Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Fredericksburg during CMS and state inspections, most recent first.
An LVN pre-poured meds for one resident and then mistakenly gave them to another resident with a similar name. The resident had no order for afternoon meds, opioids, or benzodiazepines, later became unresponsive with slow respirations and low O2 saturation, and was treated in the ED with naloxone after a urine drug screen was positive for methadone, opioids, and benzodiazepines. The other resident’s scheduled 4 PM meds were not given.
A resident with multiple complex medical conditions did not have a comprehensive, person-centered care plan addressing pain, code status, ADL status, incontinence, cognitive loss, skin risk, diet, or psychotropic drug use. The care plan only included fall risk and discharge goals, despite assessments and physician orders indicating broader needs. The new DON confirmed the care plan was incomplete and not updated in a timely manner.
A resident with severe cognitive impairment and psychiatric diagnoses was physically restrained by staff for medication administration on multiple occasions, without a care plan, assessment, or written physician order supporting the use of restraint. Staff had not been trained in therapeutic holds, and medication administration records were incomplete, resulting in a deficiency related to improper use of physical restraint.
The facility did not provide suitable and nourishing snacks to residents at bedtime, despite scheduled snack times and a policy requiring 24-hour snack availability. Interviews with residents and staff, as well as direct observation, confirmed that snacks were not offered at night, and the kitchen was closed with no snacks available. The Administrator and Dietary Manager acknowledged the lack of bedtime snacks, citing logistical and budgetary reasons.
Staff failed to label drink containers used for resident hydration, stored raw protein foods above fully cooked items in the freezer, and kept a personal beverage in the food preparation area. These actions were observed and confirmed by dietary staff and management, who acknowledged the importance of proper labeling, storage, and separation to prevent contamination.
The facility did not consistently screen new staff for TB using its baseline risk assessment, nor did it document offering hepatitis B vaccination to three staff members as required. Additionally, improper PPE use was observed during care of two residents on transmission-based precautions, including a DON entering a resident's room without donning required PPE and failing to change gloves or perform hand hygiene during medication administration for another resident.
Several residents did not receive medications as ordered, including missed doses due to unavailable stock, improper administration of a delayed-release medication, and lack of documentation for administered drugs. In addition, two tablets of a controlled substance could not be reconciled, and expired insulin was found in the medication cart, contrary to facility policy. These deficiencies were identified through observations, interviews, and record reviews involving nursing staff and pharmacy personnel.
The facility employed a Director of Food and Nutrition Services who lacked the required certification, education, and qualifications for the position. Both the DM and the Administrator confirmed the absence of certification, with the DM only enrolled in a program to obtain it at the time of the survey.
A resident with severe cognitive impairment and psychiatric diagnoses was given Haldol for disorganized schizophrenia without the required state consent form on file. Although the responsible party reported giving both written and verbal permission, the facility did not have documentation of consent at the time of administration, as confirmed by the DON.
A resident with severe cognitive impairment and psychiatric diagnoses was physically restrained by staff for medication administration without this intervention being included in the care plan, assessed, or properly documented. Leadership and staff confirmed the use of a therapeutic hold was not care planned, and staff were not trained in restraint techniques. Required consent forms and medication administration records were incomplete, and the facility's policy for restraint use was not followed.
Nursing staff administered intramuscular antipsychotic medications to a resident with severe cognitive impairment and behavioral health diagnoses using a therapeutic hold, despite lacking training or demonstrated competency in restraint techniques. Staff confirmed that no formal training or practice in therapeutic holds had occurred, and there were no records of staff education in this area, resulting in a failure to ensure appropriate competencies for resident care.
A resident with severe cognitive impairment and psychiatric diagnoses received antipsychotic medication, but the MAR was not accurately completed on two occasions, leaving administration times blank despite the medication being given. The responsible party confirmed consent and communication, but facility policy requiring MAR documentation was not followed, as acknowledged by the DON.
A resident with severe cognitive impairment and significant mobility limitations was inaccurately assessed in the MDS as not requiring a mechanical lift for transfers, despite documentation and staff confirmation that a mechanical lift had been needed since admission. The MDS nurse was in training and did not complete the prior assessments, leading to the omission.
A resident with an indwelling Foley catheter did not receive appropriate care, as the catheter was not dated or properly secured, and staff failed to follow correct PPE protocols during catheter care. Staff were unaware of these lapses, and facility policies regarding catheter care and infection control were not followed.
A medication cart was found to contain an insulin pen for a resident with type 2 diabetes that was not labeled with the date it was opened or removed from refrigeration, as required by facility policy. An LVN was unable to confirm when the insulin was opened or if it had been administered that day, and the DON confirmed that insulin should be dated and discarded after 28 days. This failure resulted in noncompliance with accepted medication labeling and storage practices.
Nine multiple occupancy rooms were found to provide less than the required 80 square feet per resident, with measurements showing only about 73 to 74 square feet per person. The Administrator acknowledged ongoing use of these rooms without confirming current room sizes or signing a waiver, despite previous reliance on waivers for non-compliant rooms.
The facility failed to ensure residents' right to a dignified existence by not maintaining wheelchair armrests, affecting three residents. The residents did not report the issues due to fear of bothering the staff, leading to feelings of depression and loss of dignity. The facility's policy on dignity was not effectively followed.
The facility failed to develop and implement comprehensive person-centered care plans for seven residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. Examples include missing information on incontinence, cardiac pacemakers, bed handrails, and fall prevention measures. These deficiencies were confirmed through staff interviews and record reviews, indicating a systemic issue in the facility's care planning process.
The facility failed to update the comprehensive care plans for two residents. One resident's care plan did not reflect her use of antianxiety medication, and another resident's care plan did not align with the facility's policy of not using chair and bed alarms for fall prevention. These deficiencies were confirmed through record reviews and staff interviews.
