Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Enchanted Rock during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a hip fracture diagnosis had an ordered acetaminophen dose that was given by the DON, but the midday administration was not documented on the MAR. The DON stated he administered the medication but failed to chart it, and the facility policy requires the person giving the medication to initial the MAR after administration.
A resident with dementia, severe cognitive impairment, partial legal blindness, and high elopement risk was found outside in a courtyard after getting out through a room window. Staff later learned the resident had exited through the window, with her wheelchair left inside near the window and the screen pushed out. Interviews described the resident as confused, wandering, and poor with safety awareness, and the ADM stated the incident was not reported because the resident did not leave the building.
A facility failed to develop complete person-centered care plans for three residents. One resident with depression, dementia, and SI had a reported suicidal discussion with a caregiver, but the care plan did not address the SI despite nursing notes, psych services involvement, and 15-minute checks. Two other residents, both with cognitive and medical diagnoses, had no discharge planning included in their care plans. The MDS nurse stated the SI and discharge plans were not in the care plans because she was not aware of them.
Missing Orders and Care Plans for Cervical Collars Two residents admitted with cervical fractures wore cervical collars, but the facility had no physician orders or care plan interventions for collar management, care, or skin monitoring for several days after admission/readmission. Staff interviews showed CNAs had no instructions for collar care, an LPN briefly removed one resident’s collar without an order, and the charge nurse confirmed neither resident had collar orders. Hospital paperwork indicated the collars were to remain on at all times and included hygiene instructions, but those directions were not reflected in the facility record.
Failure to provide RN coverage 7 days a week: Record review showed the facility had 11 dates with no RN coverage during the review period, and the DON confirmed the gaps in RN staffing. The facility policy stated that an RN provides services at least 8 hours every 24 hours, seven days a week, but the timecards did not reflect that level of coverage.
Failure to report a resident window exit incident: A cognitively impaired, partially blind resident at high risk for elopement was found outside after leaving through a room window and crossing the courtyard to an exterior door. Staff and the DON were notified, but the ADM said the event was not reported to the State because the resident did not leave the building, despite policy requiring immediate reporting of suspected abuse, neglect, exploitation, or injury of unknown source.
A resident with dementia, severe cognitive impairment, partial blindness, and high elopement risk was found outside after going out a room window without staff awareness. Staff later documented that the resident exited through the window, with the screen pushed out and her wheelchair left in front of it. The ADM stated the incident was not reported because the resident did not leave the building, and the facility did not thoroughly investigate the allegation as required by policy.
Delayed Straight Catheterization for Resident with Urinary Retention: A resident with BPH, UTI, and chronic urinary retention was ordered straight in/out catheterization 4 times daily at specific times. Staff did not provide the scheduled 3:00 PM catheterization on time, and the LVN later stated she was unaware of the updated order times because she had not reviewed them.
Insulin Pen Not Primed Before Administration: An LVN administered a resident's insulin aspart using an injection pen without first giving the required air shot/priming dose. The resident had type II DM and was ordered insulin before meals and at bedtime on a sliding scale. The LVN stated she was unaware of the priming step, and the DON confirmed that manufacturer instructions required priming for accurate dosing.
Undated Open Food Items Found in Nourishment Room Refrigerator A nourishment room refrigerator contained two open food items with no dates: a weenie wrap and a chicken express box. The chicken express box held two small containers of eaten mashed potatoes and one piece of eaten chicken. An MDS nurse confirmed the items were open and undated, and the ADM later stated the food was removed from the refrigerator.
Inaccurate documentation of scheduled catheterization: A resident with UTI, urinary retention, and BPH had an order for straight in/out catheterization 4 times daily at specific times. An LVN did not provide the 3:00 PM catheterization on time, later performed it around 4:30 PM, and documented it as 3:30 PM instead. The DON and Administrator stated staff were expected to review orders before the shift and document procedures accurately.
Improper Glucometer Disinfection Between Residents: An RN checked one resident’s blood sugar with a glucometer and then used the same device on another resident without disinfecting it with the approved germicidal wipe. The RN used alcohol wipes instead, stating the facility was out of the correct wipes. The residents had diabetes, with orders for blood sugar checks before meals, and one resident also had an order for insulin lispro based on blood sugar results.
An Activity Director assisted a resident with eating and then passed and set up meal trays for three other residents without performing hand hygiene between contacts, despite a facility policy requiring hand hygiene before and after resident contact and after touching the resident’s environment. The involved residents had conditions including dementia, DM2 with complications, acute kidney failure, visual impairment, post-CVA speech deficits, and joint pain, and required varying levels of assistance with eating. The Activity Director reported she did not sanitize or wash her hands because she did not directly touch food and prioritized delivering trays quickly, and she was unable to clearly recall or apply prior infection control training. The IP and an RN stated that staff are expected to use hand hygiene before and after resident contact and between each tray, and training records showed the Activity Director had completed hand hygiene and infection control education, although the IP later indicated staff had not been specifically trained on hand hygiene and there was no current DON.
