Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Dallas during CMS and state inspections, most recent first.
A resident with multiple health conditions, including COPD and recent pneumonia, was administered oxygen at 2 L/min instead of the physician-ordered 3 L/min after hospital readmission. The LPN did not verify the current order and relied on the oxygen setting present at arrival, failing to follow facility policy requiring order review. Facility leadership confirmed that staff are expected to check and follow physician directives, but this was not done, resulting in the resident receiving less oxygen than prescribed.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors observed an undated open box of sour cream in the walk-in refrigerator, seasoning containers left uncovered, and the oven top/back with oil debris and dust buildup. The ice machine was leaking with scale accumulation. Interviews with the Dietary Manager, a kitchen staff member, and the Dietician confirmed staff were responsible for dating, covering, and labeling food items and keeping kitchen equipment clean.
A resident with intact cognition, stroke history, prior falls, hip fracture, and significant transfer assistance needs was observed lying in bed with his call light placed on the bedside stand and out of reach. The resident stated he could not find the call light, and staff interviews confirmed that all employees were responsible for keeping the call light within reach and that the facility policy required call lights to be placed near the resident, not on the bedside stand.
Care plans did not reflect current diet orders for two residents. One resident with dementia and dysphagia had a care plan that still showed NPO with a feeding tube instead of a puree diet with thin liquids, and another resident with dementia and kidney failure had a care plan that did not include ordered double protein portions. Staff interviews confirmed the care plans were not updated to match the residents’ current diet orders.
Failure to provide nail care and hygiene assistance for a resident with encephalopathy, schizophrenia, and DM. The resident was observed in bed on isolation with long, dirty fingernails and said he wanted them trimmed and cleaned, but no one had offered help yet. Staff interviews showed the LVN, CNA, RN, and DON expected nail care to be provided during baths and as needed, with the RN stating the charge nurse was responsible for trimming the fingernails because the resident was diabetic.
Missing controlled-drug count signatures were found on Nurses Cart 300 Short Hall when the incoming and outgoing nurses failed to document shift-change narcotic counts on the narcotic count sheet. An LPN and other nurses stated they counted the narcotics but did not sign, while the DON said nurses were expected to sign after each count and that without signatures the facility could not prove the counts were completed. The facility policy required both nurses to count and sign at the beginning and end of each shift.
A controlled pain medication for a resident was found in a medication cart with 2 broken blister seals and the pill still inside the taped-over blister. The LVN said the narcotic count was correct but she did not check the blister packs during the count, and the DON stated a broken blister seal should mean the pill is discarded. The facility policy stated medications with cracked or unsecured containers are to be removed from stock and disposed of per procedure.
Infection control lapses occurred during incontinent care for two residents. One CNA cleaned a resident and then handled a clean brief while still wearing soiled gloves, and another CNA changed gloves multiple times without hand hygiene while moving from cleaning the front area to fecal care and brief changes. The DON stated staff were expected to remove gloves and sanitize hands when moving from dirty to clean, and that CNAs were trained to do so.
A resident with multiple risk factors for skin breakdown developed several advanced-stage pressure ulcers after staff failed to consistently monitor, assess, and respond to early signs of pressure injuries. Early indications of skin issues were not escalated for timely wound care intervention, weekly skin assessments were missed, and communication gaps delayed appropriate treatment, resulting in the progression of wounds to advanced stages.
A resident with Alzheimer's and cellulitis received wound care from a WCN who failed to change gloves and perform hand hygiene after cleaning the wound, contrary to the facility's infection control policy. The DON confirmed the importance of these practices to prevent pathogen transmission.
The facility failed to provide adequate personal hygiene care for five residents, resulting in unwanted facial hair and long, dirty nails. Residents expressed a desire for assistance with grooming, which was not adequately provided, despite the facility's policy emphasizing the importance of grooming assistance. The DON acknowledged the potential emotional harm of neglecting these needs.
The facility failed to maintain safe conditions for wheelchairs used by three residents, leading to potential safety hazards. A resident with severe cognitive impairment had a frayed and cracked armrest, while another with moderate impairment had a cracked and partially missing armrest cushion. A third resident with no cognitive impairment had a frayed armrest on her motorized wheelchair. The Maintenance Supervisor was unaware of these issues due to a lack of communication and documentation, despite a policy requiring regular maintenance of assistive devices.