The facility failed to ensure that menus and nutritional adequacy met the needs of residents, with missing essential food items and unposted weekly menus. Several residents' dietary preferences were not accommodated, and the dietary manager admitted to not conducting food preference assessments or timely food ordering.
The facility failed to ensure that residents received food that accommodated their preferences, specifically regarding types of eggs. Five residents with moderate cognitive impairments had their preferences for eggs either undocumented or not honored, leading to potential issues with resident satisfaction and meal interest. Interviews revealed that the Dietary Manager had not conducted any food preference assessments since starting in the role.
The facility failed to ensure no more than 14 hours between the evening meal and breakfast without a bedtime snack, affecting 4 out of 9 residents reviewed. Residents were not informed about snack options, and staff inconsistently provided snacks, leading to potential risks such as unplanned weight loss and blood sugar issues.
The facility failed to ensure proper disposal of garbage and refuse, as the area near the two dumpsters was on dirt instead of a required concrete slab. The DM was unsure how long the dumpsters had been on dirt, and the ADM was unaware of the situation, with no policy in place for proper dumpster placement.
The facility failed to maintain an infection control program, leading to deficiencies such as staff not following Enhanced Barrier Precautions, lack of proper signage for EBP, and unbagged respiratory equipment, putting residents at risk of cross-contamination and infection.
The facility failed to maintain safe wheelchair conditions for three residents, resulting in torn and worn armrests that caused discomfort and potential injury. The residents did not report the issues to staff, and the RNC acknowledged the safety and dignity concerns.
The facility assessments failed to accurately reflect the status of two residents. One resident's MDS assessment inaccurately indicated significant weight loss, while another resident's assessment failed to document a fall and inaccurately indicated the use of certain medications. The errors were confirmed by the MDS Consultant RN and the Corporate MDS Nurse, who cited a busy schedule as a contributing factor.
The facility failed to ensure a resident had a complete discharge summary, missing a physician's signature and date, at the time of a planned discharge. The resident, who was cognitively intact, was discharged home with home health services. The RN corporate MDS nurse was unaware of the issue, and the facility administrator admitted there was no policy for discharge summaries.
The facility failed to obtain a physician's order for the application of barrier cream to a resident's buttocks and peri area after incontinent care. The resident, who was severely cognitively impaired and always incontinent, had the cream applied by a CNA without proper authorization. The RNC confirmed that a physician's order was necessary for the treatment.
A facility failed to ensure proper incontinent care for a resident, as CNA G did not clean within the labial folds, risking infection. Despite passing a competency check, the CNA did not follow the facility's perineal care policy, which was confirmed by the RNC.
The facility had a medication error rate of 11.54%, with an LVN crushing and administering three medications that were on the Do Not Crush list to a resident with multiple diagnoses. The LVN did not notice the warnings and failed to follow the facility's policy and procedure.
A resident with multiple diagnoses received crushed medications that were labeled 'Do Not Crush' by an LVN, contrary to facility policy. The medications included potassium chloride, tamsulosin, and omeprazole, and were administered mixed with applesauce. The LVN admitted to not noticing the warning labels and did not consult with a physician or pharmacist as required.
The facility failed to employ a certified and qualified Dietary Manager, leading to issues such as out-of-stock food items and lack of pasteurized eggs, which could risk residents' nutrition and food safety. The DM admitted to not being certified or trained for the role and had not conducted any Resident Food Preference assessments since starting the position.
A resident with dysphagia was served pureed meat instead of the prescribed mechanical soft meat due to a shortage of the correct food texture. Staff were aware but did not take immediate corrective action, highlighting a lapse in dietary management and communication.
The facility failed to provide a minimum of 80 square feet per resident in 10 multiple occupancy rooms, with measurements ranging from 73.3 to 74.3 square feet per resident. This deficiency was confirmed through record review and direct observation, and the Maintenance Director acknowledged the need for room waivers.
The facility failed to maintain an infection prevention and control program for a resident diagnosed with Salmonella. Proper isolation protocols were not followed, and the infection was not reported to the local state authority or HHSC. Staff members were unaware of the need for contact precautions and reporting, leading to a deficiency in infection control.
Medication mix-up led to resident receiving another resident’s pills
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when an LVN administered another resident’s medications to her. The resident involved had been admitted for rehabilitation after a heart attack and bypass surgery, and her physician orders did not include afternoon medications, opioids, or benzodiazepines. After taking pills from the nurse, the resident later became unresponsive with slow respirations and a blood oxygen saturation of 65%, and EMS was called to transfer her to the hospital. At the hospital, the resident was evaluated for respiratory distress and low oxygen saturation and was treated with naloxone. The emergency department physician ordered a urine drug screen that was positive for methadone, opioids, and benzodiazepines, none of which were on the resident’s medication list. The resident stated that the last thing she remembered was taking pills from the nurse and that the pills looked different. The LVN stated she was administering afternoon medications for residents on the 100-200 hall and began pre-pouring medications because she thought she might run late. She said she dispensed medications for another resident into a small plastic pill cup with that resident’s name on it and later may have given those medications to the wrong resident because the two residents had similar names. The facility’s records and interviews also showed that the other resident did not receive the intended 4:00 PM prescriptions.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical conditions, including metastatic cancer, COPD, chronic pain, depression, and cognitive impairment. Despite the resident's admission assessment and physician orders indicating needs related to pain management, code status, ADL functional status, incontinence, cognitive loss, skin risk, diet, and psychotropic drug use, the care plan only addressed fall risk and functional discharge goals. No other focus areas or interventions were documented in the comprehensive care plan, leaving significant aspects of the resident's care unaddressed. Observations, interviews, and record reviews revealed that the care plan was not completed in a timely manner and did not reflect the resident's current needs as identified in the comprehensive assessment. The new DON, who had just assumed the role and was still being trained on care plan procedures, confirmed that the previous DON was responsible for care plans and acknowledged the importance of having a complete care plan to manage the resident's care. The facility's own policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed for the resident in question.