A resident with Parkinson's disease and intellectual disabilities did not have PASARR Level II recommendations fully incorporated into their care planning and transitions, as the facility failed to submit accurate and timely requests for specialized therapy services in the LTC Online Portal within the required timeframe. Errors in the NFSS authorization type and lack of staff awareness of submission deadlines contributed to the deficiency.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility did not post daily nurse staffing information in a visible location as required, and failed to retain staffing records for the mandated period. Observations found no current postings, and the responsible staff were unaware of the requirements, with the last posting occurring months prior. Facility policy required daily posting and 18-month retention, which was not followed.
The facility failed to develop and implement baseline care plans within 48 hours for three residents, as required by policy. Interviews revealed confusion among staff regarding the timeline and responsibilities for completing these plans. The residents had various medical conditions requiring timely care plans, but the lack of adherence to policy potentially placed them at risk of not receiving necessary care.
A resident with moderate cognitive impairment and significant physical assistance needs was found without access to a call light, which was placed out of reach on a recliner. The facility's policy requires call lights to be within reach to ensure residents can request assistance, but staff failed to comply, potentially compromising the resident's safety.
A facility failed to update a resident's DNR status in their care plan and physician orders, despite having a completed Texas OOHDNR. This oversight could result in unwanted CPR being performed. Staff interviews revealed a lack of communication and responsibility for updating the resident's code status, with the social worker and MDS Coordinator not ensuring the necessary changes were made in the electronic medical records.
A resident with multiple sclerosis and major depressive disorder alleged verbal abuse by a CNA, claiming inappropriate comments were made about her body. Despite the resident's grievance and an internal investigation by the DON, the incident was not reported to the State Survey Agency as required. The Administrator was unaware of the incident, assuming the DON would manage such grievances according to policy.
A facility failed to investigate and report an allegation of verbal abuse involving a resident with multiple sclerosis and major depressive disorder. The resident claimed a CNA made an inappropriate comment about her body. The DON conducted a limited investigation, concluding the incident was not reportable. The ADM stated grievances should be reported to the state survey agency if they involve abuse allegations.
A resident's Quarterly MDS Assessment failed to include a diagnosis of depression, despite the resident's care plan indicating the use of antidepressant medication. Interviews with facility staff revealed uncertainty about the omission, which could lead to confusion among physicians regarding the resident's care needs.
The facility failed to update care plans for two residents, one with a DNR order and another prescribed a TLSO back brace. The care plan inaccurately reflected a Full Code status for a resident with a DNR, risking unwanted CPR. Another resident's care plan lacked focus on a prescribed back brace, leading to inadequate support. Staff interviews revealed communication lapses and unawareness of necessary updates, contributing to these deficiencies.
Two residents experienced significant medication administration delays due to an LVN working in an as-needed position. One resident with multiple sclerosis received Baclofen late, while another with chronic pain and cognitive impairment had delays in receiving hydrocodone and ciprofloxacin. The facility's policy requires timely administration, but this was not followed, and the medication policy was not provided upon request.
A CNA failed to follow Enhanced Barrier Precautions (EBP) while providing catheter care to a resident with an indwelling suprapubic catheter, despite clear signage and available PPE. The CNA did not wear a gown, contrary to facility policy, which aims to prevent cross-contamination and infections. The Regional Nurse confirmed the requirement for gown and glove use during high-contact care activities.
A facility failed to provide adequate supervision for three residents, leading to significant safety concerns. One resident, with cognitive impairments, was found in another town after leaving the facility unsupervised. Another resident, diagnosed with dementia, was found outside the facility without supervision, and no follow-up assessments were conducted. A third resident managed to leave the facility without triggering door alarms, highlighting issues with safety device functionality and staff training.
The facility failed to update care plans for 16 residents identified as high risk for elopement, despite assessments indicating this risk. The care plans lacked measurable objectives and interventions to address elopement, contrary to facility policy. Interviews with the MDS nurse and DON revealed that care plans should be updated at admission, during a change of condition, and quarterly, but this was not done, leading to a significant deficiency in care planning.
A facility failed to report two incidents involving residents to the state agency. One resident with dementia eloped by taking a car and driving over 60 miles away, while another resident was found outside the facility but not reported as missing. Both incidents were not reported as required, and necessary assessments were not conducted, leading to deficiencies in resident care and safety.
A resident with severe cognitive impairment and mobility issues experienced multiple falls due to inadequate supervision and failure to ensure safety measures, such as locking wheelchair brakes and keeping the call light within reach. Despite being at high risk for falls, the resident's environment was not consistently maintained to prevent accidents, leading to repeated injuries.
