Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Cowhorn Creek during CMS and state inspections, most recent first.
A resident with a history of stroke-related hemiplegia, atrial fibrillation, seizures, hypertension, and other conditions had 15 scheduled morning medications, including antihypertensives, an anticoagulant, an anticonvulsant, respiratory and GERD medications, urinary and bowel agents, vitamins, allergy medication, and artificial tears, ordered for a specific morning time. An LVN working PRN, unfamiliar with the medication cart, did not administer these medications within the facility’s one-hour window around the ordered time and instead gave them significantly later, without a documented administration time on the MAR. In interviews, the LVN admitted the medications were late, while the RN, DON, Administrator, and ADON all stated that medications were expected to be administered on time and per physician orders, consistent with facility policy requiring administration within one hour of the prescribed time.
RN coverage was not verified for multiple days when the DON was on leave and the facility relied on a nurse practitioner to cover the required hours. Payroll and time sheet review showed no RN clock-in hours, and the Administrator stated the only documentation available was a check stub and an Excel spreadsheet of visits, which did not verify 8 consecutive hours of RN coverage as required by policy.
Kitchen sanitation and food storage deficiencies were identified when surveyors observed buildup on the dishwasher, grease accumulation on the fryer and adjacent range, and smudges on refrigerator and freezer doors. Multiple food items in Refrigerator #1, Refrigerator #2, and Freezer #1 were found without dates or labels. The Dietary Mgr and Admin stated staff were responsible for keeping equipment clean and for dating and labeling foods, and facility policies required clean refrigerators, freezers, and food service equipment.
Late Admission MDS Assessments: The facility failed to complete admission MDS assessments for five residents within the required timeframe. The affected residents had diagnoses including COPD, Alzheimer’s disease, CKD, kidney failure, anxiety, breast cancer, pain, and muscle weakness, and several required moderate to maximal assistance with ADLs; one resident had severe cognitive impairment and another was rarely to never understood. The MDS Coordinator acknowledged some assessments were late, and the DON and Administrator confirmed the MDS Coordinator was responsible for timely completion and transmission.
A resident’s admission MDS was completed and signed, but the CMS transmission occurred more than 14 days later than required. The resident had dementia, HF, and seizures, and the MDS showed intact cognition with moderate to maximal ADL assistance needs. The MDS Coordinator acknowledged some assessments were late, and the DON and Administrator stated the MDSs were expected to be completed and transmitted in a timely manner.
Incomplete Person-Centered Care Plans: The facility failed to develop comprehensive care plans for several residents with significant medical and functional needs. A resident with dementia, anxiety, pain, incontinence, ROM limits, pressure injury risk, and high-risk meds had only one care plan focus; another resident with cancer, end-stage heart disease, hemiplegia, and hospice services had no hospice care plan; a resident with CVA, hemiplegia, bipolar disorder, psychotropic use, and falls had no care plans for falls or psychotropic meds; and a resident with sepsis, MRSA sacral ulcer, gastrostomy status, seizure disorder, and anticonvulsant use had no care plans for seizures or anticonvulsants.
Expired Basaglar insulin and expired OTC gas-relief medication were found in active storage, and a resident with type II DM, retinopathy, and dementia had Basaglar 20 units held multiple times without an MD order to hold or MD notification. The nurse said she held the long-acting insulin when BG was not over 200 mg/dL, while the MD stated he had not been notified and expected the insulin to be given as ordered unless BG was below 50 mg/dL or the resident showed signs of hypoglycemia.
Palatable Food Not Served at Proper Temperature: A resident with dementia and malnutrition, a cognitively intact resident with cancer and obesity, and a cognitively intact resident with stroke and ESRD reported that meals were cold, bland, or unappetizing. Surveyors observed breakfast and lunch items that were lukewarm, rubbery, undercooked-looking, or dull in appearance, and the DM acknowledged some items could have been warmer and bland. Staff interviews and the facility policy reflected that trays should be checked for palatability, attractiveness, and safe, appetizing temperature.
Infection control practices were not followed when a CNA carried soiled linen through the hall next to her body without containing it in a bag, and an ADON intervened. In a separate event, an LPN provided direct care to a resident on EBP with a PEG tube and sacral wound without gown or gloves during multiple room entries, then reconnected tube feeding after removing gloves and without hand hygiene. The resident had MRSA, sepsis, moderate cognitive impairment, and required dependent ADL assistance.
Call Lights Not Kept Within Reach: Two residents with severe cognitive impairment and significant physical limitations were observed with call lights out of reach, including one resident whose call light was in a drawer behind the bed and another whose call light was inside a bedside table or on the floor. Staff from CNA to DON level stated everyone was responsible for ensuring call lights remained in reach, but one resident’s care plan did not address call light placement.
Resident council meetings were held on the same day each month, but a cognitively intact resident with ESRD and dialysis dependence could not attend because the meetings were scheduled on her dialysis days. The resident said she had asked to join resident council and had told the AD and council president she wanted to participate, but she was not listed as attending any meetings. The AD said she had not considered changing the meeting day, and the Administrator said she was unaware the resident wanted to attend.
A resident with sepsis and severe cognitive impairment had a Medicare skilled stay end, and the facility completed the NOMNC with the representative’s signature but did not complete the SNF ABN CMS form 10055. The SW said she handled the NOMNC but was unsure who completed SNF ABNs, while the Admin said the SW was responsible for both notices and was unfamiliar with the SNF ABN form.
Failure to Complete Significant Change MDS After Hospice Election: A resident with cancer, end stage heart disease, hemiplegia, and severe cognitive impairment elected hospice services again after radiation treatment, but the MDS Coordinator did not complete the required significant change RAI assessment. The MDS Coordinator said the change should have been captured through the facility’s weekly care meetings, while the DON and Administrator acknowledged the missed assessment and noted the MDS is used to guide the care plan and reflect the resident’s status.
Inaccurate MDS Weight Loss Coding: A resident with CVA, PE, and gout had an annual MDS that failed to code significant wt loss. Although the record showed moderate cognitive impairment, substantial assistance needs, and a mechanically altered diet, the MDS recorded no significant wt loss despite documented loss of 22.5 lbs (12.8%) over 180 days. The MDS Coordinator stated she had not known how to calculate wt loss in the EHR and acknowledged the resident should have been coded for non-physician ordered wt loss.
A resident with dementia and paranoid schizophrenia had PASRR Level 1 screenings that still showed no evidence of mental illness, and no PASRR Level II evaluation was found in the chart. The MDS Coordinator, DON, and Administrator stated the new schizophrenia diagnosis should have triggered an updated PASRR screening and Level II review.
Failure to Provide Grooming Assistance: A resident with a hx of stroke, ESRD, and dialysis dependence was observed with tangled hair and stated she could not brush it properly because of left-sided deficits and neck problems. She reported staff did not help with hair brushing, while CNA, LVN, ADON, and DON interviews showed staff believed she was mostly independent and were unaware she needed ADL/grooming assistance.
Failure to Follow Up on Eyeglass Order: A resident with dementia, paranoid schizophrenia, and impaired vision did not receive prescribed glasses after an eye exam. The resident said she had been without glasses for a long time and could not see the TV or read without them. Staff gave inconsistent accounts of who was responsible for ordering and tracking the glasses, and the SW said the order had fallen through the cracks and that there was no routine follow-up process for eyeglass orders.
Improper gait belt transfer technique was observed for a resident with hemiplegia, hemiparesis, and moderately impaired cognition who usually required total staff assistance with transfers. Two CNAs used a gait belt but also lifted the resident under both armpits during wheelchair-to-bed and bed-to-wheelchair transfers. Staff interviews confirmed the technique was inappropriate, and leadership stated the gait belt should have been used to lift the resident for stability.
Medication administration errors exceeded the allowed rate, with an 8.0% error rate based on 3 errors in 25 opportunities. An LPN held a resident’s Basaglar insulin without an order to do so, gave another resident 2 sprays per nostril of fluticasone instead of 1, and administered loratadine without checking that it had expired. The DON stated orders were expected to be followed as written, and the facility policy required comparison of the order with the MAR and documentation when meds are held.
A resident with cancer, obesity, and a regular diet order was served pork sausage at breakfast and ham at lunch even though her tray card reflected a pork dislike. She told staff she was allergic to pork and reported symptoms such as headache, dizziness, and sleepiness after eating it, but staff gave conflicting accounts about whether the dislike or allergy had been reported and whether tray cards were checked. The Dietary Manager, nursing staff, DON, and Administrator all acknowledged that resident food preferences were supposed to be honored.