Failure to Ensure Resident Freedom from Physical Restraint During Medication Administration
Penalty
Summary
Nursing staff failed to ensure that a resident was free from physical restraint, as required, when they physically restrained her for medication administration on three separate occasions. The resident, a female with severe cognitive impairment, schizophrenia, anxiety disorder, and psychosis, was known to reject care daily and had a care plan addressing her refusal of care and risk for harm. However, the care plan did not include any interventions or assessments related to the use of physical restraint or therapeutic holds for medication administration. On the dates in question, staff physically restrained the resident by having four employees hold her limbs while an injection was administered. This action was taken after the resident refused medication and became agitated, with staff and the responsible party (RP) providing verbal consent for the restraint. The facility did not have a written physician's order for the restraint at the time, nor was there documentation of an assessment to justify the use of restraint. Additionally, staff involved in the restraint had not received training or practiced the technique for performing a therapeutic hold. Interviews with facility leadership and staff confirmed that the use of restraint was not care planned, not supported by a written order, and not preceded by an assessment. The facility's policy required a written order and care plan inclusion for restraint use, but these steps were not followed. The medication administration records were also found to be incomplete or inaccurate for the relevant dates. The lack of proper documentation, assessment, and staff training contributed to the deficient practice of restraining the resident without meeting regulatory requirements.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to ensure that residents were provided with suitable and nourishing snacks outside of scheduled meal service times, specifically at bedtime. Record reviews showed that while snack times were scheduled for 9:30 AM, 2:30 PM, and 7:00 PM, there was no provision for bedtime snacks. Interviews with residents and staff confirmed that snacks were not offered at bedtime, and some residents expressed a desire to receive snacks at night. Observations further revealed that no snacks were available in the dining room at the scheduled 7:00 PM snack time, and the kitchen was closed with no staff present. The Administrator and Dietary Manager acknowledged that bedtime snacks were not being prepared or offered, citing reasons such as lack of a nourishment room, concerns about food waste, and budget constraints. Staff interviews indicated that snacks were rarely distributed, and the facility's policy stated that nourishing snacks should be available to residents 24 hours a day. The failure to provide snacks at bedtime was confirmed through multiple sources, including resident interviews, staff statements, and direct observation.
Failure to Follow Food Safety Standards in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several key areas within the kitchen. Observations and interviews revealed that drink containers used for resident hydration in the dining room were not labeled, despite staff being aware of the requirement to date and label kitchen items. The Dietary Manager (DM) acknowledged the need for continual reminders to staff regarding this practice. Additionally, raw protein food items such as chicken and beef patties were found stored above fully cooked foods like biscuit dough in the freezer, contrary to proper food storage protocols. Staff interviews confirmed their understanding that raw proteins should be stored below ready-to-eat foods to prevent cross-contamination. Further, a personal water bottle was observed stored in a carton of potatoes within the food preparation area, which staff admitted was inappropriate. The DM and dietary staff recognized the importance of keeping personal beverages in designated areas to avoid contamination. Review of facility policy and the FDA Food Code supported the need for proper food labeling, storage, and separation of raw and cooked foods. These lapses in food safety practices were directly observed and acknowledged by staff during interviews.
Deficiencies in Infection Control: Staff Screening, Vaccination, and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by lapses in pre-employment screening and vaccination procedures for staff, as well as improper use of personal protective equipment (PPE) during resident care. Specifically, two certified nursing assistants (CNAs) were not screened for tuberculosis (TB) using the facility's baseline risk assessment form prior to hire, despite providing external TB testing documentation. Additionally, there was no documentation that three staff members, including two CNAs and one licensed vocational nurse (LVN), were offered the hepatitis B vaccination upon hire, as required by OSHA and CDC guidelines. Interviews with administrative staff revealed uncertainty and lack of awareness regarding these requirements, and the facility's onboarding checklist included these items but they were not consistently completed. Observations and record reviews also identified failures in the use of PPE during the care of residents on transmission-based precautions. One male resident with a urinary catheter and contact precautions in place was observed to have had his room entered by the Director of Nursing (DON) without the DON donning the required gown and gloves. The DON acknowledged this lapse and recognized the associated risk of infection transmission. Another female resident with a gastrostomy tube and on enhanced barrier precautions was observed during medication administration, where the DON failed to change gloves and perform hand hygiene between tasks, instead using the same gloves to access the medication cart and perform documentation before continuing care. Facility policies required staff and visitors to wear gloves and gowns upon entering rooms under contact precautions and to remove gloves promptly after use, with immediate handwashing. However, these protocols were not followed during the observed incidents. The CDC and OSHA guidelines referenced in the report further support the need for baseline TB screening, risk assessment, and hepatitis B vaccination offers for healthcare personnel, which were not consistently implemented for the staff reviewed.
Multiple Failures in Medication Administration, Documentation, and Controlled Substance Management
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of several residents, as evidenced by multiple deficiencies in medication administration, documentation, and controlled substance management. For one resident with type 2 diabetes and chronic pulmonary embolism, there was no documentation of the administration of Eliquis and insulin at a scheduled time, despite the nurse stating the medications were given. The nurse attributed the missing documentation to a computer error, acknowledging that such omissions could result in confusion about what medications had been administered. Another resident with dementia received divalproex sodium delayed-release tablets that were crushed prior to administration, contrary to pharmacy guidance and manufacturer instructions. The pharmacist was unaware that the medication was being crushed and indicated that this could affect the medication's absorption and effectiveness. The DON confirmed that the medication should not have been crushed and that the order was later changed to an appropriate formulation. Additionally, a resident with tardive dyskinesia did not receive multiple doses of Austedo XR due to the medication not being available in the facility, and the missed doses were not properly documented in the medical record. The DON and ADON were not aware of the missed doses until after the fact, and there was no formal process for confirming new medication orders in the electronic medical record, leading to further missed doses for other residents. The facility also failed to maintain accurate records for controlled substances. For one resident, two tablets of hydrocodone-acetaminophen could not be accounted for, and the facility's investigation was unable to reconcile the missing doses. The process for shift-to-shift narcotic counts was described, but discrepancies still occurred. In another instance, expired insulin vials for a resident with diabetes were found in the medication cart past the facility's policy for discarding opened insulin, and it was unclear if the expired insulin had been administered. The DON confirmed that insulin should be discarded after 28 days and that unlabeled insulin should not be administered.