The facility did not post daily nurse staffing information, including the current date, total number, and actual hours worked by RNs, LVNs, CNAs, and the resident census at the beginning of each shift. This information was missing from May 23 to May 28, and outdated data was observed on May 28. The ADM confirmed the requirement to post this information to inform residents and visitors.
The facility did not maintain documentation for its QAPI program from March to May 2024. While records showed QAPI meeting minutes from August 2023 to February 2024, no signed team signature sheets were found for the following months. The temporary ADM, who started in May 2024, reported being unable to locate any documentation of meetings after February 2024, which hindered the facility's ability to identify and resolve issues. The facility's policy requires monthly meetings with signed attendance.
The facility failed to maintain resident dignity during meals, as staff were observed standing while assisting residents with eating and using cell phones instead of engaging with residents. A resident had exposed wound VAC tubing, and there was a delay in serving meals to another resident. Staff interviews revealed uncertainty about proper procedures, highlighting a lack of attention to resident dignity.
The facility experienced a 12% medication error rate due to late administration of medications to several residents. Medications such as Potassium, Eliquis, and others were not given within the prescribed time frames by MAs, who cited challenges like residents being in therapy or refusing meds. These issues were not communicated to the charge nurse or DON, violating the facility's policy of administering meds within 60 minutes of the scheduled time.
The facility failed to ensure timely administration of Eliquis, a blood thinner, to four residents, resulting in significant medication errors. Medication aides administered the drug late, citing reasons such as residents' preferences and activities. The residents, who had conditions like heart failure and hypertension, expressed concerns about the timing, but these were not reported to the charge nurse or DON, contrary to facility policy.
The facility failed to maintain an effective infection control program, as staff did not adhere to hand hygiene and equipment disinfection protocols. CNAs and an LVN were observed not performing hand hygiene after resident contact during meal service, and MAs did not disinfect blood pressure cuffs between uses. An LVN also neglected hand hygiene after glove removal during blood sugar tests, risking cross-contamination.
The facility failed to maintain an effective pest control program, with gnats observed in various areas, including the conference room, nurse's station, and resident rooms. Staff and residents were aware of the issue, but it was not documented in the pest control logbook. The Maintenance Supervisor acknowledged the presence of gnats but did not specify actions taken. Pest control logs showed treatments in the kitchen but lacked documentation for resident areas, contributing to the ongoing gnat problem.
The facility failed to secure IV medications, leaving eight doses of Nafcillin unsupervised at the nurse's station. LVN G, responsible for the medications, left them unattended due to disorganization caused by storms and staff lateness. The DON confirmed that medications should be locked when not in use, as per facility policy.
Failure to Follow Physician Orders for Oxygen Administration
Penalty
Summary
A deficiency occurred when a resident requiring respiratory care, including oxygen therapy, did not receive care consistent with physician orders and professional standards. The resident, an elderly male with multiple diagnoses including COPD, vascular dementia, and recent pneumonia, was readmitted to the facility with hospital discharge instructions to continue oxygen at 3 L/min via nasal cannula for comfort. However, upon return, nursing staff administered oxygen at 2 L/min instead of the ordered 3 L/min, without verifying the current physician order. The LPN responsible for the resident's care assumed the 2 L/min setting was correct because that was the level upon the resident's arrival and did not check the physician's order. The LPN also did not document the resident's vital signs in the electronic record, instead recording them in a personal notebook. The resident's oxygen saturation was noted to be 92% while on 2 L/min, but the LPN did not consider this a concern and did not consult the physician or review the written orders. The facility's policy required verification of physician orders prior to oxygen administration, but this step was omitted. Interviews with facility leadership confirmed that staff were expected to review and verify orders upon a resident's return from the hospital. The ADON and ADM both stated that orders should be checked to ensure residents receive care as directed by the physician. The failure to verify and follow the correct oxygen order resulted in the resident receiving a lower oxygen flow rate than prescribed, contrary to both facility policy and professional standards of practice.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen. During an observation on 07/23/2025 at 9:18 AM, an open box of single packet sour cream in the walk-in refrigerator was not dated. In the same observation, seasoning containers of black pepper, whole celery seed, garlic powder, Italian seasoning, and meat tenderizer were not tightly covered and were exposed to air. The kitchen observation also found the top and back of the oven had oil debris and dust buildup, and the ice making machine was leaking with scale accumulation around it. These conditions were identified during surveyor observation of the kitchen environment and equipment used to prepare and serve food for residents. Interviews with the Dietary Manager, a kitchen staff member, and the facility Dietician confirmed that kitchen staff were responsible for dating, labeling, covering food items, and keeping the oven and ice machine clean. The Dietary Manager stated all employees had been in serviced regarding dating, labeling, covering food items, and cleaning and properly maintaining kitchen equipment. Facility policies and the Food Code excerpts reviewed by surveyors reflected requirements for dated and labeled food storage, tightly covered containers, and clean kitchen equipment.