Incomplete MAR Documentation for Resident Medication
Penalty
Summary
Clinical records were not maintained in accordance with accepted professional standards and practices for 1 of 5 residents reviewed. Resident #1 was an [AGE] year-old female admitted with a primary diagnosis of periprosthetic fracture around the internal prosthetic right hip joint, subsequent encounter, and her MDS showed a BIMS score of 6, indicating severe cognitive impairment. Her order summary included acetaminophen 500 mg, 2 tablets by mouth three times daily for pain, with a maximum dose of 3 grams per day. The MAR for Resident #1 did not show documentation of the midday acetaminophen dose on 05/10/2026. During interview, the DON stated he was the one who gave the medication that day but did not document it. He also stated residents should not have blanks in their MAR because it could mean the resident did not receive the medication or the nurse did not document correctly. The facility policy titled, Administering Medications, states the individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
Failure to Supervise a High-Risk Resident Who Eloped Through a Window
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for one resident who was identified as severely cognitively impaired, partially legally blind, and at high risk for elopement. The resident’s record showed diagnoses including dementia, muscle weakness, cognitive communication deficit, partial legal blindness, and need for assistance with personal care. Her quarterly MDS documented a BIMS score of 3, indicating severe impairment, and her care plan identified wandering, exit-seeking behavior, poor safety awareness, and the use of a wander guard with monitoring interventions. The resident was found outside in the courtyard between the 300 and 400 halls trying to come back into the building. A maintenance supervisor responded to an alarm and found her outside the 400 hall exit door, then learned she had gotten out through a window in a room on the 300 hall. The resident’s wheelchair was found positioned in front of the window, the window was open, and the screen had been pushed out onto the ground outside the building. The report also states that the resident had no wheelchair with her outside and was brought back into the building by staff. Staff interviews described the resident as confused, able to wander, and partially blind. The maintenance supervisor stated he later limited the opening of the 300 hall room windows and the resident’s room window. The DON stated the resident was the only one with a revised elopement assessment and that her risk score was high. The ADM stated she did not report the incident because the resident did not get out of the building. The report identified this as an Immediate Jeopardy situation related to accidents and hazards and supervision.
Incomplete Care Plans for Suicidal Ideation and Discharge Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and time frames for 3 of 8 residents reviewed. For Resident #42, who had diagnoses including recurrent depressive disorder, Alzheimer’s disease, unspecified dementia, muscle weakness, pain, restlessness and agitation, and suicidal ideations, the care plan did not reflect the resident’s suicidal discussion with her caregiver. The record showed that the caregiver reported the resident had verbalized thoughts of wanting to commit suicide and described a possible plan involving a bedsheet, while the resident later denied intent to harm herself and stated she had said she was ready to die but would not kill herself. Resident #42 was assessed privately, offered counseling and social work support, and was placed on 15-minute checks, with harmful items removed from her room and psychological services consulted. The psychological evaluation documented that staff reported the suicidal statements and that the resident remained confused, forgetful, restless, agitated, and anxious, with limited assessment due to cognitive status. During interview, the MDS nurse stated the care plan did not mention the suicidal ideation because she was not aware of it. For Resident #22 and Resident #4, the care plans did not include discharge planning. Resident #22 had diagnoses including epilepsy, diabetes mellitus type II, difficulty walking, mild cognitive impairment, cognitive communications deficit, and need for assistance with personal care, and her MDS documented moderate cognitive impairment and use of a walker and wheelchair. Resident #4 had diagnoses including dementia, major depressive disorder, and cognitive communication deficit, and her MDS documented she was cognitively intact and used a wheelchair. The MDS nurse stated she did not have discharge plans for Residents #22 and #4 in their care plans and stated the care plan was used as a form of communication to staff.
Missing Orders and Care Plans for Cervical Collars
Penalty
Summary
The facility failed to ensure that two residents with cervical collars received treatment and care in accordance with physician orders, the comprehensive person-centered care plan, and their stated needs. Resident #27 was readmitted with a cervical collar after a cervical spine fracture and prior cervical fixation, but the record showed no physician orders for the collar or for how it was to be managed for 40 days after readmission. His care plan also had no nursing focus, goals, or interventions related to the cervical collar, even though staff observed that he wore a hard collar with Velcro straps and removable pads. Resident #27’s record included hospital documentation stating that he needed a cervical neck brace at discharge, and staff interviews showed that CNA staff had no instructions on the CNA care plan for the collar. An LVN stated she briefly removed the collar daily to assess the surgical site, but confirmed there were no physician orders for the collar or for when it should be removed or how it should be cared for. The resident stated he had worn the collar for months, had asked his physician if he could remove it to clean it, and said he sometimes removed it briefly to clean his neck. Resident #52 was admitted with a cervical fracture and wore a cervical collar, but the record showed no physician orders for collar care, skin care, or monitoring for 6 days after admission. Hospital records stated the collar was to be worn at all times for at least 12 weeks, possibly 6 months, and that a second pair of pads should be provided for hygiene. His care plan also had no focus, goals, or interventions for the collar. CNA staff stated they had no instructions for caring for the collar and would only clean around it, while the charge nurse confirmed that neither resident had orders for their cervical collars. The administrator and ADON stated that when a resident is admitted or readmitted with a medical device such as a cervical collar, the nurse should verify or obtain the order.
