residents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, the facility did not have RN coverage on one day in October 2023, two days in November 2023, and four days in December 2023. This deficiency was confirmed through a review of the facility's Payroll Based Journal Staffing Data Report for fiscal year quarter 1 of 2024 and interviews with the Director of Nursing (DON) and other staff members. The DON acknowledged the lack of RN coverage on the specified days, attributing it to the other RN being on maternity leave and her own recent employment at the facility. She admitted that there was no excuse for the lack of coverage and that it was her responsibility to create nursing schedules. Other staff members, including Licensed Vocational Nurses (LVNs) and an Assistant Director of Nursing (ADON), had mixed opinions on the impact of not having an RN present, with some stating that LVNs were capable of handling most situations, while others emphasized the importance of having an RN for specific tasks and higher-level training. The facility's policy, dated September 28, 2023, stated that the facility would utilize the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Despite this policy, the facility failed to meet the requirement on multiple occasions, potentially leaving residents and staff without adequate supervisory coverage for coordination of events such as emergency care and disasters. The deficiency was highlighted through interviews with various staff members, who provided differing perspectives on the necessity of having an RN on duty every day. The DON and some LVNs believed that the absence of an RN did not negatively impact resident care, while others pointed out the limitations of LVNs in performing certain tasks and the additional knowledge that RNs bring to resident care.
Failure to Provide Timely Meals and Snacks
Penalty
Summary
The facility failed to ensure residents received three meals daily at regular times comparable to normal mealtimes in the community and did not provide suitable, nourishing alternative meals and snacks for residents who wanted to eat at non-traditional times or outside of scheduled meal service times. Observations revealed that residents were left waiting for extended periods before being served their meals. For instance, on one occasion, the first resident tray was delivered 25 minutes after the posted mealtime, and the last resident was served almost an hour later. Additionally, residents reported not being offered snacks at regular intervals, with some stating they had to use their own money to purchase snacks from vending machines due to the facility's failure to provide them as scheduled. Interviews with staff and residents confirmed these observations. A Licensed Vocational Nurse (LVN) mentioned that meal service delays had worsened since the firing of the Dietary Manager. During a Resident Council Meeting, residents expressed dissatisfaction with the availability and frequency of snacks, stating they were not offered snacks on most days. The Director of Nursing (DON) and other staff members were unaware of the consistent failure to provide snacks, and the Administrator admitted there was no specific facility policy for the service of meals and snacks, relying instead on state and federal guidelines. This lack of adherence to scheduled meal and snack times could place residents at risk of diminished nutritional status and food dissatisfaction.
Failure to Conduct Timely Background Checks for New Hires
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property. Specifically, the facility did not complete criminal history background checks for two employees, Cook C and DA E, prior to or at the time of hire. Cook C was hired on 03/19/24, and DA E was hired on 03/12/24, but their background checks were only completed on 04/08/24. This lapse in procedure could place residents at risk of abuse, neglect, exploitation, or misappropriation of their property by staff members. Interviews with facility staff, including HR, RN K, DON, and ADON, confirmed the oversight and acknowledged the potential risks associated with not conducting background checks prior to hiring. HR admitted to discovering the missing background checks on 04/08/24 and running them that day. The staff emphasized that not performing these checks could result in hiring individuals with a history of criminal activity, which could jeopardize the safety and well-being of the residents.
Failure to Include Oxygen Therapy in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident that included necessary instructions for oxygen therapy. The resident, a [AGE] year-old female with a history of biliary tract disease, peritonitis, and wheezing, was admitted to the facility and required oxygen therapy. Despite this need, the baseline care plan completed for the resident did not mention oxygen therapy, and there were no active orders for it in her records. Observations confirmed that the resident was receiving oxygen at 2-3 liters per minute (lpm) on multiple occasions, and the resident herself confirmed that she had been on oxygen since having pneumonia the previous month. Interviews with various staff members, including LVNs, RNs, the ADON, and the DON, revealed that the responsibility for completing the baseline care plan was not clearly executed, leading to the omission of the resident's oxygen therapy needs. The facility's policy required a baseline care plan to be developed within 48 hours of admission to ensure that immediate care needs were met. However, the failure to include oxygen therapy in the baseline care plan for this resident could result in missed or incorrect care. Staff interviews indicated that an incomplete baseline care plan could negatively impact the care a resident receives. The ADON admitted to completing the baseline care plan but could not find any orders for oxygen therapy in the resident's electronic health record (EHR), suggesting a communication gap or oversight in documenting the resident's care needs.
Failure to Ensure Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care, including oxygen therapy, received such care consistent with professional standards of practice and the resident's care plan. Specifically, Resident #97, a [AGE] year-old female with a history of biliary tract disease, peritonitis, allergies, and wheezing, was administered oxygen without a physician's order. The resident's baseline care plan and active orders did not mention oxygen therapy, yet her oxygen saturation levels were recorded multiple times, indicating she was receiving oxygen at 2 or 3 liters per minute (lpm) since her admission. Observations and interviews with the resident and staff revealed that the resident had been receiving oxygen at 3 lpm because she felt that 2 lpm was insufficient. Multiple staff members, including Licensed Vocational Nurses (LVNs), a Registered Nurse (RN), the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that oxygen should only be administered based on physician's orders found in the Electronic Health Record (EHR). However, no such orders were found for Resident #97. The facility's policies on oxygen administration and medication orders also emphasized the necessity of a physician's order for oxygen therapy, which was not adhered to in this case.
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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 Childress
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Manor Ii | 24.1 mi | ★★★★★ | 2 | 0 |
| Memphis Convalescent Center | 28.6 mi | ★★★★★ | 4 | 0 |
| Wellington Care Center | 28.6 mi | ★★★★★ | 9 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.