Unsafe Storage of Food in Residents’ Personal Refrigerators: Two residents’ personal refrigerators contained expired and spoiled food, and both refrigerators were dirty with no thermometer or temperature logs present. One resident with depression, CKD, and DM2 had expired dairy dip and a dirty refrigerator, while another resident with anxiety, depression, and hypoxemia had expired potato salad with mold and melted sherbert left uncleaned. Staff gave conflicting accounts of who was responsible for cleaning and monitoring the refrigerators.
A resident with ALS who was dependent on staff for all care and used a communication device was subjected to disrespectful and undignified treatment by multiple CNAs. Staff sprayed air freshener over the resident, made derogatory comments, rushed care, failed to provide privacy, and did not allow adequate time for communication. These actions did not align with the resident's care plan or facility policy, resulting in a failure to maintain the resident's dignity and quality of life.
A resident with ALS and significant care needs reported multiple grievances via email regarding delayed response to call lights, rough care, and missed treatments. These complaints were not documented or investigated according to facility policy, and staff interviews confirmed a lack of follow-through and recordkeeping for the reported concerns.
A resident with ALS and significant care needs was subjected to abuse by two CNAs: one sprayed air freshener directly over the resident despite her respiratory issues, and another roughly repositioned her in bed while speaking in a loud, rude manner and not allowing time for communication. The resident's requests and needs were disregarded, and staff and leadership minimized the incidents, failing to uphold policies protecting residents from abuse.
The facility failed to maintain food safety and sanitation standards in the kitchen. Observations revealed open sugar bins, unlabeled and undated food items in Freezer #1, and significant grease and food residue on kitchen equipment. Staff interviews indicated a lack of cleaning protocols and recent management changes, contributing to these deficiencies.
The facility failed to involve residents in their care planning, as several residents were not invited to or did not attend care plan meetings in the past six months. Interviews and record reviews revealed a lack of coordination and documentation by the MDS Coordinator and social worker, leading to residents not participating in their care plans.
The facility failed to provide palatable and appropriately tempered food and drink to residents, affecting their quality of life. Multiple residents reported dissatisfaction with the taste, temperature, and variety of meals, as well as the lack of condiments. The Dietary Manager, new to the facility, acknowledged these issues, which were exacerbated by the recent departure of the previous manager.
The facility failed to provide snacks between meals, resulting in more than 14 hours between the evening meal and breakfast for residents. Interviews revealed that residents were not offered snacks at bedtime, and staff were unclear about snack preparation and distribution responsibilities. This deficiency could affect all residents, risking unplanned weight loss and medication side effects.
A resident with hemiplegia and moderate cognitive impairment was unable to reach their call button due to improper placement, leading to a deficiency in accommodating their needs. Despite staff awareness of the importance of call light accessibility, the resident's call light was found out of reach, compromising their ability to request assistance.
A facility failed to notify the Ombudsman of a resident's discharge, as required by regulations. The resident, with moderate cognitive impairment and multiple diagnoses, was transferred to another facility without the Ombudsman being informed. Interviews revealed that staff were unaware of the notification requirement, and no procedure was in place to ensure compliance.
The facility failed to provide baseline care plans to two residents upon admission, compromising effective and person-centered care. One resident, a 73-year-old female with hemiplegia and anxiety, did not receive a signed copy of her care plan. Another resident, a male with diabetes and cirrhosis, had no completed care plan or MDS assessments. Staff interviews revealed a lack of awareness and communication regarding the provision of these essential care plans.
A resident with left-sided hemiplegia did not receive necessary ROM exercises or therapy services to prevent further decrease in mobility. Despite the resident's moderate cognitive impairment and desire for therapy, the facility lacked a restorative nursing program and did not document ROM exercises as part of daily care. Staff interviews confirmed the absence of a program and the importance of ROM exercises, but no contracture management policy was provided.
A resident experienced significant weight loss shortly after admission, which was not promptly addressed by the facility. Despite having a care plan in place for potential nutritional issues, the facility failed to follow its weight policy, resulting in a delay in notifying the dietitian and primary physician. The resident's weight loss was linked to recent pneumonia and a UTI, but the facility's inaction placed the resident at risk for further health complications.
A facility failed to attempt a gradual dose reduction (GDR) for a resident on Abilify, despite a pharmacy recommendation to reduce the dose. The resident, with severe cognitive impairment and schizophrenia, continued to receive the medication daily. The Nurse Practitioner disagreed with the GDR due to ongoing symptoms and a previous failed reduction, but the GDR was not reviewed or signed in a timely manner, potentially leading to overmedication.
A resident with dementia and glaucoma was not transported to scheduled ophthalmologist appointments due to facility transportation issues. The resident's RP had to arrange transportation for a rescheduled appointment, as the facility cited distance and insurance coverage as barriers. Staff interviews revealed a lack of coordination and communication regarding the resident's transportation needs.
A facility failed to submit a timely MDS discharge assessment for a resident with insomnia, repeated falls, and schizophrenia, who was discharged to another nursing facility. The MDS Coordinator was responsible for the submission, but the assessment was neither completed nor transmitted within the required timeframe, contrary to facility policy and CMS guidelines.
A resident with amyotrophic lateral sclerosis was fed by a CNA who stood while feeding, contrary to the facility's policy of sitting at eye level to promote dignity. The resident felt rushed and ignored, and the DON and Administrator acknowledged this could be a dignity issue, potentially leading to negative outcomes.
A resident with dementia was verbally abused by another resident, who called her derogatory names on two occasions. Despite the incidents being reported by the resident's family, the facility's DON and Administrator did not consider it abuse and failed to document or report it to HHSC. Staff interviews indicated that verbal abuse should be reported, highlighting a lapse in following the facility's abuse prevention policy.
A facility failed to report an alleged verbal abuse incident between two residents to the appropriate authorities within the required timeframe. Despite one resident's family member reporting the incident to the Administrator, it was not documented or reported to the Health and Human Services Commission (HHSC). Interviews with staff indicated that such behavior should be considered verbal abuse and reported, but the facility's policy was not followed.
A facility failed to report and investigate an incident where a resident was verbally abused by another resident. Despite being informed by the family member of the affected resident, the facility's DON and Administrator did not consider the incident as verbal abuse requiring reporting. Interviews with staff indicated that such behavior should be reported, but the facility's inaction could place residents at risk of further abuse.
A resident with multiple diagnoses, including parkinsonism and dementia, experienced a fall during a transfer due to inadequate supervision and failure to use two-person assistance as required. The incident revealed gaps in communication and training among staff, who relied on verbal reports rather than consulting the electronic care plan. The facility acknowledged deficiencies in ensuring staff proficiency in accessing and understanding care plans.
A facility failed to maintain an effective infection control program when an LVN did not perform hand hygiene between glove changes during incontinent care for a resident with multiple health issues, including a urinary tract infection. The LVN admitted to forgetting this critical step, and the facility's policy lacked specific guidance on hand hygiene.
Late Administration of Multiple Scheduled Medications by LVN
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and procedures that assure accurate and timely administration of medications for one resident. The resident was an older adult with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, atrial fibrillation, seizures, and hypertension. Physician orders included numerous scheduled medications such as antihypertensives (Amlodipine, Carvedilol, Losartan), an anticoagulant (Eliquis), an anticonvulsant (Keppra), medications for respiratory issues (Mucinex), GERD (Pantoprazole), urinary incontinence (Myrbetriq), constipation (Senna), vitamin supplements, allergy medication (Zyrtec), and artificial tears. The resident’s care plan identified risks related to impaired breathing pattern, decreased cardiac output, seizures, incontinence, bruising and bleeding due to anticoagulant therapy, and high blood pressure, with repeated interventions to administer medications as ordered. Record review of the MAR for the first part of the month showed that these medications were scheduled for administration at 7:00 a.m. on a specific date, but the MAR did not reflect an actual administration time. During an observation at 8:54 a.m. that same morning, LVN A was seen preparing and administering all 15 of the resident’s scheduled morning medications, including the antihypertensives, anticoagulant, anticonvulsant, respiratory medication, GERD medication, urinary incontinence medication, constipation medication, vitamins, allergy medication, and artificial tears. LVN A stated she worked on an as-needed basis and that the only time she was late passing medications was when she was unfamiliar with the medication cart and needed extra time to find items. In interviews later that day, LVN A acknowledged that the resident’s morning medications were late, confirming that even with the one-hour window before and after the scheduled time, the medications were still administered late beyond the 7:00 a.m. order. RN B, the DON, the Administrator, and the ADON each stated that medications were expected to be given on time and in accordance with physician orders, and that the facility’s practice allowed a one-hour window before and after the scheduled administration time. The facility’s “Administering Medications” policy, last revised in 04/2019, specified that medications are to be administered in a safe and timely manner, in accordance with prescriber orders and required time frames, and within one hour of their prescribed time, with administration times documented in the medical record. The late administration of the 15 ordered medications for this resident constituted a failure to follow these policy requirements and physician orders.