Failure to Provide RN Coverage 7 Days a Week
Penalty
Summary
The facility failed to use the services of a registered professional nurse for at least 8 consecutive hours a day, 7 days a week. Record review of RN timecards for the period 11/1/2025 through 4/15/2026 showed 11 dates with no RN coverage, including 11/15/2025, 11/16/2025, 12/27/2025, 12/28/2025, 12/29/2025, 2/28/2026, 3/1/2026, 3/14/2026, 3/15/2026, 3/29/2026, and 4/13/2026. The report states this was a review of 1 of 1 facility for RN services and that the facility did not have an RN on those dates. During an interview on 4/16/2026 at 4:00 PM, the DON confirmed the 11 dates without RN coverage were correct and stated the potential negative outcome for residents could be that they would not have the services of an RN's critical thinking skills. A review of the facility's Staffing, Sufficient and Competent Nursing policy dated August 2022 stated that the facility provides sufficient nursing staff and that a registered nurse provides services at least 8 hours every 24 hours, seven days a week.
Failure to Report Resident Window Exit Incident
Penalty
Summary
The facility failed to ensure that an alleged incident involving a resident leaving through a window was reported immediately, and no later than 24 hours, to the administrator and to the State Survey Agency as required. The deficiency involved a female resident with dementia, muscle weakness, cognitive communication deficit, partial legal blindness, and a need for assistance with personal care. Her records showed she was severely cognitively impaired, used a wheelchair, and was considered high risk for elopement and falls due to impaired vision and poor safety awareness. On the day of the incident, the resident was found outside in the courtyard between two halls after staff discovered her trying to enter a door from the outside. The maintenance supervisor and other staff determined that she had gotten out of a room window in another resident room, with the window opened and the screen pushed out. The resident’s wheelchair was found in front of the window, and the room door was partially jammed with drawers pulled out from the closet base. The resident was returned to the building and assessed, and no injuries were noted at that time. Facility documentation and interviews showed that the administrator and DON were notified of the incident, but the administrator stated the event was not reported to the State because the resident did not get out of the building. The administrator also stated corporate decided the incident was not reportable. Staff interviews confirmed the resident had exited through the window and crossed the courtyard before being found at the exterior door. The facility policy stated that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately, and that immediately means within 24 hours when the event does not involve serious bodily injury.
Failure to Thoroughly Investigate Resident Window Exit
Penalty
Summary
The facility failed to ensure that an allegation involving Resident #44 was thoroughly investigated after the resident went out of a window without staff awareness. Resident #44 was admitted with diagnoses including dementia, muscle weakness, cognitive communication deficit, partial legal blindness, and need for assistance with personal care. Her records also showed severe cognitive impairment, a high elopement risk assessment, and care plan interventions for wander guard use, exit-seeking monitoring, and redirection due to prior wandering behavior. On the day of the incident, Resident #44 was found outside in the courtyard area between the 300 and 400 halls trying to come back into the building. A maintenance supervisor responded to an alarm and found her on the outside of the 400 hall exit door. Staff later documented that the resident had gotten out of the building and into the secured courtyard through a window in her room. The room window was open, the screen was pushed out onto the ground outside, and the resident’s wheelchair was found positioned in front of the window. The resident was confused, partially blind, and had impaired cognition. She was returned to her room after the incident. Interviews showed that staff were aware the resident had exited through the window, but the administrator stated the incident was not reported because the resident did not get out of the building. The administrator also stated the matter was brought to corporate and was decided not to be reportable. The DON stated he was not in the facility when the resident went out the window. The facility policy required all allegations of abuse, neglect, exploitation, or mistreatment to be reported and thoroughly investigated, with findings documented and a follow-up investigation report provided within five business days. The report indicates the facility did not thoroughly investigate the allegation that Resident #44 went out the window without staff awareness.
Delayed Straight Catheterization for Resident with Urinary Retention
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident with bladder incontinence and urinary retention who required straight in/out urinary catheterization four times daily. Resident #55 was admitted with diagnoses including UTI and urinary retention, and hospital records noted chronic urinary retention with home in/out catheterization to continue. The physician ordered catheterizations at 3:00 AM, 9:00 AM, 3:00 PM, and 9:00 PM to support the resident’s BPH and history of UTIs. During observations on 4/14/2026, the resident was in his room and attended physical therapy, but the 3:00 PM catheterization had not been provided by 4:15 PM. The LVN later stated she performed the in and out catheter at about 4:30 PM and was unaware of the specific scheduled times because she had not reviewed the updated physician orders. She stated the prior order did not specify times. The Administrator and DON stated their expectation was that nursing staff review and follow physician orders before taking a shift on the floor.
Insulin Pen Not Primed Before Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors for 1 of 6 residents reviewed, Resident #22. Resident #22 was admitted on 1/10/2026 with a diagnosis of type II diabetes mellitus and was receiving insulin aspart before meals and at bedtime per physician order, with a sliding scale dose of 2 units for a blood sugar of 150 to 200. On 4/15/2026, LVN G checked Resident #22's blood sugar at 163, prepared the 3 mL insulin aspart injection pen, attached a needle, set the dose to 2 units, and administered the insulin without giving the required air shot/priming dose before injection. LVN G stated she was unaware of priming the injection pen and had not performed the procedure before giving the insulin. The DON stated the expectation was to follow the manufacturer's instructions for insulin pen administration, including priming the needle for accurate dosing. The facility policy also stated nursing staff would have access to manufacturer instructions for insulin delivery systems prior to use.