Call Light Not Within Resident Reach
Penalty
Summary
The facility failed to ensure that Resident #33 had the call light device within reach while he was lying in bed in his room. Resident #33 was a male admitted on 07/03/2025 with a BIMS score of 14, indicating intact cognition, and had diagnoses including stroke, history of falling, and hip fracture. His record also showed occasional urinary incontinence, frequent bowel incontinence, and substantial to maximal assistance needed for bed-to-chair and toilet transfers. His care plan identified him as using a wheelchair, being at risk for falls, and being at risk for skin breakdown and pressure ulcers related to incontinence and impaired mobility. During observation on 07/21/2025 at 11:29 AM, Resident #33 was lying in bed and his call light was on the bedside stand, out of his reach. The resident stated he could not find his call light device. Staff interviews later confirmed that the call light should always be within the resident's reach and that all employees were responsible for ensuring this before leaving a room. The facility's call light policy stated that residents should have a call light within reach and that call lights should be placed near the resident, never on the floor or bedside stand.
Care plans did not reflect current diet orders
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for 2 of 8 residents reviewed, and the care plans did not reflect current diet orders. Resident #1 had diagnoses including dementia, heart failure, and dysphagia, with a BIMS score of 7 and a history of being NPO with a feeding tube. Her care plan, revised on 06/13/25, described her as NPO with a feeding tube and included interventions for the dietary manager to monitor food preferences and provide feedings and water flushes as ordered, but it did not reflect the physician order for a regular puree diet with thin liquids that began on 07/10/25. During interview, the resident stated she had previously been NPO due to a feeding tube and was currently on a pureed diet. Resident #2 had diagnoses including heart failure, dementia, and kidney failure, with a BIMS score of 13. His care plan, dated 06/06/25, reflected a liberalized renal diet with interventions to monitor and discuss food preferences and offer snacks within diet, but it did not include the physician order for double protein portions that began on 06/13/25. The resident stated he received double protein for meals and was included in care planning, though he did not recall meals being discussed. The Regional MDS Nurse Consultant stated the care plan should have been updated to reflect the diet change, and the DON stated care plans were expected to be resident centered and up to date with diet orders. The facility policy required a comprehensive care plan that was individualized, person centered, and communicated vital information to staff providing direct resident care.
Failure to Provide Nail Care and Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary ADL assistance to maintain good grooming and personal hygiene for a resident who was unable to carry out those activities independently. Resident #82 was a [AGE] year old male admitted on 07/14/2025 with diagnoses including encephalopathy, undifferentiated schizophrenia, necrotizing fasciitis, and type 2 diabetes mellitus without complications. His care plan dated 07/22/2025 reflected an ADL self-care performance deficit and the need for staff assistance, and the record noted frequent urinary and bowel incontinence and risk for impaired thought process related to encephalopathy. During observation on 07/21/2025, the resident was lying in bed on isolation precautions for positive COVID-19 and had long, dirty fingernails. He stated he wanted them trimmed and cleaned, but nobody had offered assistance yet. Staff interviews showed the LVN, CNA, RN, and DON all expected fingernail care to be provided during bathing and as needed, with the RN stating the charge nurse was responsible to trim the resident’s fingernails because he was diabetic. The DON stated the nursing team was responsible to ensure residents had clean and trimmed fingernails unless they refused. The facility policy stated nursing assistants would provide nail care to residents requiring assistance and would obtain permission and instructions from the charge nurse before cutting fingernails or toenails.