RN Coverage Not Verified for Multiple Days
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. Record review of the payroll-based journal for FY Quarter 4 2025 showed no RN coverage on 08/28/2025, 08/29/2025, 09/01/2025, 09/02/2025, and 09/03/2025. Record review of employee time sheets from August 2025 and September 2025 also showed no RN clock-in hours on those same dates. During an interview on 02/12/2026, the Administrator stated the DON was on leave during those dates and that the facility partnered with a company of nurse practitioners. She stated the nurse practitioner covered the 8 hours during those dates, but the company could not provide timesheets because the nurse practitioner was salaried. The Administrator said the company provided a check stub and a picture of an Excel spreadsheet showing the number of visits on the dates in question, but she was unable to verify that the nurse practitioner covered the required 8-hour timeframe. The facility policy dated August 2022 stated that a registered nurse provides services at least 8 hours every 24 hours, seven days a week.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in one kitchen reviewed for food service safety. During observations, the top of the dishwasher had a brown dry crusty substance and later a light brown gritty substance, and the Dietary Manager identified the material as food particles. The Dietary Manager also stated that water was washing up onto the top of the dishwasher and that the machine had previously been adjusted by the service company, but the buildup remained visible during the survey observations. The facility also failed to keep food storage equipment clean and to ensure food items were dated and labeled in Refrigerator #1, Refrigerator #2, and Freezer #1. Refrigerator #1 had white smudges on the outside doors and contained multiple bags of food items without dates or labels, including sausage patties, brown food patties, and an unknown red meat item. Refrigerator #2 had white drip marks on the outside door and contained a bag of purple jelly substance with no date or label. Freezer #1 had light colored smudges on the outside doors and contained multiple unlabeled and undated food items, including green, yellow, and orange food items, breaded food items, pink meats, beige food items, light beige meats, and round red food items. The facility further failed to keep the fryer and adjacent range free of grease buildup. On observation, the fryer had an excessive amount of grease buildup down the front and sides, the range next to it also had excessive grease buildup, and food crumbs were on the floor between the two pieces of equipment. Record review showed the facility had cleaning schedules for daily, weekly, and other routine cleaning tasks, and the Dietary Manager and Administrator stated that staff were responsible for keeping equipment surfaces clean and for dating and labeling foods. The facility policies also stated that refrigerators and freezers should be kept clean and that foods should be covered, labeled, dated, and routinely monitored.
Late Admission MDS Assessments
Penalty
Summary
The facility failed to complete admission MDS assessments within the required timeframe for 5 of 18 residents reviewed for MDS completion: Resident #28, Resident #44, Resident #53, Resident #55, and Resident #72. Each of these residents had an admission date in January 2026, and the record review showed that the admission assessments were completed after the required 14-calendar-day window. The CMS Submission/Transmission Reports for these residents identified the assessments as late and showed completion dates beyond the allowed timeframe. Resident #44 was admitted with diagnoses including COPD, muscle weakness, and anxiety disorder, and the MDS showed a BIMS of 13 with moderate assistance needed for most ADLs. Resident #53 was admitted with Alzheimer’s disease, diabetes, and anxiety disorder, and the MDS showed a BIMS of 03 with maximal assistance needed for most ADLs. Resident #55 was admitted with muscle weakness, generalized anxiety disorder, and breast cancer, and the MDS indicated a BIMS was not conducted because the resident was rarely to never understood; maximal assistance was needed for most ADLs. Resident #72 was admitted with pain, kidney failure, and muscle weakness, had a BIMS of 15, and required maximal assistance with most ADLs. Resident #28 was admitted with repeated falls, UTI, and CKD, and the MDS showed a BIMS of 10 with maximal assistance needed for most ADLs. During interview, the MDS Coordinator said she was responsible for completing and submitting MDS assessments, that admission assessments should be signed when completed, and that she knew she had some late assessments. The DON and Administrator both stated that the MDS Coordinator was responsible for completing and transmitting admission MDSs in a timely manner, and the Administrator stated the facility followed the RAI manual as it pertains to MDS timing.
Late Transmission of Admission MDS Assessment
Penalty
Summary
The facility failed to ensure an encoded, accurate, and complete admission MDS assessment for Resident #7 was transmitted to the CMS system within the required timeframe after completion. Resident #7 was admitted on 12/24/25 with diagnoses including dementia, heart failure, and seizures. The admission MDS was identified as a new record and showed a BIMS score of 15, indicating intact cognition, with moderate to maximal assistance required for most ADLs. The MDS completion signature was dated 01/02/26, and the assessment was to be transmitted by 01/16/26. A CMS Submission/Transmission Report showed the admission assessment was transmitted on 01/23/26, more than 14 days after the completion signature date. During interview, the MDS Coordinator stated she was responsible for completing and submitting MDS assessments and acknowledged that some assessments were late. The DON and Administrator both stated the MDS Coordinator was responsible for timely completion and transmission of admission MDSs, and the Administrator stated the facility followed the RAI manual as it pertained to MDS timing.
Incomplete Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 4 of 18 residents reviewed. The deficiency involved Resident #5, Resident #14, Resident #41, and Resident #59, and the report states that the missing care plan elements included medical, nursing, mental, and psychosocial needs identified in the comprehensive assessments. Resident #5 had diagnoses including unspecified dementia with anxiety, hypertension, malnutrition, anxiety disorder, depression, and chronic embolism and thrombosis of the deep vein right lower extremity. The quarterly MDS showed clear speech, a BIMS score of 13, functional range-of-motion limitation affecting both lower extremities, dependence for multiple ADLs, bowel and bladder incontinence, pain requiring scheduled and PRN medication, risk for pressure injury, use of a pressure-reducing bed device, and use of anticoagulant and opioid medications. The comprehensive care plan dated 03/17/2025 contained only one focus problem related to dependence on staff to anticipate and meet personal activity needs and did not address range-of-motion limitations, ADL assistance, incontinence, active diagnoses, pain, pressure injury risk, or high-risk medication use. Resident #14 had diagnoses including malignant neoplasm of the parotid, end stage heart disease, and hemiplegia. The significant change MDS showed a BIMS of 05, substantial assistance needed for ADLs such as bed mobility, dressing, and bathing, and use of antiplatelet medication, opioids, diuretics, and antibiotics. The consolidated physician orders showed an order for hospice services, but the comprehensive care plan dated 1/11/2026 did not include a hospice care plan. Resident #41 had diagnoses of CVA, hemiplegia, and bipolar disorder, a BIMS of 07, substantial assistance needs for toileting, transfer, and bathing, and use of antidepressant and antianxiety medications. Incident and accident reports documented falls on 12/08/2025 and 01/05/2026, but the care plan dated 01/20/2026 did not include care plans for the falls or for high-risk psychotropic medication use. Resident #59 had diagnoses of sepsis, MRSA infection of a sacral pressure ulcer, and gastrostomy status. The quarterly MDS showed a BIMS of 08, dependent ADL assistance, use of antidepressant, diuretic, and anticonvulsant medications, and a seizure disorder. The comprehensive care plan dated 01/20/2026 did not include a care plan for anticonvulsant use or seizure activity. During interviews, the MDS Coordinator stated care plans were to include all items coded on the MDS and that falls, high-risk medication use, hospice services, and diagnoses should be care planned for resident safety. The DON stated major diagnoses, conditions, medications, and falls should be care planned with interventions, and the ADM stated she expected staff to follow the interventions decided on by the MDS coordinator and interdisciplinary team.