Unqualified Food and Nutrition Services Director
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to manage the food and nutrition service, as required by regulations. Specifically, the Director of Food and Nutrition Services (DM) did not possess the necessary certification, education, or qualifications for the position. Record review showed the DM was hired without the required certification, and both the DM and the Administrator confirmed during interviews that the DM was not certified as a food services manager at the time of the survey. The Administrator acknowledged awareness of the certification requirement and prior citation for this deficiency, but allowed the DM to continue in the role while enrolled in an educational program to obtain certification.
Failure to Obtain Required Consent for Antipsychotic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was fully informed and able to participate in her treatment regarding the administration of an antipsychotic medication. Specifically, a resident with severe cognitive impairment and multiple psychiatric diagnoses, including schizophrenia and psychosis, was administered Haldol by an LVN without evidence of the required state consent form (Form 3713) in her medical record. The resident's care plan included interventions for medication refusal and behavioral issues, and her responsible party (RP) reported providing both written and verbal consent for the medication. However, the facility did not have the necessary documentation of consent on file at the time of administration. The Director of Nursing (DON) confirmed that the consent form had not been completed for the antipsychotic medication and acknowledged the oversight. The facility's policy required proper documentation and initialing of the medication administration record (MAR), but the absence of the signed consent form indicated a lapse in ensuring the resident's right to be informed and to participate in her care and treatment decisions.
Failure to Care Plan and Document Therapeutic Hold for Medication Administration
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with severe cognitive impairment and multiple psychiatric diagnoses, including schizophrenia, anxiety disorder, and psychosis. The resident was known to reject care daily and had a history of restlessness, agitation, and aggressive behaviors. Despite these identified needs, the care plan did not include specific interventions or measurable objectives related to the use of a therapeutic hold for medication administration, even though this intervention was used multiple times. Interviews with facility leadership, including the DON and ADON, confirmed that the use of physical restraint (therapeutic hold) for medication administration was not included in the resident's care plan, nor was there an assessment documenting the need for such restraint. The staff proceeded with holding the resident for medication administration based on verbal orders from the physician and consent from the resident's representative, but without formal documentation, care planning, or staff training on safe restraint techniques. The facility's own policy required that any use of restraint be prescribed, assessed, and included in the care plan, which was not followed in this case. Additionally, there were lapses in documentation and medication administration records, as well as a lack of completion of required consent forms for antipsychotic medication. Staff interviews revealed that non-pharmacological interventions were attempted, but when unsuccessful, the resident was physically restrained by multiple staff members to administer injections. The absence of a care plan addressing the use of therapeutic holds, lack of staff training, and incomplete documentation placed the resident at risk of not receiving care and services consistent with her identified needs and resident rights.
Failure to Ensure Nursing Staff Competency in Therapeutic Holds for Medication Administration
Penalty
Summary
The facility failed to ensure that licensed nurses and nursing staff possessed the specific competencies and skill sets necessary to care for residents as identified through assessments and care plans, particularly in the use of therapeutic holds for medication administration. A resident with severe cognitive impairment, schizophrenia, anxiety disorder, and psychosis was admitted and consistently refused care and medication. The care plan included interventions for refusal, such as trying alternate staff or approaches, notifying family and physician, and providing alternate settings, but did not address the use of therapeutic holds. On multiple occasions, nursing staff administered intramuscular antipsychotic medications to the resident using a therapeutic hold, involving four staff members to restrain the resident for injection. The DON, ADON, and LVN involved confirmed that no staff had received training or practiced therapeutic holds or restraint techniques for medication administration. The decision to use a therapeutic hold was made after consulting with the psychiatric nurse practitioner and physician, and verbal permission was obtained from the resident's representative, but there was no evidence of staff competency or training in this area. Record review and staff interviews revealed that there were no training records or documentation to show that nursing staff were educated or competent in performing therapeutic holds safely. Staff described discussing their approach among themselves prior to entering the resident's room but acknowledged a lack of formal training or practice in restraint techniques. This lack of training and competency could place residents at risk due to staff not having the appropriate skills to provide care as required by resident needs and care plans.
Failure to Accurately Document Antipsychotic Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was properly informed of, and participated in, their treatment regarding the administration of antipsychotic medication. Specifically, for a resident with severe cognitive impairment and multiple psychiatric diagnoses, the June Medication Administration Record (MAR) did not reflect that RisperDAL Consta was administered on two scheduled dates. The MAR entries for these dates were left blank, despite the medication being given according to the Director of Nursing (DON). The resident's care plan included interventions for medication refusal and behavioral issues, and the responsible party (RP) confirmed ongoing communication and consent for the medication. Interviews and record reviews confirmed that the facility's policy required staff to initial the MAR after administering each medication, but this was not done for the two identified dates. The DON acknowledged the importance of accurate MAR documentation to ensure staff are aware of what medications have been administered. The lack of proper documentation could result in residents not being fully informed or involved in their treatment as required.