Missing Controlled-Drug Count Signatures
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met when the facility failed to ensure controlled drugs on Nurses Cart 300 Short Hall were counted and documented at every shift change. Record review on 07/21/25 showed missing off-duty and on-duty signatures on the narcotic count sheet for the 10:00 PM to 6:00 AM shift on 06/07/2025, the 2:00 PM to 10:00 PM shift on 06/08/2025, and the 6:00 AM to 2:00 PM shift on 06/16/2025. LVN I, who was responsible for the cart, reviewed the count sheets with the surveyor and identified the missing signatures. During interviews, LVN K stated she should have signed the narcotic sheet after counting the narcotics at the beginning and end of her shift and was not sure why she did not sign it. LVN J stated she counted the narcotics on her shift but forgot to sign the count sheet. LVN L could not be reached for interview. The DON stated nurses were expected to sign the narcotic count sheet at the beginning and end of the shift after completing the count with the incoming and off-going nurse, and that without signatures the facility could not prove the counts were completed. The facility policy required the incoming and outgoing nurses to count and justify narcotics at each change of shift and to record the date and signature verifying the count at the beginning and end of each shift.
Broken Seal on Controlled Medication in Medication Cart
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with accepted professional principles for 1 of 3 medication carts reviewed. On observation of Nurses Cart 300 Short Hall on 07/21/25 at 12:57 PM, LVN I had Resident #24’s hydrocodone acetaminophen 5-325 mg tablet, a controlled medication used for pain, in a blister pack with 2 broken seals, with the pill still inside the broken blister and taped over. The medication was kept in the cart in this condition when it was observed by surveyors. During interview on 07/21/25 at 1:03 PM, LVN I stated the narcotic count had been done at shift change and was correct, but she did not check the blister packs during the count. She stated she was unaware when the blister pack seals were broken and did not know who may have damaged them. She stated nurses and med aides were responsible for checking medication blister packs for broken seals during narcotic counts at shift change, and that when a broken seal was observed, the pill would be wasted with another nurse. The DON later stated that if a blister pack seal was broken, the pill should be discarded and that it was not acceptable to keep a pill in an opened or taped-over blister pack. The facility policy stated that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of per procedure, and reordered from the pharmacy.
Infection Control Lapses During Incontinence Care
Penalty
Summary
The facility failed to maintain an infection control program designed to prevent the development and transmission of infection for two residents during incontinent care. Resident #21’s quarterly MDS showed diagnoses of dementia, diabetes mellitus, and elevated blood pressure, with a BIMS score of 08 indicating moderately impaired cognition and maximal assistance needed for toileting hygiene. During observation, CNA F provided incontinence care while wearing gloves, cleaned the resident’s peri-area and buttocks, then removed the soiled brief and placed a clean brief under the resident while still wearing the same soiled gloves before completing the care and washing hands at the end. In interview, CNA F stated gloves should be changed and hand hygiene performed when moving from dirty to clean, and CNA A stated the failure exposed the resident to infections. Resident #15’s quarterly MDS showed diagnoses of dementia, muscle weakness, and need for assistance with personal care, with a BIMS score of 13 indicating intact cognition and maximal assistance needed for toileting and personal hygiene. During observation, CNA G performed incontinence care and changed gloves multiple times without performing hand hygiene between changes while moving from cleaning the resident’s front pubic area to cleaning fecal material from the buttocks, removing the soiled brief, placing a clean brief, applying barrier skin, and repositioning the resident. In interview, CNA G stated hand hygiene should be performed between glove changes when moving from dirty to clean, and CNA A stated the failure exposed the resident to infections. The DON stated staff were expected to remove gloves and sanitize hands when going from dirty to clean, that CNAs were trained to perform hand hygiene between glove changes, and that failure to do so could lead to cross-contamination and possible spread of infection.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of pressure ulcers and to provide care consistent with professional standards for a resident who was admitted without wounds but later developed multiple pressure injuries. The resident, who had significant risk factors including impaired mobility, contractures, dementia, and other comorbidities, was dependent on staff for all activities of daily living. Despite being identified as high risk for skin breakdown, early signs of pressure injuries, such as a blood blister and bruising on the right foot and discoloration on the left hip, were not adequately monitored or addressed. Documentation shows that initial findings were reported by hospice staff and noted in weekly skin assessments, but interventions were limited to the application of barrier creams and skin prep, without escalation or timely wound care consultation. The facility did not consistently perform or document weekly skin assessments as required by policy, with at least one missed assessment and delayed recognition of worsening skin conditions. When new or worsening wounds were identified, such as the open area on the left hip and necrotic wounds on the right foot and toe, there was a lag in obtaining wound care consultations and implementing appropriate treatment orders. Communication gaps were evident, as the wound care nurse was not promptly informed of changes, and the responsible party was not always notified about new or worsening wounds. The care plan and interventions were not updated in a timely manner to reflect the resident's changing condition. Interviews with staff revealed a lack of clarity regarding roles and responsibilities for skin monitoring and wound care, with reliance on CNAs and charge nurses to identify and report issues, but without a robust system to ensure follow-up and escalation. The wound care nurse became involved only after significant deterioration had occurred, and the wound care physician confirmed that the wounds had been present and worsening for more than five days before surgical intervention. The facility's failure to monitor, assess, and respond to early signs of pressure injuries resulted in the resident developing multiple advanced-stage pressure ulcers.