Expired Medications in Active Storage and Held Insulin Without MD Notification
Penalty
Summary
Expired medications were found in active storage in medication room [ROOM NUMBER] for the 300 and 400 halls. During observation, a Basaglar insulin pen with an expiration date of November 2025 was noted in the refrigerator, and a box of OTC gas-relief medication with an expiration date of August 2024 was noted in the active OTC storage. The facility’s policy stated that all expired medications were to be removed from active supply and destroyed in accordance with facility policy, regardless of amount remaining. Resident #15, an elderly female with type II diabetes, retinopathy, and dementia, had severe cognitive impairment with a BIMS of 05 and was dependent for ADLs. Her care plan identified unstable glucose levels and directed that medications be administered as prescribed. She had an order for Basaglar 20 units every morning, and the MAR showed that the insulin was held on multiple days in January and February 2026. The nurse who held the Basaglar stated she did so when the resident’s blood sugar was not over 200 mg/dL because she believed the order for Novolog applied to the long-acting insulin as well. She stated she did not notify the MD when Basaglar was held because there was no change in the resident’s level of consciousness or vital signs. The MD stated he had not been notified that Basaglar was being held and said it should only be held if blood glucose was below 50 mg/dL or if the resident showed signs of hypoglycemia. The DON and Administrator stated they expected nurses to follow MD orders and notify the MD when any medication was held.
Palatable Food Not Served at Proper Temperature
Penalty
Summary
The facility failed to provide food that was palatable and attractive for 3 of 8 residents reviewed for palatable food. Resident #5, who had diagnoses including unspecified dementia, protein-calorie malnutrition, and dysphagia, was cognitively intact, required set-up assistance with eating, and was ordered a regular diet with thin liquids. During interview, she stated the food was terrible, often cold, and had no flavor. Resident #32, who had diagnoses including acute embolism and thrombosis of the right upper extremity, ovarian cancer, anal cancer, and obesity, was cognitively intact and independent with eating. She stated the food was awful, served cold and bland, and described wilted lettuce and sandwich meat that tasted bad, like it had been left sitting out. Resident #39, who had a primary diagnosis of stroke and further diagnoses of end stage renal disease and dependence on renal dialysis, was cognitively intact and usually required setup or clean-up assistance with eating. She stated the food had no seasoning and was cold by the time it arrived. During observation and interview, Resident #32 and Resident #39 were eating breakfast and described the sausage as undercooked and pale in the center, the toast as rubbery and cold, and breakfast as cold and bland. At lunch, surveyors sampled trays with the Dietary Manager and observed the hamburger steak as lukewarm, the broccoli partly bright and crunchy but also dull-colored, soft, and lukewarm, the mashed potatoes lukewarm and bland, and the peach cobbler cold. Staff interviews reflected awareness of complaints about food being nasty, cold, or bland, and the Dietary Manager and Administrator stated the person plating the food was responsible for ensuring it looked good, tasted good, and was served at the appropriate temperature. The facility policy stated trays should be inspected to ensure food appears palatable and attractive and is served at a safe and appetizing temperature.
Infection Control and EBP Failures
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for hall 300 and for one resident reviewed for infection control practices. During an observation on 02/09/2026 at 9:35 a.m., CNA B walked down the 300 hall carrying soiled bedding next to her body and not contained in a bag. ADON C immediately told her that dirty linen could not be carried outside the room if it was not in a bag and not next to her body. CNA B later stated she knew it was an infection control issue to hold dirty linen next to her body and carry it into the hallway, and that germs could be transferred to another resident from her clothes during care. The second deficiency involved Resident #59, a male admitted with diagnoses including sepsis, MRSA infection of a sacral pressure ulcer, and gastrostomy status. His quarterly MDS showed a BIMS score of 08, indicating moderate cognitive impairment, and he required dependent assistance with ADLs. His care plan dated 02/06/2026 identified enhanced barrier precautions related to his PEG tube and sacral wound, with an intervention requiring staff to use gowns and gloves during high-contact resident care activities that could transfer MDROs from staff hands and clothing. Physician orders for February 2026 included EBP related to the gastrostomy tube. During observations on 02/10/2026, LVN A entered Resident #59's room and adjusted him in bed and untucked his PEG tube without a gown or gloves, later returned and adjusted his sheets and covers and repositioned his PEG tube without a gown, and then administered PEG meds, removed her gloves, and reconnected the tube feeding without gloves and without washing her hands. LVN A stated she believed gown and gloves were only needed for incontinent care, wound care, or bathing, and acknowledged she entered without PPE to adjust him and did not realize she removed her gloves before reconnecting the PEG feeding. The DON stated staff were expected to wear a gown and gloves for EBP when their task required touching the resident, and the Administrator stated she expected nurses and CNAs to follow the facility policy on infection control and EBP.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure residents received services with reasonable accommodation of their needs when call lights were not kept within reach for two residents. Resident #14 had diagnoses including malignant neoplasm of the parotid, end stage heart disease, and hemiplegia, and a significant change MDS showed severe cognitive impairment with a BIMS score of 5 and dependence for multiple ADLs. During observations, Resident #14 stated she could not find her call light when she needed help to be cleaned up and later while waiting for lunch; the call light was found closed in a drawer of the bedside dresser, about 3 feet behind the head of the bed and out of her reach and sight, with no sitter, family member, or roommate present. Resident #26 had hemiplegia and hemiparesis following a stroke affecting the left non-dominant side, and a quarterly MDS showed severe cognitive impairment with a BIMS score of 3 and dependence on staff for ADLs. The resident’s comprehensive care plan did not address keeping the call light in reach. During observations, Resident #26 was found with the call light inside the bedside table with the drawer shut and unable to be reached, and later the call light cord was behind the head of the bed with the button on the floor out of reach. Staff interviews showed multiple employees were responsible for ensuring call lights were in reach, including CNAs, MA staff, LVN staff, the ADON, the DON, and the Administrator. Staff stated call lights were important so residents could request assistance and so staff would know when help was needed. The DON stated all staff, including housekeeping and maintenance, were responsible for checking call light placement when in residents’ rooms, and the Administrator stated it was the responsibility of all staff to ensure residents had their call lights in reach.
Resident Council Meetings Scheduled on Dialysis Days
Penalty
Summary
The facility failed to ensure Resident #39 was able to attend resident council meetings because the meetings were scheduled on her dialysis days. Resident #39 was a cognitively intact female resident admitted with a primary diagnosis of stroke and additional diagnoses of end stage renal disease and dependence on renal dialysis. Her MDS reflected clear speech, ability to understand and be understood, and a BIMS score of 15. Her care plan documented that she received dialysis on Tuesdays, Thursdays, and Saturdays. Record review showed resident council meetings were held on Tuesdays, including meetings on 08/12/2025, 09/09/2025, 10/07/2025, 11/11/2025, 12/09/2025, and 01/06/2026, and Resident #39 was not listed as attending any of them. During interview, Resident #39 stated she had been asking to be part of resident council since admission, had participated in resident council at prior facilities, and had told the AD and resident council president that she wanted to attend. The AD stated she had not thought about changing the meeting days so Resident #39 could attend, and the Administrator stated she was unaware Resident #39 wished to attend resident council meetings.
Missing SNF ABN for Medicare Coverage Termination
Penalty
Summary
The facility failed to ensure that a resident was informed before or at admission, and periodically during the stay, of services available in the facility and the charges for those services, including charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. The deficiency involved Resident #74, a male admitted with a primary diagnosis of sepsis and a responsible party representative. His annual MDS reflected a recent Medicare stay that began on 11/09/2025 and ended on 01/16/2026. The assessment also indicated he had clear speech, was understood, could understand others, and had a BIMS score of 7, indicating severe cognitive impairment. Record review showed Resident #74’s NOMNC was completed on 01/14/2026 with signature confirmation from his representative, stating services would end on 01/16/2026. However, the SNF ABN CMS form 10055 was not completed, even though it would have informed the resident and representative of the option to continue skilled services at a private pay rate. During interviews, the Social Worker stated she issued beneficiary notices such as the NOMNC but was unsure who completed SNF ABNs and said she only completed the NOMNC. The Administrator stated the Social Worker was responsible for both the NOMNC and the SNF ABN, was unfamiliar with the SNF ABN form, and was unsure why Resident #74 did not receive one.
Failure to Complete Significant Change MDS After Hospice Election
Penalty
Summary
The facility failed to ensure that Resident #14, a [AGE]-year-old female with diagnoses of malignant neoplasm of the parotid gland, end stage heart disease, and hemiplegia, was comprehensively assessed using the CMS-specified RAI process after a significant change in status. Record review showed she had severe cognitive impairment with a BIMS score of 05 and required substantial assistance with ADLs such as bed mobility, dressing, and bathing. Her medication regimen included antiplatelet, opioid, diuretic, and antibiotic medications, and she had an order for hospice services after previously coming off hospice to receive radiation treatment for cancer. The MDS Coordinator stated that a significant change assessment should have been completed when the resident elected hospice services again, but it was overlooked and was due within 14 days of the hospice order. She also stated the facility’s weekly standard of care meetings should have identified the need for the assessment. The DON stated she relied on the MDS Coordinator to complete MDS assessments and care plans timely and acknowledged that missing the significant change MDS could result in the care plan not being completed and services or interventions being overlooked. The Administrator stated she was unaware of the missing assessment, and the facility’s MDS policy stated assessments should accurately reflect the resident’s status.