Undated Open Food Items in Nourishment Room Refrigerator
Penalty
Summary
Food safety requirements were not met in the 100 hall nourishment room because two food items in the refrigerator were open and not dated. During observation, a weenie wrap was found opened with no date, and a chicken express box was also opened with no date. The chicken express box contained two small containers of eaten mashed potatoes and one piece of eaten chicken. An MDS nurse confirmed the open, undated food items during interview, and the ADM later stated the food was removed from the refrigerator. No policy was provided before exit.
Inaccurate Documentation of Scheduled Catheterization
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one resident who was admitted with diagnoses including UTI and urinary retention. The resident’s hospital records showed a history of BPH and chronic urinary retention, with an order for straight in/out catheterization four times daily at 3:00 AM, 9:00 AM, 3:00 PM, and 9:00 PM. During observations on 4/14/2026, the resident was in his room, attended PT, and returned to his room, but LVN Z had not provided the scheduled 3:00 PM catheterization. The resident stated at 4:15 PM that he had not received the catheterization. During interview the next day, LVN Z stated she performed the in-and-out catheterization at about 4:30 PM but documented it as having been done at 3:30 PM. She stated she was unaware of the updated physician’s order specifying exact times and had not reviewed the new orders. The Administrator and DON stated their expectation was that nursing staff review physician’s orders before taking a shift and document accurately with the correct dates, times, residents, and procedures. The facility’s charting and documentation policy required all services provided to be documented in the medical record and stated documentation must be objective, complete, and accurate.
Improper Glucometer Disinfection Between Residents
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The deficiency involved two residents reviewed for infection prevention measures, both of whom had diabetes and orders for blood sugar monitoring before meals, with one resident also ordered to receive insulin lispro prior to meals based on blood sugar results. During an observation, RN BB checked the blood sugar of one resident with a glucometer and did not disinfect the device with an appropriate blood borne pathogen disinfectant before using the same glucometer on a second resident. The observation showed RN BB used alcohol wipes to cleanse the glucometer after the first resident and again before the second resident. RN BB stated she used alcohol wipes instead of the germicidal blood borne pathogen wipes because the facility was out of wipes, and she had not reported the lack of germicidal wipes to the DON. Record review showed the glucometer manufacturer’s instructions identified validated disinfecting wipes for the meter and stated that all parts of the glucose monitoring system should be considered potentially infectious and capable of transmitting blood-borne pathogens between patients and healthcare professionals. The facility’s policy for obtaining a finger stick glucose level also required cleaning the glucometer with germicidal wipes or a bleach and water solution between each resident following manufacturer recommendations. The DON stated the expectation was to disinfect the glucometer with approved germicidal wipes between resident uses and that alcohol wipes were not the correct disinfectant.
Failure to Perform Hand Hygiene During Meal Service and Tray Passing
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene during meal service. An Activity Director assisted multiple residents with meals and meal tray delivery without performing hand hygiene between resident contacts, contrary to the facility’s handwashing/hand hygiene policy. The policy, dated 1/2025, states that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and requires hand hygiene immediately before touching a resident, after touching a resident, and after touching the resident’s environment or contaminated surfaces. Record review showed that one resident was an older female with moderate dementia with mood disturbance, type 2 diabetes mellitus with diabetic neurological complications, and generalized muscle weakness. Her MDS indicated moderate cognitive impairment and a need for set-up/clean-up assistance with eating, and her care plan documented that she could eat with tray set-up and supervision. Another resident was an older male with acute kidney failure, type 2 diabetes mellitus without complications, and blindness in one eye, with intact cognition and independence in eating, requiring only set-up assistance. A third resident was an older male with speech and language deficits following cerebrovascular disease, type 2 diabetes mellitus without complications, and joint pain, cognitively intact and independent with eating, with a care plan indicating he could eat with tray set-up and supervision. On the observed date at midday, the Activity Director was seen in the dining area holding a spoon and offering bites of food to an unidentified female resident, then repositioning the resident’s wheelchair and handing her the spoon, without performing hand hygiene afterward. She then went to the open kitchen door, spoke with staff, took a hallway meal cart, and began passing trays. She delivered and set up lunch trays in the rooms of the three identified residents, moving items on bedside tables and discarding an item in the trash, but did not wash or sanitize her hands between residents or while in or exiting their rooms. During interview, the Activity Director stated she did not perform hand hygiene because she did not directly touch the food and believed it was more important to deliver trays quickly so food would not get cold. She reported having received hand hygiene training but could not recall specifics and stated she did not know she was supposed to use hand hygiene between residents, after feeding, or when passing trays. The Infection Preventionist and an RN both stated that staff should use hand hygiene before and after resident contact, including contact with resident belongings and the environment, and between each tray. Training records showed the Activity Director had completed hand hygiene and infection control training in November 2025, while the Infection Preventionist later stated staff had been trained on basic infection control and influenza but not hand hygiene, and that there was no current DON at the facility.