Inaccurate MDS Assessment of Transfer Needs
Penalty
Summary
The facility failed to ensure that assessments accurately reflected a resident's status, specifically for one resident who was reviewed for assessment accuracy. The quarterly Minimum Data Set (MDS) submitted on 1/22/2025 did not indicate that the resident required a mechanical lift for transfers, despite documentation and staff interviews confirming that the resident had required the use of a mechanical lift since admission. The resident's care plan included fall prevention measures involving the use of a Hoyer lift, and the Certified Occupational Therapy Assistant (COTA) confirmed the resident was unable to stand or bear weight at all. The Assistant Director of Nursing (ADON), who was serving as the MDS nurse, stated she was still in training and had not completed the prior two MDS submissions for this resident. She was unable to explain why the earlier assessment failed to document the need for a mechanical lift, even though she recalled the resident had always required it. The resident was noted to have severely impaired cognition and was unable to be interviewed during the survey. The inaccurate assessment could result in the resident not receiving the required care.
Deficient Catheter Care and Infection Control Practices
Penalty
Summary
A resident with a history of benign prostatic hyperplasia and moderately impaired cognition was admitted with an indwelling Foley catheter following an episode of urinary retention and treatment for a urinary tract infection. The facility failed to ensure that the resident received appropriate care and treatment for the catheter, as observations revealed the catheter and associated equipment were not dated, and the catheter tubing was not attached to the securement device as required by facility policy. Staff interviews confirmed a lack of awareness regarding the absence of dating and improper securement, with staff attributing the missing date to the catheter being inserted at the hospital. Additionally, during catheter care, a CNA was observed improperly donning and doffing personal protective equipment (PPE), including putting on gloves before the gown, not changing gloves or performing hand hygiene after repositioning the resident, and removing gloves before the gown at the end of care. The CNA admitted to not following correct PPE procedures and identified the risk of cross-contamination. Facility policies required proper PPE use and securement of the catheter, but these were not followed, and relevant infection control policies were not provided upon request.
Failure to Label Opened Insulin Pen in Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals, specifically insulin, were labeled in accordance with accepted professional principles and facility policy. During an observation of a medication cart, an insulin pen assigned to a resident with type 2 diabetes mellitus and hyperglycemia was found without a label indicating the date it was opened or removed from refrigeration. The only information present was the pharmacy label. The LVN assisting with the observation was unable to confirm when the insulin pen was opened or removed from the fridge and stated that the facility's process is to label insulin pens and vials with the date of opening, keeping them for 29 days after removal from refrigeration before discarding. The LVN was also unsure if the resident had been administered insulin from the unlabeled pen that day. The DON confirmed that facility policy requires insulin to be dated when opened and discarded after 28 days. Review of the facility's policy on medication labeling and storage corroborated this requirement, stating that multi-dose vials must be dated and discarded within 28 days unless otherwise specified by the manufacturer. The failure to label the insulin pen with the date of opening or removal from refrigeration constituted noncompliance with both professional standards and facility policy.
Failure to Provide Minimum Square Footage in Multiple Occupancy Rooms
Penalty
Summary
The facility failed to provide the required minimum of 80 square feet per resident in nine multiple occupancy rooms, as determined through interviews and record reviews. Specifically, rooms 109, 111, 112, 201, 204, 209, 211, 315, and 317 were each classified to accommodate three residents, but measurements showed that each resident would have only approximately 73 to 74 square feet of space, which is below the regulatory requirement. These findings were based on room size measurements from 2023 and 2024, as well as a review of the facility's Form 3740 Bed Classifications completed by the Administrator. During interviews, the Administrator acknowledged that the facility continued to use these rooms despite their non-compliance with space requirements and indicated that room waivers had been used in the past two years for these rooms. However, the Administrator also stated that she had not signed a room waiver and had not confirmed the room sizes during the survey or upon follow-up. No residents were specifically identified as being affected at the time of the survey, but the report notes the occupancy status of each room during the review.
Failure to Maintain Wheelchair Armrests Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure the residents' right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. This deficiency was observed in three residents who relied on wheelchairs for mobility. Resident #11's wheelchair had a torn and sharp left armrest, which made him feel depressed. Despite being moderately cognitively impaired, he did not report the issue because he did not want to bother the staff. His care plan included promoting dignity and assisting with ADLs as needed, but this was not effectively implemented in this case. Resident #15's wheelchair had both armrests torn and worn, causing him to feel a loss of dignity. He also did not report the issue to the staff for fear of being a bother. His care plan similarly emphasized promoting dignity and assisting with ADLs. Resident #18's wheelchair had both armrests torn and worn, with the left armrest missing foam and exposing the baseboard. This condition made him feel down and undignified. Like the other residents, he did not complain to the staff about the issue. The RNC acknowledged that worn and torn armrests on residents' wheelchairs were a safety and dignity issue. She stated that the facility had a process for reporting maintenance needs, but it appeared that staff had not noticed the issues because the residents did not complain. The facility's policy on dignity emphasized that each resident should be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. However, this policy was not effectively followed in the cases of Residents #11, #15, and #18.