Inaccurate MDS Weight Loss Coding
Penalty
Summary
An inaccurate MDS assessment was completed for one resident when the facility failed to correctly code significant weight loss on the annual MDS. The resident was a male admitted with diagnoses including cerebral infarction, pulmonary embolus, and gout. The annual MDS documented a BIMS score of 09, indicating moderate cognitive impairment, and showed the resident required substantial assistance with bed mobility, transfers, and toileting. The MDS also recorded a weight of 176 pounds and indicated no weight loss of 5% or more in the last month and no weight loss of 10% or more in the last 6 months. Record review showed the resident’s weights were 198 pounds on 06/07/2025, 178 pounds on 11/07/2025, and 175.5 pounds on 12/07/2025, reflecting a loss of 22.5 pounds, or 12.8%, over 180 days. A nutrition care plan noted the resident had a nutritional problem or potential nutritional problem related to a mechanically altered diet due to CVA. During interview, the MDS Coordinator stated she had been unaware until recently how to calculate weight loss in the EHR and said the resident should have been coded for non-physician ordered weight loss on the annual MDS. The Administrator stated it was the MDS Nurse’s responsibility to produce accurate MDSs and care plans.
Failure to Update PASRR Screening for New Mental Illness Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program for a resident who had a diagnosis of paranoid schizophrenia. Record review showed the resident had diagnoses including dementia, paranoid schizophrenia, and pain, and a quarterly MDS dated 10/24/25 indicated a BIMS score of 11 with moderate cognitive impairment and an active diagnosis of schizophrenia. The comprehensive care plan also noted the resident was prescribed an antipsychotic medication related to paranoid schizophrenia. The PASRR Level 1 Screening form dated 09/01/20 reflected no evidence or indicator of mental illness, and a later PASRR Level 1 Screening form dated 02/10/26 also reflected no evidence or indicator of mental illness. No PASRR Level II evaluation was found in the resident's electronic medical record, and one was not provided by the facility. During interviews, the MDS Coordinator said the resident received the paranoid schizophrenia diagnosis on 9/24/24 and that a new diagnosis should prompt an updated PASRR Level 1 Screening. The DON and Administrator stated they expected the diagnosis to have been reflected on the PASRR Level 1 Screening and that the MDS Coordinator was responsible for identifying new diagnoses and updating the screening so a PASRR Level II evaluation could be conducted.
Failure to Provide Grooming Assistance
Penalty
Summary
The facility failed to ensure necessary grooming and personal hygiene assistance was provided for Resident #39, who was reviewed for ADLs. Resident #39 was a female admitted with a primary diagnosis of stroke and additional diagnoses of end stage renal disease and dependence on renal dialysis. Her quarterly MDS reflected that she had clear speech, was cognitively intact with a BIMS score of 15, and usually required setup or clean-up assistance with personal hygiene. Her comprehensive care plan identified a self-care deficit with bathing, dressing, and feeding and included interventions to encourage participation in daily care, maintain a consistent routine, and provide ADL assistance as needed. During observation and interview, Resident #39 stated staff believed she could do more for herself than she actually could. She was sitting on the side of her bed, had difficulty holding her head up, and reported neck problems and upcoming surgery. She used her right hand to lift her left arm and let it drop, explaining that her left side did not function properly after her stroke and that she was unable to brush her hair properly. Her hair was observed sticking up and tangled in some areas. She stated staff did not help her brush her hair and became tearful during the interview. Staff interviews reflected that CNA B normally helped her dress and wipe down on dialysis days and would comb her hair if asked, while the LVN, ADON, and DON stated they were unaware she needed assistance with grooming and ADLs and believed she usually did things independently.
Failure to Follow Up on Eyeglass Order
Penalty
Summary
The facility failed to ensure that a resident received follow-up on an eye doctor’s recommendation for glasses. Resident #9 had diagnoses including dementia, paranoid schizophrenia, and pain, and the quarterly MDS indicated moderate cognitive impairment, impaired vision, and a need for maximal assistance with most ADLs. The comprehensive care plan did not identify visual impairment. A complete eye exam record dated 01/09/26 documented that the resident stated she did not receive her glasses and included a prescription for glasses with a note to order them. During observation and interviews, Resident #9 stated she had been without her glasses for a long time and could not see the television or read without them. She said she had been asking staff about her glasses and that her roommate, who saw the eye doctor the same day, had already received hers. Staff interviews showed no clear follow-up process: an LVN said the mobile vision company ordered glasses if recommended, the ADON said the Social Worker followed up on eye appointments and glasses, and the Social Worker initially did not know whether the glasses had been ordered. The Social Worker later stated the order had fallen through the cracks and that she did not have a process to follow up on eyeglass orders unless someone brought it to her attention. The DON and Administrator stated the Social Worker handled referrals and follow-up for eyeglasses.
Improper Gait Belt Transfer Technique
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices were used to prevent accidents for Resident #47 during transfers. Resident #47 was a female admitted with hemiplegia and hemiparesis following a brain bleed affecting the right-dominant side. Her quarterly MDS reflected unclear speech, a BIMS score of 8 indicating moderately impaired cognition, functional limitation in range of motion affecting one side of the upper and lower extremities, and a usual need for total staff assistance with transfers. Her care plan directed extensive assistance by one staff member for transfers related to a stroke. During an observation, CNA D and CNA F transferred Resident #47 from her wheelchair to the bed and later from the bed back to the wheelchair. CNA D applied a gait belt around the resident’s waist, but both CNAs placed their arms under the resident’s armpits and lifted her by applying pressure underneath the armpits while also pulling on the gait belt. The resident was pivoted during both transfers. The same transfer method was used for the return transfer to the wheelchair. During interviews, CNA F stated she normally applied the gait belt but still lifted residents underneath their arms during a two-person transfer, especially when a resident grabbed onto her arm, and said she used the gait belt only during one-person transfers. LVN H stated the gait belt should have been used to lift the resident and that lifting under the arms was inappropriate. ADON C stated the proper use of the gait belt was to place it around the resident’s waist and lift using the belt for stability, and she expected staff to use it properly. The DON and Administrator also stated staff were expected to use gait belts appropriately. CNA D’s competency reflected use of a gait belt or mechanical lift as per care plan, but the facility could not locate CNA F’s competencies.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent and was found to have an 8.0% medication error rate, based on 3 errors out of 25 opportunities involving 2 residents. One error involved Resident #15, an older female with type II diabetes, retinopathy, and dementia, who had a BIMS score of 05 and was dependent for ADLs. Her care plan stated that medications were to be administered as prescribed, and her MAR showed Basaglar Insulin 20 units every morning. On 02/10/2026, the MAR documented that the Basaglar was held at 7:00 a.m. because vitals were outside parameters, but there were no directions on the MAR to hold the Basaglar. During observation and interview, the LVN checked the resident’s blood glucose and stated she believed the insulin should be held because the resident had no order for insulin when the blood glucose was 149, and she thought the sliding-scale Novolin R hold parameter applied to all insulin. The second resident, Resident #59, was an older male with sepsis, MRSA infection of a sacral pressure ulcer, gastrostomy status, and a seizure disorder. His BIMS score was 08, indicating moderate cognitive impairment, and he required dependent assistance with ADLs. His physician orders and MAR included fluticasone propionate nasal spray, 1 spray per nostril daily, and loratadine 10 mg daily per PEG tube. During observation, the LVN administered 2 sprays per nostril of fluticasone instead of the ordered 1 spray per nostril and did not check the expiration date on the loratadine before giving it. During interview, the LVN stated the extra spray would not negatively affect the resident and that the expired loratadine would probably only be less effective. The DON stated she expected medication orders to be followed as written and that missed or held medications should be reported to the MD, and the Administrator stated nurses were responsible for checking for expired medications. The facility policy required nurses to compare the practitioner’s order with the MAR and document when medications are held.