Failure to Timely Submit PASARR Specialized Services Requests
Penalty
Summary
The facility failed to incorporate recommendations from the PASARR Level II determination and evaluation report into a resident's assessment, care planning, and transitions of care. Specifically, the facility did not submit a complete and accurate request for nursing facility specialized services (NFSS) in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team (IDT) meeting, as required. Record review showed that a resident with Parkinson's disease and intellectual disabilities was admitted and had a care plan that included a specialized wheelchair and recommendations for occupational and physical therapy (OT/PT) through the PASARR program. The IDT meeting discussed initiating therapy services, and the NFSS forms were completed for both OT and PT referrals. However, the NFSS forms were initially submitted with the incorrect Authorization Type as 'new' instead of 'restart,' resulting in denial and the need for resubmission. The Director of Rehabilitation (DOR) was unaware of the requirement to submit the NFSS within 20 business days from the last IDT meeting. Interviews confirmed that the facility did not have a PASARR policy in place and relied on state regulations. This failure to timely and accurately process the PASARR-related service requests led to the deficiency identified during the survey.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Post and Retain Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent location as required. Multiple observations on different dates and times revealed that the nurse staffing posting was not visible in the facility's halls. On one occasion, the most recent staffing sheet, dated several months prior, was found under the receptionist's counter rather than being displayed. Interviews with the administrator and receptionist confirmed that they were unaware of the requirement to post the staffing information daily and to retain these records for at least 18 months. The receptionist, who was responsible for posting the staffing sheet, admitted to having stopped this practice, with the last posting occurring several months before the survey. Record review showed that the facility's policy required daily posting of nurse staffing data, including the number of licensed and unlicensed nursing personnel responsible for direct care, within two hours of each shift's start. The policy also required that these records be kept for a minimum of 18 months or as required by state law. The failure to follow these procedures resulted in the absence of current staffing information being posted and a lack of retention of required records.
Failure to Implement Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for three residents within 48 hours of their admission, as required by their policy. This deficiency was identified during a review of records and interviews with staff. The residents involved had various medical conditions, including chronic obstructive pulmonary disease, type 2 diabetes, cognitive impairments, and fractures, which necessitated timely and individualized care plans to address their specific needs. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) revealed a lack of clarity and consistency in the process of completing baseline care plans. The DON stated that charge nurses were responsible for filling out the care plans, but there was a misunderstanding about the timeline, with some staff believing they had up to three days to complete them. Additionally, one LVN mentioned not being informed about the requirement to complete baseline care plans, indicating a communication gap within the facility. The facility's policy, revised in July 2024, clearly stated that baseline care plans should be developed within 48 hours of admission and include essential healthcare information. However, the failure to adhere to this policy resulted in the absence of completed baseline care plans for the three residents, potentially placing them at risk of not receiving the necessary care and services to meet their needs.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #207, had access to a call light within reach, which is necessary for requesting assistance. During an observation, the call light was found on a recliner approximately three feet away from the resident, who was in bed and unable to reach it. Resident #207, who has moderate cognitive impairment and requires substantial assistance for various activities, was unaware of the call light's location. The resident's care plan specifically included the intervention to ensure the call light was within reach, highlighting the importance of this accommodation given her medical conditions, including fractures and muscle weakness. Interviews with staff, including a CNA and the DON, confirmed that the call light was not placed within reach, as required by the facility's policy. The CNA admitted to forgetting to return the call light to the resident's reach after her rounds, acknowledging that the resident would not have been able to reach it in its current position. The DON emphasized the importance of call lights for resident safety, noting that without access, residents might attempt to move independently, risking falls or other injuries. The facility's policy mandates that call lights be accessible to residents to ensure timely assistance, which was not adhered to in this instance.
Failure to Update Resident's DNR Status
Penalty
Summary
The facility failed to ensure that residents have the right to formulate an advance directive and determine their choice regarding CPR. Specifically, for one resident, the facility did not obtain a DNR order or update the care plan after the completion of a Texas OOHDNR. This oversight could lead to staff performing CPR on a resident who did not wish to be resuscitated. The resident in question had a history of serious medical conditions, including hemiplegia, hemiparesis, and dementia, and was unable to complete a mental status interview. Interviews with staff revealed a breakdown in communication and responsibility regarding the resident's code status. The MDS Coordinator and the DON indicated that the social worker was responsible for updating the care plan and communicating changes in code status. However, this did not occur, resulting in the resident's care plan and physician orders incorrectly indicating a full code status. Staff members noted that code status information was typically communicated through the facility's electronic medical records system and the 24-hour report, but in this case, the necessary updates were not made, potentially leading to unwanted resuscitation efforts.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse involving a resident to the State Survey Agency within the required timeframe. The incident involved a resident with multiple sclerosis and major depressive disorder, who alleged that a CNA made inappropriate comments about her body. The resident, who had intact cognition, reported feeling frustrated and upset by the comments, which prompted her to file a grievance. Despite the grievance being investigated by the Director of Nursing (DON), the incident was not reported to the state agency as required by facility policy. Interviews revealed that the DON was informed of the incident by another CNA and conducted an investigation, during which the accused CNA denied making the specific comment. The DON concluded that the incident was not reportable, as she believed the resident did not use the exact phrasing in her complaint. The Administrator was unaware of the incident and assumed the DON would handle such grievances appropriately. The facility's policy mandates reporting all alleged violations to the appropriate authorities, but this was not adhered to in this case.