Care Plan Deficiencies in Long-Term Care Facility
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for seven residents, leading to deficiencies in addressing their medical, nursing, and psychosocial needs. For instance, Resident #11's care plan did not reflect his frequent urinary and occasional bowel incontinence, despite his moderate cognitive impairment and the need for moderate assistance with care. This oversight was confirmed by both the resident and the RNC, who acknowledged the importance of including incontinence in the care plan to ensure accurate and consistent care. Similarly, Resident #15's care plan lacked critical information about his cardiac pacemaker, including its type, model, serial number, insertion date, and next operational check. This omission was noted despite the resident's moderate cognitive impairment and the presence of a pacemaker for six years. Both the RNC and the Corporate MDS Nurse admitted the importance of this information for quick reference in case of a malfunction, highlighting the risk of missed care. Other residents also experienced significant care plan deficiencies. Resident #16's care plan did not include her bowel incontinence, Resident #19's care plan lacked details about his bed handrails, and Resident #21's care plan failed to address her edema, compression stockings, and diuretic use. Additionally, Resident #22's care plan for fall prevention was not measurable, and Resident #29's care plan did not include his bed handrails. These deficiencies were confirmed through interviews with staff and record reviews, indicating a systemic issue in the facility's care planning process.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for two residents. Resident #21's care plan was not updated to reflect her use of antianxiety medication, despite it being indicated in her quarterly MDS assessment and physician orders. Interviews with the RNC and Corporate MDS Nurse confirmed that the care plan was not updated, which could result in missed or inappropriate care for the resident who was moderately cognitively impaired and required assistance with ADLs. Resident #22's care plan was not revised to align with the facility's policy of not using chair and bed alarms for fall prevention. Despite the policy, the care plan still included the evaluation for bed/chair alarms. Interviews with facility staff confirmed that chair and bed alarms were not used, and the MDS consultant RN acknowledged that the care plan should have been updated to reflect the current policy. This oversight could lead to inconsistencies in the care provided to the resident, who was also moderately cognitively impaired and had a history of falls.
Failure to Ensure Nutritional Adequacy and Menu Compliance
Penalty
Summary
The facility failed to ensure that menus and nutritional adequacy met the needs of residents. Observations revealed that essential food items such as pasteurized eggs, shelled eggs, bananas, bread, and onions were missing from the kitchen. Several residents expressed their preferences for specific types of eggs, which were not accommodated due to the unavailability of these items. Additionally, the kitchen staff served only one slice of bacon instead of the two slices specified in the menu, affecting multiple residents. The dietary manager admitted to not conducting resident food preference assessments since starting the job and acknowledged issues with timely food ordering and delivery. The facility also failed to post the weekly at-a-glance menu, which could result in residents not being aware of what will be served. This was confirmed through multiple observations and interviews with both residents and staff. The dietary manager and assistant dietary manager were aware of the requirement to post the menus but failed to do so. The dietary manager also lacked training on ordering food items, which contributed to the unavailability of essential ingredients. Record reviews of several residents indicated that their dietary needs and preferences were not adequately documented or followed. For instance, one resident with dysphagia was served pureed food but did not receive all the items listed on the menu. Other residents with moderate cognitive impairment had their food preferences either not documented or not followed. Interviews with residents revealed dissatisfaction with the food service, including missing items and unmet preferences. The facility's policy on resident nutrition services was not adhered to, leading to these deficiencies.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to ensure that residents received food that accommodated their preferences. Specifically, five residents were not served their preferred types of eggs, and there was no documentation of dietary assessments reflecting these preferences. Resident #13, #17, #18, #24, and #29 all had moderate cognitive impairments and expressed specific preferences for eggs, which were not documented or honored in their care plans or diet cards. For example, Resident #13's diet card noted 'no eggs,' while she preferred fried eggs, and Resident #18's diet card noted 'extra eggs,' but he preferred hard-boiled eggs for his chef salad. Interviews with the Dietary Manager (DM) and the Administrator (ADM) revealed that the DM, who started on 2/1/2024, had not conducted any resident food preference assessments. The ADM confirmed that the DM was required to be certified and had received training, but could not explain why the resident preferences were not completed. The lack of proper documentation and adherence to resident food preferences could affect all residents with food preferences, potentially leading to a decrease in resident choices and diminished interest in meals.
Failure to Ensure Timely Snacks and Adequate Nutrition
Penalty
Summary
The facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, unless a nourishing snack was served at bedtime. This failure was observed in 4 out of 9 residents reviewed for meal frequency. The facility did not make residents aware of how to obtain a snack when desired, and residents were not offered bedtime snacks as required. This issue was identified through observations, interviews, and record reviews, which revealed that the facility's posted meal service times did not include information about snack availability after specified times. Additionally, residents reported not being informed about snack options, and staff interviews confirmed that snacks were only provided to residents with specific orders or those who requested them from the nurse's station. The dietary consultant and other staff members acknowledged the potential negative effects of not offering snacks, such as unplanned weight loss and issues related to blood sugar levels. The facility's snack list did not include all residents, and there was no documentation of residents receiving bedtime snacks. Interviews with various staff members, including the dietary manager, assistant dietary manager, licensed vocational nurse, and certified nursing assistant, indicated inconsistencies in snack distribution and awareness among residents. The facility's policies and procedures on snacks, dated September 2017, aimed to provide adequate nutrition to residents, but the implementation was found lacking in this instance.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed on 5/13/2024. The area near the facility's two dumpsters was on dirt instead of a concrete slab, which is required by the FDZ Food Code for outdoor storage surfaces. The observation noted that there was only a concrete slab big enough for one dumpster. During an interview on 5/14/2024, the DM stated that the dumpsters had been moved to the dirt ground due to space constraints but was unsure how long they had been there. On 5/16/2024, the ADM was interviewed and stated she was unaware of the dumpsters being on dirt and mentioned there was no policy requiring dumpsters to be on a concrete slab. The FDZ Food Code mandates that outdoor storage surfaces for refuse must be constructed of nonabsorbent material such as concrete or asphalt and be smooth, durable, and sloped to drain.