Resident Served Pork Despite Reported Dislike
Penalty
Summary
The facility failed to ensure Resident #32 received food that accommodated her stated pork dislike during meal service. Resident #32 was a cognitively intact female with diagnoses including acute embolism and thrombosis of the right upper extremity, ovarian and anal cancer, and obesity. Her record showed multiple allergies, but pork was not listed on the face sheet. Her care plan addressed nutritional problems related to cancer and potential injury related to allergies, but it did not address food preferences, and the allergy intervention did not list the allergies. The order summary reflected a regular diet with regular texture and consistency. During interview, Resident #32 stated she was allergic to pork, though she ate it because the portions were small and she did not want to be hungry. She reported that when she ate pork she got a headache, became dizzy, and became sleepy. During breakfast observation, she was served pork sausage that appeared undercooked and pale in the center, and she stated she had told kitchen staff about her allergies but continued to receive pork. During lunch observation, she was served ham and ate it because she did not want to go hungry; her meal ticket reflected she disliked pork, but the baked ham was not marked off. Staff interviews showed inconsistent awareness and handling of the resident’s pork preference. The Dietary Manager stated he relied on charted allergies, verbal reports, and tray cards, and said dislikes or allergies should be marked off so the item would not be included on the tray. Nursing staff gave conflicting statements about whether Resident #32 had reported a pork allergy or dislike, and several staff said they checked tray cards, though one ADON stated she did not check likes and dislikes during meal service. The DON and Administrator stated they expected dietary and nursing staff to ensure resident preferences were honored. The facility policy stated multidisciplinary staff would assess residents’ food likes and dislikes and make reasonable efforts to accommodate resident choices and preferences.
Unsafe Storage of Food in Residents’ Personal Refrigerators
Penalty
Summary
The facility failed to maintain safe and sanitary storage of residents’ food items in 2 of 5 personal refrigerators reviewed. For Resident #12, record review showed a female resident admitted with major depression, chronic kidney disease, and type II diabetes, with a BIMS score of 15 and independence with ADLs. During observation and interview, her refrigerator contained half of a 16-ounce dairy-based vegetable dip that had expired in 08/2025, and the refrigerator interior was dirty with spilled brown liquid and crumbled food wrappers. No thermometer or temperature log was present, and Resident #12 stated she last ate the dip around Christmas, had not gotten sick, but thought it tasted funny. She also stated staff had not opened her refrigerator to check the food or temperature. For Resident #63, record review showed a female resident admitted with anxiety, depression, and hypoxemia, with a BIMS score of 11 and partial assistance needed with ADLs. During observation and interview, her refrigerator contained a 10-ounce container of potato salad that expired in 12/2025 and had green and brown fuzzy substance on it. The freezer area contained melted sherbert that the resident said had been there since the summer and had not been cleaned. No thermometer or temperature logs were noted for her refrigerator, and she stated no one cleaned the refrigerator or checked the temperature. Staff interviews showed differing responsibility assignments, with one LVN stating housekeeping was responsible for cleaning and temperature logs, while the Administrator stated nursing was responsible for ensuring personal refrigerators were clean and free of expired foods and that no follow-up had been done to ensure this was happening. The DON stated housekeeping was responsible for cleaning out residents’ personal refrigerators and that expired or moldy food could place residents at risk for foodborne illness, upset stomach, or intestinal tract issues.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with respect and dignity, and did not provide care in a manner that promoted or enhanced her quality of life. Multiple certified nursing assistants (CNAs) engaged in actions that were disrespectful and failed to honor the resident's rights. These included a CNA spraying air freshener over the resident's bed, pillow, and head, then making derogatory comments about the odor in the room. Another CNA told the resident she wished she would not have to return to the room, and stated she would not be back that day. Additional CNAs rushed the resident during care, failed to provide privacy during incontinent care, and did not allow the resident adequate time to communicate her needs using her communication device. One CNA told the resident she had only ten minutes to use the bedpan and that she should be thankful for the care she received, while another CNA did not take the time to listen to the resident's needs and stated she did not have time for all of it. The resident involved had a diagnosis of ALS, resulting in significant muscle weakness, impaired coordination, speech disturbances, and required substantial assistance with most activities of daily living (ADLs). She was dependent on staff for all care, used a communication device to express her needs, and was on hospice services. The resident's care plan included interventions to ensure privacy, allow time for communication, and provide a calm environment. Despite these documented needs, staff failed to follow the care plan and did not provide care in a manner that respected the resident's dignity or communication limitations. Video footage and interviews confirmed that staff interactions were often rushed, dismissive, and at times rough or abrupt. Staff did not consistently provide privacy, failed to allow the resident time to respond, and made inappropriate comments in the resident's presence. The resident's representative reported that concerns about staff behavior were brought to facility administration, but no action was taken. Facility policy required all employees to treat residents with kindness, respect, and dignity, but these standards were not upheld in the care provided to this resident.
Failure to Investigate and Document Resident Grievances
Penalty
Summary
The facility failed to file and investigate grievances reported by a resident's representative for one resident who had significant care needs due to ALS and other medical conditions. The resident, who had limited mobility and communication abilities, sent multiple emails to the ADON reporting that staff were not responding to her call light, were rough and rude during care, and were not providing timely assistance with toileting and breathing treatments. These grievances were sent on three separate occasions, but there was no documentation that they were logged or investigated according to facility policy. Interviews with facility staff revealed that the ADON received the resident's emails and forwarded them to the administrator, but did not retain access to the emails after a company change. The DON and social worker both stated that grievances should be documented and addressed promptly, but neither recalled receiving or documenting the specific complaints from this resident. The administrator acknowledged receiving some complaints but did not have documentation of addressing the emails sent to the ADON, and stated that if she was not aware of a grievance, she could not address it. A review of the facility's grievance log showed only one complaint from the resident during the relevant period, despite multiple emails and verbal reports of concerns. The facility's grievance policy requires staff to guide residents in filing grievances and to document and address all complaints, but this process was not followed for the resident's reported issues. As a result, the resident's grievances were not formally investigated or resolved as required by policy.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from abuse in two separate incidents involving certified nursing assistants (CNAs). In the first incident, a CNA entered the resident's room with an aerosol can of air freshener, concealed it, and sprayed it over the resident's bed, pillow, and head, despite the resident's known respiratory issues and use of oxygen. The resident had previously communicated to staff that air fresheners irritated her breathing, but her request was disregarded. Video footage confirmed the CNA's actions and the resident's immediate distress, including crying out and facial grimacing. The CNA made dismissive remarks about the odor in the room and the resident's response, and then left the room. In the second incident, another CNA was observed abruptly grabbing the resident by both shoulders and roughly repositioning her in bed. The CNA spoke to the resident in a loud and rude tone, telling her not to "do all that hollering" and did not allow the resident time to respond using her communication device. The resident, who had ALS and was dependent on staff for all activities of daily living, reported feeling that staff were often rough, rude, and did not take the time to listen to her needs. She described feeling ignored and anxious when staff did not answer her call light promptly or provide adequate time for her to communicate. Interviews with staff and facility leadership revealed a lack of awareness regarding the resident's request to avoid air fresheners and a general minimization of the incidents, with some staff characterizing the actions as poor customer service rather than abuse. The facility's policies require protection from abuse and support for resident rights, but these were not upheld in the documented incidents. The resident's representative also reported bringing video evidence of the abuse to facility administration, but no action was taken at that time.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed in their kitchen. Specifically, the sugar was stored in a bin that was left open, which could lead to contamination. Additionally, several food items in Freezer #1 were not labeled or dated, including packages of beef franks and various other food items, which could result in serving expired or unidentified foods. The kitchen equipment was not maintained in a clean condition. The deep fryer and stove were observed to have a significant buildup of grease and food particles, and the doors of Freezer #1, Refrigerator #1, and the milk cooler lid were smeared with food residues. These unsanitary conditions were noted over multiple days, indicating a lack of regular cleaning and maintenance. Interviews with staff revealed that the responsibility for cleaning and labeling fell to the cooks, but there was no cleaning checklist in place. The previous Dietary Manager had left recently, and the interim manager acknowledged the issues but had not yet implemented corrective measures. The Administrator confirmed that dietary staff were expected to maintain cleanliness and proper labeling, but these standards were not being met, potentially risking foodborne illness and contamination.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were involved in the development and implementation of their person-centered care plans. Specifically, residents identified as AR #1, AR #2, AR #44, AR #6, and AR #8 were not invited to or did not attend care plan meetings within the last six months. These residents expressed a desire to participate in their care planning and were aware of their right to be present at these meetings. Record reviews revealed that care plan meetings were either not documented or not conducted with resident participation, as evidenced by the absence of meeting notes in the electronic health records (EHR) for these residents. Interviews with facility staff, including the MDS Coordinator, social worker, DON, and Administrator, highlighted a lack of coordination and communication regarding the scheduling and documentation of care plan meetings. The social worker was responsible for inviting residents and their families, but often did not document refusals to participate. The MDS Coordinator and social worker typically conducted meetings without resident or family involvement. The Administrator was unaware of the residents' concerns about not attending their meetings, despite the facility's policy requiring interdisciplinary team involvement and resident participation in care planning.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. This deficiency was observed in eight residents and four anonymous residents. Several residents reported that the food did not taste good, was often cold, and lacked necessary condiments such as salad dressing, sugar, and coffee creamer. These issues were identified through interviews, observations, and record reviews. Resident #4, who has moderate cognitive impairment, expressed dissatisfaction with the taste and temperature of the food. Resident #19, with intact cognition, also reported that the food was terrible and often cold. During an observation, Resident #19 received a meal that did not match her order and lacked salad dressing. Resident #27, with intact cognition, mentioned that the food was never served on time and was always cold. Resident #29, also with intact cognition, complained about cold coffee and the lack of sugar or cream. Additional residents, including Resident #36 with severe cognitive impairment, Resident #38 with intact cognition, and Resident #54 with intact cognition, echoed similar concerns about the food being cold, burnt, or repetitive. Resident #64, with intact cognition, noted that the food was often hard and overcooked. During a group interview, anonymous residents reported having the same meals repeatedly and expressed dissatisfaction with the quality and variety of the food. The Dietary Manager, who was new to the facility, acknowledged the issues and mentioned that the previous manager had recently quit, which may have contributed to the problems.