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of the Wound Care Nurse (WCN) during wound care for a resident. The resident, a female with Alzheimer's disease and cellulitis of the left lower leg, was observed during a wound care procedure. The WCN initially performed hand hygiene and donned gloves before removing the dressing and cleaning the wound. However, after cleaning the wound, the WCN did not change gloves or perform hand hygiene before applying the treatment and wrapping the wound, which is a breach of infection control protocols. The Director of Nursing (DON) confirmed that the facility's policy requires staff to change gloves and perform hand hygiene after cleaning a wound to prevent the transmission of pathogens. The facility's handwashing policy, dated December 2018, emphasizes hand hygiene as the primary means to prevent infection spread, specifically before and after direct resident contact and changing a dressing. The WCN acknowledged the oversight and the importance of hand hygiene in preventing infection transfer.
Deficiency in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate personal hygiene care for five residents, leading to deficiencies in grooming and personal care. Residents were observed with unwanted facial hair and long, dirty, or untrimmed nails, which were not addressed by the staff. These observations were made during various interviews and record reviews, highlighting a lack of attention to the residents' grooming needs. Resident #45, who had no cognitive impairment, was observed with facial hair and a frayed wheelchair armrest. She expressed a desire to have the facial hair removed and the armrest repaired but was unsure whom to inform. Resident #18, with moderate cognitive impairment, had long, dirty nails and expressed a preference for them to be trimmed more frequently. Resident #17, with severe cognitive impairment, also had long, dirty nails, and a CNA acknowledged the need for trimming but had not yet done so. Resident #9, with severe cognitive impairment, had facial hair and expressed a desire for assistance in removing it. Resident #67, with moderate cognitive impairment, had long toenails and facial hair, and was unsure about how to request assistance for grooming. The Director of Nursing acknowledged the importance of grooming and the potential emotional harm of neglecting these needs. The facility's policy on activities of daily living emphasized the importance of grooming assistance, which was not adequately provided in these cases.
Failure to Maintain Safe Wheelchair Conditions
Penalty
Summary
The facility failed to ensure that assistive devices, specifically wheelchairs, were maintained and free of hazards for three residents. Resident #9, who has severe cognitive impairment and requires extensive assistance for daily care, was observed with a frayed and cracked armrest on her wheelchair. She spends most of her time in the wheelchair and expressed a desire for a new armrest. Resident #18, with moderate cognitive impairment and substantial assistance needs, was found with a cracked and partially missing armrest cushion on his wheelchair. He noted that the missing part could affect his comfort. Resident #45, who has no cognitive impairment but requires substantial assistance, had a frayed armrest on her motorized wheelchair and mentioned that a replacement would be appreciated. The Maintenance Supervisor, responsible for wheelchair repairs, stated that he had not been informed by staff about any wheelchairs needing repair, despite keeping a maintenance logbook at the nurse's station. The logbook, reviewed from January to May 2024, showed no entries for wheelchair armrest repairs. The Director of Nursing (DON) acknowledged that damaged or missing armrests could lead to skin degradation and emphasized the importance of maintaining wheelchair armrests for resident safety and comfort. The facility's policy on Adaptive Devices and Equipment, dated December 2022, requires that devices and equipment be maintained according to the manufacturer's instructions and that defective or worn devices be repaired or discarded. However, the lack of communication and documentation regarding the maintenance needs of the wheelchairs led to the deficiency, potentially placing residents at risk of injury from unsafe equipment.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information, including the current date, total number, and actual hours worked by Registered Nurses, Licensed Vocational Nurses, Certified Nurse's Aides, and the resident census at the beginning of each shift. This information was not posted in a prominent place readily accessible to residents and visitors from May 23, 2024, to May 28, 2024. During an observation on May 28, 2024, it was noted that the staffing information dated May 23, 2024, was still posted at the facility's main entrance. In an interview, the Administrator acknowledged that the hours should be posted to inform family members and residents about the staffing levels during each shift. The facility's policy, dated December 2017, requires that nurse staffing data be posted at the beginning of each shift.