Infection Control Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection control program, leading to several deficiencies. For Resident #16, CNAs did not follow Enhanced Barrier Precautions (EBP) by failing to sanitize their hands before entering and reentering the room. Additionally, CNA A placed a dirty dressing back onto Resident #16's wound after it fell onto a dirty brief during incontinent care. RN F also failed to wear a gown while performing a dressing change for Resident #16, despite being trained on EBP guidelines. These actions were confirmed through observations and interviews with the involved staff, who acknowledged their mistakes and the potential for cross-contamination and infection as a result of their actions. For Resident #29, the facility failed to have proper signage indicating that the resident was on EBP. During a dressing change, it was observed that there was no sign on the door to indicate the need for EBP, although the necessary PPE was available in a plastic bin outside the room. LVN H admitted that the sign must have come off and was not replaced, emphasizing the importance of such signage to prevent cross-contamination and infection. Resident #134's nebulizer mask and oxygen tubing were left unbagged when not in use, contrary to the facility's policy. During a medication pass, it was observed that the oxygen mask and tubing were not stored in plastic bags, which is necessary to prevent dust and contaminants from entering and causing infection. LVN C acknowledged missing this detail and the importance of bagging the equipment to protect the resident from potential contamination. The facility's policy and procedure on respiratory therapy tasks and equipment were not followed in this instance.
Failure to Maintain Safe Wheelchair Conditions
Penalty
Summary
The facility failed to maintain mechanical, electrical, and patient care equipment in safe operating condition for three residents. Resident #11's wheelchair had a torn and sharp left armrest vinyl, which he reported had caused him to cut his arm. He did not report the issue to staff because he did not want to bother anyone. Resident #15's wheelchair had both armrests torn and worn, causing him to feel a loss of dignity. He also did not report the issue to staff for the same reason. Resident #18's wheelchair had both armrests torn and worn, with the left armrest missing foam and exposing the baseboard. He did not complain to the staff either. The residents' medical records indicated that they were moderately cognitively impaired and required manual wheelchairs for mobility. The facility's comprehensive person-centered care plans for these residents included promoting dignity and assisting with ADLs as needed. However, the observations on 05/14/2024 revealed that the wheelchairs were in poor condition, which was confirmed by the residents during interviews. The residents expressed that the damaged wheelchairs made them feel depressed and uncomfortable. The RNC acknowledged that the worn and torn armrests were a safety and dignity issue. She stated that she had not noticed the need for repairs and that staff were supposed to write down repair needs in the Maintenance book at the nurse's station. The facility did not provide a policy or procedure to address safe equipment or maintenance of wheelchairs upon request. The facility's incident and accident reports did not show any injuries related to equipment issues, but the potential for harm was present. The Maintenance Director was not available for an interview.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility assessments failed to accurately reflect the status of two residents. Resident #14's significant change MDS assessment inaccurately indicated significant weight loss, which was not supported by the weight variance report. The MDS Consultant RN confirmed the error, acknowledging the importance of accurate MDS assessments for proper care planning. Resident #14's diagnoses included hemiplegia, cerebrovascular diseases, dysphagia, and Alzheimer's disease. Resident #21's quarterly MDS assessment failed to document a fall and inaccurately indicated the use of antidepressant and diuretic medications. The resident's records showed a fall event and the use of antianxiety medication, but no antidepressant or diuretic during the specified period. The Corporate MDS Nurse admitted to the oversight, citing a busy schedule. The facility's policy requires personnel to certify the accuracy of the MDS assessments, which was not adhered to in these cases.
Incomplete Discharge Summary
Penalty
Summary
The facility failed to ensure that a resident had a complete discharge summary at the time of a planned discharge. Specifically, Resident #31's discharge summary lacked a physician's signature and date. The resident, who was cognitively intact, was discharged home with home health services. The RN corporate MDS nurse was unaware of why the discharge summary was incomplete and stated she would investigate, but no response was provided before the survey exit. Additionally, the facility administrator admitted there was no policy for resident discharge summaries.
Failure to Obtain Physician's Order for Barrier Cream Application
Penalty
Summary
The facility failed to ensure that Resident #16 received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not obtain a physician's order for the application of barrier cream to Resident #16's buttocks and peri area after incontinent care. Resident #16, who was severely cognitively impaired and always incontinent of bowel and bladder, had a comprehensive care plan addressing urinary incontinence but lacked an active order for the barrier cream, which was being applied by the CNA without proper authorization. During an observation, CNA A was seen applying Calmoseptine Ointment to Resident #16's buttocks, including three open wound areas, without a physician's order. CNA A mentioned that the barrier cream was provided by a hospice worker, but she did not verify if there was an official order for its use. The RNC confirmed that a physician's order was necessary for the barrier cream as it is considered a treatment, and acknowledged that hospice orders should be integrated with the facility's orders. The facility's policy on medication and treatment orders, revised in July 2016, mandates that orders for medications and treatments must be consistent with principles of safe and effective order writing.
Failure to Provide Proper Incontinent Care
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. During an observation, CNA G was seen providing incontinent care to Resident #6 but did not separate and clean within the labial folds. This improper care practice was confirmed by CNA G during an interview, where she acknowledged that she was supposed to clean between the folds to remove germs and prevent infections. The Resident's quarterly MDS indicated that she was always incontinent for bladder and bowel, and her medical history included cerebral infarction, dementia, hypothyroidism, neuropathy, and glaucomatous flecks. The Resident's electronic face sheet and quarterly MDS indicated impaired cognition and continuous incontinence. Despite passing a competency check for perineal care in March 2024, CNA G failed to follow the facility's policy on perineal care, which requires separating the labia and cleaning from front to back. The RNC confirmed that the labial folds need to be cleaned to ensure proper hygiene and prevent bacterial infections. The facility's policy on perineal care, revised in October 2010, outlines the necessary steps for proper cleaning, which were not followed in this instance.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure its medication error rates were not 5% or greater, resulting in a medication error rate of 11.54%. This was based on 3 errors out of 26 opportunities involving one resident. Specifically, an LVN crushed three medications for a resident that were on the Do Not Crush list. The medications included potassium chloride, tamsulosin, and omeprazole, all of which had clear warnings on their medication cards indicating they should not be crushed. The LVN administered these crushed medications mixed with applesauce to the resident after the resident requested them to be crushed. The resident involved had multiple diagnoses, including encephalopathy, chronic obstructive pulmonary disease, poisoning by cardiac-stimulant glycosides, congestive heart failure, and cognitive communication deficit. The LVN admitted to not noticing the do not crush warning and stated she was trained to not crush medications unless there was a specific provider order. The facility's policy and procedure required checking the Medications Not to Be Crushed list and consulting with a pharmacist for suitable alternatives if necessary.