Failure to Provide Snacks Between Meals
Penalty
Summary
The facility failed to ensure that there were no more than 14 hours between the evening meal and breakfast the following day, unless a nourishing snack was provided at bedtime, which could extend the time to 16 hours if agreed upon by a resident group. This deficiency was identified for 6 out of 8 residents reviewed for meal frequency. The facility did not offer snacks at bedtime as required, leading to extended periods without food for residents. Interviews with residents and staff revealed that residents were not provided snacks during the day or at bedtime, and requests for snacks were denied due to the kitchen being closed. Staff interviews indicated a lack of clarity and responsibility regarding snack preparation and distribution. The facility's policies stated that nursing staff should offer bedtime snacks, but there was no system in place to ensure this was done, and no training was provided to staff on preparing snacks. The deficiency could affect all residents, putting them at risk for unplanned weight loss, medication side effects, and diminished quality of life.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call button was within reach while in bed, which is a deficiency in accommodating the resident's needs and preferences. The resident, who was moderately cognitively impaired and required extensive assistance with activities of daily living due to hemiplegia and hemiparesis following a stroke, was unable to reach the call button placed on the left side, out of reach of his functional left hand. This situation was observed during an interview, where the resident expressed difficulty in pushing the button and resorted to yelling for assistance. Interviews with staff, including CNAs and LVNs, revealed that there was an expectation for the call light to be placed within reach of the resident's stronger side. However, the call light was found in the trash can during one observation, indicating it was not accessible. The staff acknowledged the importance of proper call light placement to prevent falls and ensure residents can call for help. The facility's policy on call light usage emphasized the need for the call light to be within easy reach, but this was not adhered to in the case of the resident.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a facility-initiated discharge for a resident, which is a regulatory requirement. The resident, a male with moderate cognitive impairment and diagnoses including insomnia, repeated falls, and schizophrenia, was discharged to another nursing facility. The facility did not send a copy of the discharge notice to the Ombudsman, which could prevent residents from accessing advocacy services and understanding their discharge/transfer options and appeal processes. Interviews revealed that the Ombudsman was not informed of the discharge and had to request discharge lists multiple times. The Social Worker (SW) and Director of Nursing (DON) were unaware of the requirement to notify the Ombudsman, and there was no procedure in place for this task. The Administrator (ADM) confirmed that the SW was now responsible for notifying the Ombudsman, but prior to the survey, no one was assigned this responsibility. The facility did not provide a related policy upon request, indicating a lack of established procedures for notifying the Ombudsman of discharges.
Failure to Provide Baseline Care Plans to New Residents
Penalty
Summary
The facility failed to ensure that baseline care plans, which are essential for providing effective and person-centered care, were completed and provided to two residents upon their admission. For one resident, a 73-year-old female with hemiplegia, cerebral infarction, and anxiety, the baseline care plan was completed but not signed by the resident or her representative. During an interview, the resident expressed that she did not remember the baseline care plan meeting and had not received a copy of the care plan, which she wanted to review to understand her discharge timeline. Another resident, a male with diabetes mellitus, cirrhosis, and anxiety, had no completed MDS assessments or baseline care plan in his electronic health record. He reported that no care plan had been discussed with him, and he was unsure of his goals or the medications prescribed to him. Interviews with facility staff, including the MDS nurse and social worker, revealed a lack of awareness and communication regarding the provision of baseline care plans to residents. The Director of Nursing and the Administrator acknowledged the importance of these care plans and the need for timely completion and communication with residents, but they were unaware of the lapses in this process.
Failure to Provide Contracture Prevention Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM) for a resident with left-sided hemiplegia. The resident, a male with a history of hemiplegia, diabetes mellitus type II, and cerebral infarction, was admitted to the facility and had a moderate cognitive impairment. Despite his condition, which included upper and lower ROM impairment on one side of his body, the resident did not receive occupational therapy (OT), physical therapy (PT), or restorative nursing for ROM. The resident expressed a desire for therapy to maintain mobility and prevent stiffness, noting that it had been over 60 days since he last received therapy services. Interviews with facility staff revealed that there was no restorative nursing program in place for residents discharged from therapy. The Director of Rehabilitation (DOR) and the Director of Nursing (DON) acknowledged the importance of ROM exercises to prevent contractures, but confirmed that no such program existed, and ROM exercises were not documented as part of daily care. The Administrator stated that it was the nursing staff's responsibility to ensure contracture management and prevention, and that CNAs should be trained to perform ROM exercises. Despite requests, the facility did not provide a contracture management policy before the survey exit.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, resulting in a significant weight loss that was not promptly addressed. The resident, a male with multiple medical conditions including neuromuscular dysfunction of the bladder, pulmonary candidiasis, and dysphagia following a cerebral infarction, experienced an 11.3-pound weight loss from admission to a few days later, indicating a 5.51% weight loss. Despite the facility's policy requiring a re-weigh within 24 hours of a significant weight loss, this was not done, and the resident's weight was not monitored according to the facility's protocol. The resident's care plan included interventions for potential nutritional problems, such as monitoring lab work, serving diet as ordered, and weighing per facility protocol. However, the facility did not adhere to these interventions, as evidenced by the lack of timely weight monitoring and failure to notify the dietitian and primary physician of the significant weight loss. Interviews with staff revealed that there were discrepancies in weight entries, and a performance improvement project was initiated to address these issues, but the deficiency had already occurred. The resident's weight loss was attributed to recent pneumonia and a urinary tract infection, as noted by the resident's responsible party. The facility's interim DON and other staff acknowledged the importance of identifying and addressing weight loss to prevent further health decline. However, the facility's failure to follow its weight policy and promptly address the resident's weight loss placed the resident at risk for malnourishment and other health complications.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated for a resident receiving Abilify, an antipsychotic medication. The resident, who had a history of stroke, schizophrenia, and muscle weakness, was admitted to the facility and had a severe cognitive impairment with a BIMS score of 3. The resident was dependent on staff for activities of daily living and received antipsychotic medication daily. Despite a pharmacy recommendation to reduce the dose of Abilify from 5 milligrams to 2.5 milligrams, there was no indication that the physician reviewed or responded to this recommendation. The Nurse Practitioner disagreed with the GDR recommendation due to the resident's continued symptoms and a previous failed reduction attempt. However, the GDR was not reviewed or signed in a timely manner, as it was only signed in December, nearly a year after the recommendation was made. The facility's policy requires that residents receiving psychoactive medications are monitored for effectiveness and that periodic dosage reductions are attempted unless medically contraindicated. The delay in reviewing and signing the GDR could lead to residents being overmedicated.