Failure to Investigate and Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were investigated for one resident reviewed for abuse and neglect. Specifically, the facility did not report to the State Survey Agency an incident where a resident alleged that a CNA made an inappropriate comment about her body. The resident, who has multiple sclerosis and major depressive disorder, reported that the CNA told her that her clothes were too small and that her behind was too large. The grievance was investigated by the DON, who spoke to the CNA involved, who denied making the comment. The DON concluded that the incident was not reportable because the resident did not use the exact phrasing when questioned. The facility's policy requires an immediate investigation when there is suspicion or reports of abuse, neglect, or exploitation. However, the investigation conducted was limited to interviews with the alleged perpetrator and the victim, without further inquiry. The ADM stated that grievances should be responded to by appropriate parties and reported to the state survey agency if they involve allegations of abuse, neglect, exploitation, or misappropriation. The ADM also noted that the investigation should have been more thorough than just interviewing the involved parties.
Omission of Depression Diagnosis in Resident's MDS Assessment
Penalty
Summary
The facility failed to conduct an accurate comprehensive assessment of a resident's functional capacity, specifically omitting a diagnosis of depression in the resident's Quarterly MDS Assessment. The resident, a male with a history of type 2 diabetes mellitus and anxiety disorder, was admitted with a diagnosis of depression, which was not reflected in the MDS assessment. Despite the resident's care plan indicating the use of antidepressant medication and interventions for monitoring effectiveness, the MDS assessment only listed anxiety disorder under psychiatric/mood disorders. Interviews with facility staff revealed a lack of clarity regarding the omission. The LVN responsible for completing the MDS and care plans acknowledged the oversight, while the DON, who oversees the accuracy of MDS assessments, was also unsure why the depression diagnosis was not included. This oversight could lead to confusion among physicians regarding the resident's care needs.
Failure to Update Care Plans for DNR Status and Back Brace
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental needs. For one resident, the care plan inaccurately reflected a Full Code status, despite the resident having a Texas Out of Hospital Do Not Resuscitate (OOHDNR) order completed by the Medical Power of Attorney. This discrepancy was not communicated effectively, leading to the risk of performing CPR against the resident's wishes. Interviews with staff revealed that the social worker was responsible for updating the care plan, but the MDS Coordinator was unaware of the need for revision. Another resident was prescribed a thoracic-lumbar-sacral orthoses (TLSO) back brace to be worn daily, but this was not included in the care plan. The resident occasionally refused to wear the brace, and the care plan lacked any focus, goals, or interventions related to the brace. The MDS Coordinator acknowledged that new orders should be reviewed and discussed by the interdisciplinary team (IDT) during morning meetings, but the care plan was not updated to reflect the brace requirement. The Director of Nursing (DON) confirmed that the intervention for the brace was added only after surveyor intervention. The facility's policy on comprehensive care plans emphasizes the need for person-centered care plans that include measurable objectives and timeframes. However, the failure to update the care plans for these residents placed them at risk of not receiving proper care and services. The lack of communication and coordination among staff members contributed to these deficiencies, as the care plans did not accurately reflect the residents' needs and preferences.
Medication Administration Delays
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #2, diagnosed with multiple sclerosis and using a wheelchair due to bilateral impairments, received her Baclofen medication 32 minutes late. This medication is crucial for managing muscle stiffness and pain associated with her condition. The delay in administration was observed and recorded, indicating a lapse in adhering to the prescribed medication schedule. Resident #6, who suffers from chronic pain and severe cognitive impairment, experienced multiple delays in medication administration. Her hydrocodone, prescribed for pain relief, was administered late on two occasions: once by 3 hours and 10 minutes and another time by 1 hour and 25 minutes. Additionally, her ciprofloxacin, an antibiotic for a urinary tract infection, was given 2 hours and 10 minutes late. These delays were attributed to LVN O, who was working in an as-needed position and was running behind schedule. Interviews with staff revealed that LVN O was aware of the delays and had reported them to the Director of Nursing (DON). However, there was a lack of communication and support, as LVN P only learned of the situation independently and offered assistance. The facility's policy requires medications to be administered within one hour of the scheduled time, but this was not adhered to. Despite a request for the facility's medication administration policy, it was not provided, highlighting a gap in procedural compliance.
Infection Control Breach Due to Non-Compliance with EBP
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not adhere to Enhanced Barrier Precautions (EBP) while providing catheter care to a resident. The resident, who was admitted with conditions including benign prostatic hyperplasia, urinary retention, and obstructive uropathy, required EBP due to the presence of an indwelling suprapubic catheter. Despite the presence of signage and personal protective equipment (PPE) at the resident's room entrance, the CNA neglected to don a gown, although gloves were worn during the procedure. The CNA acknowledged awareness of the EBP protocol and signage but admitted to forgetting to don the gown. The Regional Nurse confirmed that the facility's policy required staff to wear both gloves and a gown during high-contact resident care activities to prevent cross-contamination and infections. The facility's policy on EBP was designed to reduce the transmission of multidrug-resistant organisms by mandating targeted gown and glove use during specific care activities, including those involving urinary catheters.