Significant Medication Error Due to Crushing 'Do Not Crush' Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors during a medication pass. Specifically, LVN C crushed three medications for a resident that were labeled with 'Do Not Crush' warnings. The medications included potassium chloride, tamsulosin, and omeprazole, all of which were observed to be crushed and mixed with applesauce before administration. This action was contrary to the facility's policy and the medication cards' explicit instructions, which clearly indicated that these medications should not be crushed. The resident involved had multiple diagnoses, including encephalopathy, chronic obstructive pulmonary disease, and congestive heart failure, and required assistance with medication management. Despite being trained to check for 'Do Not Crush' warnings and to consult with a physician or pharmacist if necessary, LVN C admitted to not noticing the warning labels and proceeded to crush the medications. The facility's 'Medications Not to Be Crushed' list and policy on medication administration were not adhered to, leading to this significant medication error.
Inadequate Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The Dietary Manager (DM) did not have the necessary certification, education, or qualifications to serve as the Director of Food and Nutrition Services. The DM admitted to not being certified or trained as a kitchen manager and was promoted from a dietary aide position. The DM also stated that he had not conducted any Resident Food Preference assessments since starting the position on 2/1/2024. Additionally, the DM was not trained on ordering food for the kitchen menu items, leading to out-of-stock items such as bananas, bread, and onions. The DM also failed to ensure the availability of pasteurized eggs, which were not in stock for three days, affecting residents who preferred fried eggs for breakfast. The facility's Administrator (ADM) confirmed that the DM was not certified and was aware that the DM was taking classes but was unsure of the certification timeline. The job description for the Dietary Manager required credentials in Dietary Management, which the DM did not possess. The U.S. Public Health Service Food Code mandates that the person in charge be a certified food protection manager, a requirement that the DM did not meet. This deficiency could place residents at risk of foodborne illness and inadequate nutrition due to the lack of proper food safety and nutrition management in the facility.
Failure to Provide Correct Diet Texture
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual needs for one resident. Specifically, Resident #2, who had a diet order for mechanical soft ground meat and pureed fruits and vegetables, was served pureed meatloaf instead of the prescribed mechanical soft meat. This discrepancy was observed during lunch on 5/14/24. Interviews with staff revealed that the cook ran out of mechanical soft meat and substituted it with pureed meat without informing the appropriate personnel or taking corrective measures. The dietary manager and other staff were aware of the issue but did not take immediate action to rectify it. Resident #2, a 71-year-old with diagnoses including polyneuropathy, muscle weakness, dysphagia, and cognitive communication deficits, was moderately cognitively impaired and required partial assistance with eating. Despite the dietary consultant's assertion that the resident was not at risk of choking due to the texture change, the facility's policies clearly state that each resident should receive the correct diet as ordered by the physician. The facility's failure to adhere to these policies and ensure the correct diet texture for Resident #2 highlights a significant lapse in dietary management and communication among staff members.
Inadequate Space Per Resident in Multiple Occupancy Rooms
Penalty
Summary
The facility failed to provide a minimum of 80 square feet per resident for residents in 10 multiple occupancy rooms. Specifically, rooms 109, 111, 112, 201, 204, 209, 210, 211, 315, and 317 were found to have less than the required space per resident. The measurements of these rooms ranged from 73.3 to 74.3 square feet per resident, which is below the regulatory requirement. This deficiency was identified through record review and direct observation by the Maintenance Director, who confirmed the inadequate space in these rooms. The issue was documented in Form 3740 Bed Classifications, completed by the Administrator, which classified these rooms to have three resident beds each. However, the actual space per resident did not meet the minimum requirement. During an interview, the Maintenance Director acknowledged the need for room waivers for the affected rooms. This deficiency could potentially impact the residents' living conditions and their ability to perform activities of daily living comfortably.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an infection prevention and control program for a resident diagnosed with Salmonella. The resident's records did not include a physician's order or a sign indicating contact precautions, and the facility did not report the infection to the local state authority or HHSC. This oversight was identified through interviews and record reviews, revealing that the resident had multiple episodes of diarrhea and was diagnosed with Salmonella on two separate occasions. Despite this, proper isolation protocols were not followed, and the infection was not reported as required. The resident's care plan indicated contact precautions, but this was not reflected in the consolidated physician orders. Interviews with the DON and other staff members revealed a lack of awareness and adherence to reporting requirements and isolation protocols. The DON admitted to not entering the contact precautions order into the resident's records, and the ADM was unaware of the need to report the Salmonella infection. Staff members also confirmed that there were no signs on the resident's door indicating contact precautions, and standard precautions were not consistently followed. The facility's policy on infection prevention and control was not adhered to, as evidenced by the lack of proper documentation, communication, and reporting. The DON, who was also the Infection Preventionist, acknowledged the importance of reporting contagious infections but failed to do so. The facility's failure to follow established protocols and guidelines for infection control and reporting contributed to the deficiency, potentially affecting other residents and staff members.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 97 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
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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 Enchanted Rock | 0.3 mi | ★★★★★ | 19 | 1 |
| Knopp Nursing & Rehab Center Inc | 0.4 mi | ★★★★★ | 17 | 0 |
| Knopp Healthcare And Rehab Center Inc | 1.9 mi | ★★★★★ | 9 | 0 |
| Avir At Comfort | 20 mi | ★★★★★ | 10 | 0 |
| Hilltop Village Nursing And Rehabilitation | 21 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.