Failure to Maintain QAPI Documentation
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of its ongoing Quality Assurance and Performance Improvement (QAPI) program for the period from March 2024 to May 2024. Record reviews revealed that while QAPI meeting minutes were maintained from August 2023 to February 2024, there were no signed QAPI team signature sheets found for the subsequent months. During interviews, the temporary Administrator (ADM), who assumed the role in May 2024, stated that he and his staff were unable to locate any documentation of QAPI meetings after February 2024. The ADM acknowledged that without monthly meetings, the facility would not be able to identify problems, create resolutions, or assess the effectiveness of solutions. The facility's QAPI policy, dated January 12, 2027, mandates monthly meetings to monitor and evaluate all areas of facility services and practices, with all attending team members required to sign in at each meeting.
Failure to Maintain Resident Dignity During Meals
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity during meal times, as observed in the dining room. Activity Coordinator A was seen standing next to seated residents while assisting them with eating, which is not in line with promoting a dignified dining experience. Additionally, the Assistant Director of Nursing (ADON) was observed using a cell phone while sitting at a table with residents who required assistance with eating, leading to a lack of attention and engagement with the residents. Resident #45 was observed with exposed tubing from a wound vacuum-assisted closure device, which was draped across the side of her wheelchair, compromising her dignity. Furthermore, there was a delay in serving meals, as Resident #18 began eating over six minutes before Resident #13 received their tray, despite sitting at the same table. These observations indicate a failure to provide a dignified and respectful dining experience for the residents. Interviews with staff revealed uncertainty about proper procedures, such as whether to wait for all residents at a table to be served before starting meals and how to handle exposed medical equipment. The Director of Nursing (DON) expressed expectations for staff to be attentive and promote a home-like environment during dining, emphasizing the importance of minimizing visible medical equipment to maintain resident dignity.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12 percent error rate during a medication pass observation. This deficiency involved five residents who did not receive their medications in a timely manner as per physician orders. Specifically, medications such as Potassium, Eliquis, Prostat, Carbidopa Levodopa, Ropinirole, Baclofen, and Lyrica were administered late by medication aides MA E and MA F. The delay in administration was observed during a survey, with medications being given outside the prescribed time frames, which could potentially affect the therapeutic dosages and health status of the residents. Interviews with the medication aides revealed that they were aware of the one-hour window before and after the scheduled administration time but faced challenges such as residents being in therapy, not wanting medications at the scheduled time, or being otherwise occupied. Despite these challenges, the aides did not communicate these issues to the charge nurse or the Director of Nursing (DON). The facility's policy requires medications to be administered within 60 minutes of the scheduled time, which was not adhered to, leading to the observed deficiency.
Significant Medication Errors in Eliquis Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically concerning the administration of Eliquis, a blood thinner, to four residents. Medication aides MA E and MA F did not administer the medication at the prescribed times, which were set by the physician. This failure was observed on 05/28/24, where MA E administered Eliquis late to three residents, and MA F administered it late to one resident. The residents involved had various medical conditions, including chronic heart failure, hypertension, and diabetes, and were at risk of blood clotting due to the delayed administration of their blood thinner medication. Resident #130, a female with chronic pain, heart failure, and anxiety, received her Eliquis at 10:20 a.m. instead of the scheduled 9:00 a.m. Resident #32, a male with hypertension, heart failure, and diabetes, received his Eliquis at 10:32 a.m. instead of 9:00 a.m. Resident #3, a female with similar conditions, received her medication at 10:51 a.m. instead of 9:00 a.m. Lastly, Resident #43, a female with multiple sclerosis and hypertension, received her Eliquis at 11:38 a.m. instead of 9:00 a.m. The residents expressed concerns about the timing of their medication, but these concerns were not communicated to the charge nurse or the Director of Nursing (DON). Interviews with the medication aides revealed that they were aware of the scheduled times but cited reasons such as residents' preferences, therapy sessions, and other activities for the delays. The DON stated that he expected to be notified of any late medication administration, as per the facility's policy, which considers late administration a medication error. However, the aides did not report these incidents, leading to a failure in adhering to the facility's medication administration policy.