Failure to Transport Resident to Vision Appointments
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities. The resident, an elderly female with diagnoses including dementia and glaucoma, was not transported to scheduled appointments with an ophthalmologist on two occasions. The resident had moderately impaired vision and required corrective lenses, and her care plan indicated she needed assistance with daily activities due to her cognitive impairment and physical limitations. The resident's responsible party (RP) had arranged an appointment with a specialist ophthalmologist, as local doctors were unable to provide the necessary care due to the resident's inability to lie flat. However, the facility did not transport the resident to her appointment in October, citing transportation issues and the need for the van for other residents. The RP was informed that the facility could not transport the resident to the specialist due to distance, and the resident's insurance did not cover transportation to the appointment. Interviews with facility staff revealed a lack of coordination and communication regarding the resident's transportation needs. The social worker and ADON were aware of the transportation issues, but the facility did not provide a solution, leaving the RP to arrange transportation for the rescheduled appointment in December. The facility's policy indicated that the social services department should coordinate care for ancillary medical services, but this was not effectively implemented in this case.
Failure to Submit Timely MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure that an encoded, accurate, and complete Minimum Data Set (MDS) discharge assessment for a resident was electronically completed and transmitted to the CMS System within the required 14 days after completion. This deficiency was identified during a review of the records for a resident who was discharged to another nursing facility. The resident, a male with diagnoses including insomnia, repeated falls, and schizophrenia, was discharged without the necessary MDS discharge assessment being completed or transmitted, as required by federal guidelines. Interviews with the MDS Coordinator and the Administrator revealed that the MDS Coordinator was responsible for completing and submitting the MDS assessments, and the corporate MDS Coordinator was expected to monitor these submissions. Despite the facility's policy requiring timely submission of assessments, the discharge assessment for the resident was not completed or submitted, and the MDS Coordinator was unable to explain how this oversight occurred. The facility's policy and the CMS RAI Manual both emphasize the importance of timely submission to ensure compliance with federal and state guidelines.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during feeding, as observed with one resident diagnosed with amyotrophic lateral sclerosis and other conditions requiring maximal assistance with activities of daily living. The resident, who had difficulty with communication and required staff assistance for feeding, was fed by a CNA who stood while feeding her, which is against the facility's policy of sitting at eye level to promote dignity and respect. The CNA did not sit due to the presence of a communication device stand, which the resident refused to move, and the CNA did not attempt to relocate it. Interviews with other CNAs and the Director of Nursing (DON) confirmed that sitting while feeding is the expected practice to ensure residents do not feel rushed or disrespected. The resident expressed feeling rushed and ignored when she communicated her discomfort with the feeding pace. The DON and Administrator acknowledged that standing while feeding could be a dignity issue and might lead to negative outcomes such as weight loss or decreased quality of life. The facility's policy emphasizes treating residents with dignity and respect at all times.
Failure to Report and Document Verbal Abuse Incident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, which was not reported or documented as required. A female resident with a history of myocardial infarction, muscle wasting, and dementia, among other conditions, was verbally abused by a male resident who called her derogatory names on two separate occasions. The incidents were not documented in the facility's incident reports, grievance reports, or the resident's progress notes, despite being reported by the resident's family member via email to the facility's administrator. The male resident, who had severe cognitive impairment and was admitted for short-term care following heart surgery, was involved in these incidents. Despite the verbal altercations, the facility's Director of Nursing (DON) and Administrator did not consider the incidents as abuse and did not report them to the Health and Human Services Commission (HHSC). The DON and Administrator believed the name-calling was mutual and did not warrant further investigation or reporting, even though the facility's policy required immediate reporting and investigation of any abuse allegations. Interviews with various staff members, including CNAs and LVNs, revealed a general understanding that verbal abuse, such as cussing and yelling, should be reported to the Abuse Coordinator. However, the facility's failure to document and report the incidents as required by their abuse prevention policy indicates a lapse in following proper procedures to ensure resident safety and compliance with regulatory standards.
Failure to Report Alleged Verbal Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving two residents to the appropriate authorities within the required timeframe. Resident #1, a female with a history of myocardial infarction, muscle wasting, and dementia, among other conditions, was allegedly verbally abused by Resident #3, a male with congestive heart failure and severe cognitive impairment. The incident was reported by Resident #1's family member via email to the facility's Administrator, but it was not documented in the facility's incident or grievance reports. Resident #1 reported that Resident #3 called her derogatory names on two separate occasions, once outside on the patio and another time when Resident #3 entered her room uninvited. Despite Resident #1's discomfort and the presence of a staff member during one of the incidents, the Director of Nursing (DON) and the Administrator did not consider the name-calling as verbal abuse and did not report it to the Health and Human Services Commission (HHSC). The Administrator believed there was no need to report the incident as both residents had exchanged derogatory names, and there was no injury involved. Interviews with various staff members, including CNAs and LVNs, indicated that yelling or cussing at a resident is considered verbal abuse and should be reported to the Abuse Coordinator. However, the facility's policy on abuse prevention was not followed, as the incident was not reported or investigated as required. The failure to report the alleged verbal abuse in a timely manner could potentially place other residents at risk, as acknowledged by the DON and other staff members.
Failure to Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by state law. Specifically, the facility did not report an incident where a resident was verbally abused by another resident. The incident involved a resident who was called a derogatory name by another resident on two separate occasions. Despite the family member of the affected resident notifying the facility's administrator via email, the incident was not documented in the facility's incident reports, grievance reports, or the resident's progress notes. The Director of Nursing (DON) and the Administrator were aware of the incident but did not consider it as verbal abuse that required reporting. The DON stated that the incident was merely name-calling and did not warrant further documentation or reporting. The Administrator also did not report the incident to the Health and Human Services Commission (HHSC), as she believed there was no injury involved and both residents had exchanged derogatory names. This lack of action was contrary to the facility's abuse prevention policy, which mandates immediate reporting and investigation of all allegations of abuse. Interviews with various staff members, including CNAs and LVNs, indicated that they considered yelling and cussing at a resident as verbal abuse that should be reported to the Abuse Coordinator. However, the facility's failure to report and investigate the incident in a timely manner could potentially place residents at risk of further abuse. The facility's policy requires that all allegations of abuse be reported immediately to ensure the safety of residents and to comply with state and federal guidelines.
Inadequate Supervision and Assistance During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who required two-person assistance for transfers. The incident involved a resident with multiple diagnoses, including parkinsonism, dementia, and impaired range of motion, who was cognitively intact with a BIMS score of 15. The resident was dependent on staff for transfers and other activities of daily living. On the day of the incident, a CNA attempted to transfer the resident from a recliner to a bed without the required two-person assistance, resulting in the resident sliding off the bed and landing on the floor without injury. Interviews with staff revealed a lack of consistent communication and verification of care requirements. Several CNAs reported relying on verbal reports from previous shifts or charge nurses rather than consulting the electronic Kardex system, which contained the resident's care plan. This practice led to a misunderstanding of the resident's need for two-person assistance during transfers. The CNA involved in the incident was not available for comment, and other staff members confirmed the importance of following the care plan to prevent falls and injuries. The facility's administration acknowledged the deficiency in training and communication regarding the use of the electronic charting system and the importance of adhering to the care plan. The DON and ADON were responsible for training CNAs, but there was a gap in ensuring that all staff were proficient in accessing and understanding the care plans. The facility's Fall Prevention Program emphasized the need for an interdisciplinary approach to prevent falls, but the incident highlighted a failure to implement these guidelines effectively.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) who did not perform hand hygiene after removing gloves during the provision of incontinent care to a resident. This resident, a female with multiple diagnoses including amyotrophic lateral sclerosis, muscle weakness, and urinary tract infection, required maximal assistance with activities of daily living. During an observation, the LVN was seen removing gloves and applying new ones without performing hand hygiene, which is a critical step in preventing cross-contamination and infection spread. Interviews with the LVN, the Director of Nursing (DON), and the Administrator confirmed the expectation for proper hand hygiene between glove changes. The LVN admitted to forgetting to perform hand hygiene, acknowledging its importance in preventing urinary tract infections. The DON, who also serves as the infection control preventionist, stated that random checks are conducted to ensure compliance with hand hygiene protocols. However, the facility's infection prevention and control policy did not address handwashing or hand hygiene, highlighting a gap in the facility's infection control measures.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 87 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Texarkana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cornerstone Retirement Community | 0.9 mi | ★★★★★ | 8 | 0 |
| Reunion Plaza Senior Care And Rehabilitation Cente | 1 mi | ★★★★★ | 25 | 2 |
| Avir At Texarkana | 1.6 mi | ★★★★★ | 7 | 3 |
| The Villa At Texarkana | 1.7 mi | ★★★★★ | 9 | 0 |
| Heritage Plaza Nursing Center | 1.8 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Cowhorn Creek.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.