Inadequate Supervision and Elopement Risks in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for three residents, leading to significant safety concerns. One resident, with a history of alcohol abuse and cognitive impairment, was found in another town after leaving the facility without supervision. Despite being identified as an elopement risk, the resident did not have a functioning wander guard, and staff failed to conduct required visual checks. The resident's absence was not immediately noticed, and the facility did not report the incident to the appropriate authorities, as advised by corporate risk management. Another resident, diagnosed with dementia and other cognitive impairments, was found outside the facility unsupervised. The resident was identified as an elopement risk, yet there were no skin assessments conducted after the incident to ensure the resident's safety. The facility did not report this incident, as the resident was still on the premises, and there was a lack of documentation and follow-up on the resident's condition post-incident. A third resident, also identified as an elopement risk, managed to leave the facility without triggering door alarms. The resident was found walking down the street and was brought back to the facility. Despite having a wander guard, the door alarms did not function as expected, and staff were not adequately trained on elopement procedures. The facility's failure to ensure proper functioning of safety devices and lack of staff training contributed to the resident's unsupervised exit.
Failure to Update Care Plans for High Elopement Risk Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 16 out of 26 residents reviewed, specifically regarding their high risk for elopement. Despite the residents being identified as high risk through their Elopement Risk Assessments, their care plans did not reflect this risk, nor did they include measurable objectives and timeframes to address it. This oversight was contrary to the facility's policy, which mandates that care plans include strategies and interventions for residents identified as at risk for wandering or elopement. The report highlights that the care plans for these residents were not updated to reflect their high elopement risk, even though the facility's policy requires such updates. Interviews with the MDS nurse and the DON revealed that care plans are supposed to be updated at admission, during a change of condition, and quarterly. However, the MDS nurse could not explain why the care plans lacked goals or interventions for elopement risk, and the DON acknowledged that the care plans should have been updated as they drive the care provided by the staff. The facility's policy on wandering and elopements, revised in March 2019, states that residents identified as at risk should have care plans that include strategies to maintain their safety. Additionally, the facility's comprehensive care plan policy from July 2022 requires that care plans be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. Despite these policies, the care plans for the residents in question did not reflect their high risk for elopement, indicating a significant deficiency in the facility's care planning process.
Failure to Report Elopement and Neglect Incidents
Penalty
Summary
The facility failed to report two significant incidents involving residents to the state agency within the required timeframe. The first incident involved a resident with a history of alcohol abuse and dementia who eloped from the facility by taking a car from the parking lot and driving over 60 miles away. Despite the involvement of police and the resident being found in another town, the facility's COO directed staff not to report the incident to the Health and Human Services Commission (HHSC). The resident did not have a wander guard bracelet, and the facility's front doors did not lock overnight, contributing to the elopement. The second incident involved another resident who was identified as an elopement risk due to dementia and impaired safety awareness. This resident was found outside the facility on a sidewalk by an Activities Director (AD) after an alarm sounded. Although the resident was redirected back inside, no skin assessment was conducted, and the incident was not reported to the state agency because the resident was still on the premises. The facility's policy required a skin assessment and incident report, but these were not completed. Both incidents highlight the facility's failure to adhere to its policies and state regulations regarding the reporting of elopements and potential neglect. The lack of timely reporting and appropriate follow-up actions could place residents at risk of harm. The facility's policies on wandering and elopements, as well as abuse, neglect, and exploitation, were not followed, leading to deficiencies in the care and safety of the residents involved.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to maintain a safe environment for a resident, identified as Resident #1, who was at high risk for falls due to severe cognitive impairment and physical limitations. The resident's medical history included unspecified dementia, abnormalities of gait and mobility, lack of coordination, and cognitive communication deficit. Despite these conditions, the nursing staff did not consistently ensure that the resident's wheelchair brakes were locked when not in use, nor was the call light always within reach as per the resident's care plan. Resident #1 experienced multiple falls over several months, with incidents occurring both when attempting to transfer from the wheelchair and while in bed. These falls resulted in various injuries, including lacerations and bruising. Observations revealed that the resident's environment was not adequately supervised or arranged to prevent these accidents. For instance, the wheelchair was often found unlocked, and the call light was not always accessible, which contributed to the resident's attempts to move independently despite needing assistance. Interviews with staff members, including CNAs and the DON, confirmed awareness of the resident's high fall risk and the necessary precautions that should have been in place. However, lapses in following these precautions were evident, such as failing to lock the wheelchair or ensure the call light was within reach. These oversights in care and supervision directly contributed to the resident's repeated falls and injuries, highlighting a deficiency in maintaining a safe environment for residents at risk of accidents.
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 80 citations issued within 25 miles in the last 12 months — including the 2 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 Fredericksburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Fredericksburg | 0.3 mi | ★★★★★ | 2 | 1 |
| Knopp Nursing & Rehab Center Inc | 0.5 mi | ★★★★★ | 17 | 0 |
| Knopp Healthcare And Rehab Center Inc | 1.9 mi | ★★★★★ | 9 | 0 |
| Avir At Comfort | 20.2 mi | ★★★★★ | 10 | 0 |
| Hilltop Village Nursing And Rehabilitation | 20.9 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.