Infection Control Deficiencies in Hand Hygiene and Equipment Disinfection
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to proper hand hygiene and equipment disinfection protocols. Specifically, CNAs and an LVN were observed not performing hand hygiene after direct contact with residents while serving meals. This included touching residents and their personal items without using hand sanitizer or washing hands, despite being trained to do so. The staff's actions were observed during meal service, where they failed to use hand sanitizer between serving trays and did not wash their hands after every third use of hand sanitizer, as per facility policy. Additionally, two medical assistants (MAs) failed to disinfect blood pressure cuffs between resident uses. This oversight occurred during routine blood pressure checks for several residents, where the MAs did not sanitize the equipment before or after use, potentially leading to cross-contamination. Interviews with the MAs revealed a lack of awareness regarding the necessity of cleaning the cuffs, despite understanding the potential for germ transmission. Furthermore, an LVN did not perform hand hygiene after removing gloves when using a glucometer for blood sugar tests on residents. The LVN believed that wearing gloves and changing them between tests was sufficient to prevent the spread of germs, neglecting the importance of hand hygiene after glove removal. These deficiencies in infection control practices were identified through observations, interviews, and record reviews, highlighting a significant risk of cross-contamination and infection among residents.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of gnats in multiple areas. Observations over several days revealed gnats in the conference room, nurse's station, dining room, and resident rooms. Staff interviews indicated that the presence of gnats was known but not reported or documented in the pest control logbook. The Licensed Vocational Nurse (LVN) mentioned that the administrator handles pest control issues, and the Maintenance Supervisor acknowledged seeing gnats but did not specify how they were addressed. Residents also reported seeing gnats frequently, but they did not know whom to inform. The pest control logbook at the nurse's stations on Floors 200 and 300 showed no entries regarding gnats, despite their presence. The Maintenance Supervisor stated that staff usually inform him verbally about pest issues, but the logbook was not utilized for documentation. The facility's pest control service agreement outlined monthly pest control services, but the logs did not reflect any actions taken to address the gnat problem. Record reviews of pest control logs from March to May 2024 indicated treatments for gnats in the kitchen and recommendations for deep cleaning. However, there was no documentation of gnat issues in resident or common areas. The facility's policy required monitoring and tracking pest issues, but the lack of documentation and communication among staff contributed to the ongoing presence of gnats, potentially affecting residents' comfort and well-being.
Failure to Secure IV Medications at Nurse's Station
Penalty
Summary
The facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents. During an observation, eight doses of IV antibiotic medication were left unsupervised at the nurse's station on Floor 200. The medications, specifically Nafcillin 2g/50ml in 100mL NS, were intended for administration via PICC line every four hours. The surveyor observed the unsupervised medications for approximately 10 minutes before LVN G, who was responsible for the medications, returned and placed them on an overbed table. LVN G then left the medications unattended again for another five minutes before finally securing them in the locked medication room. In an interview, LVN G acknowledged that the IV bags should have been locked up but cited disorganization due to bad storms and staff lateness as reasons for the oversight. The Director of Nursing (DON) confirmed that it was the facility's expectation for IV antibiotics to be secured when not in use, either in medication carts or the medication room. The facility's policy, dated December 2018, mandates that medications be stored securely to prevent tampering, exposure, or misuse, and only authorized personnel should have access to them.
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 1,184 citations issued within 25 miles in the last 12 months — including the 50 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 Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Simpson Place | 0.6 mi | ★★★★★ | 16 | 0 |
| Ventana By Buckner | 1.2 mi | ★★★★★ | 3 | 0 |
| Fair Park Health & Rehabilitation Center | 2 mi | ★★★★★ | 7 | 0 |
| Autumn Leaves | 4.6 mi | — | 0 | 0 |
| Forest Park Nursing & Rehabilitation | 4.7 mi | ★★★★★ | 13 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.