Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Giddings during CMS and state inspections, most recent first.
A resident with COPD, HTN, lymphedema, and moderately impaired cognition had a care plan that did not include an order for larger lunch and dinner portions. During observation, the resident’s meal tray and ticket showed the same portion sizes as another resident’s, despite the meal card noting large portions at lunch and dinner. The MDS nurse, DON, and Administrator each stated that the order should have been included in the care plan.
Missing Person-Centered Care Plans for Activities and ADLs: The facility failed to include required activity preferences, 1:1 activity interventions, and ADL needs in the care plans for three residents. Two residents with severe cognitive impairment and mental health diagnoses had no documented activity care plans despite stated preferences for music, groups, reading, news, and religious services, and one resident with dementia, weakness, poor memory, and dependence for multiple ADLs had no ADL documentation on the comprehensive care plan. Interviews with the Activity Director, MDS Coordinator LVN, Activity Assistant, and Administrator confirmed these items were expected to be care planned.
Failure to provide needed grooming and nail care: A resident with severe cognitive impairment was observed with facial hair on her face, and two residents with severe cognitive impairment were observed with blackish/brownish substance under their fingernails. Records showed all three residents needed assistance with ADLs, and their care plans did not document ADL needs. Staff stated nail care and facial hair checks were to be completed during showers and as needed, with diabetic nail care done by nurses and other nail care done by CNAs.
Failure to Provide and Document Resident Activity Programming: Three residents with dementia, depression, anxiety, and severe cognitive impairment did not have documented activity plans tied to their preferences, and participation records showed missed activity days. During observation, an Activity Assistant sat away from residents while they held activity items they did not understand, and she stated she did not always document activities and had no proof the activities occurred. The Activity Director and Administrator stated activities and resident preferences were expected to be documented and individualized.
A resident with pain, encephalopathy, cerebellar stroke syndrome, and moderate cognitive impairment had hydrocodone-acetaminophen changed from PRN to scheduled TID, but the medication card in the cart was not updated to reflect the new direction. Staff interviews confirmed the label still showed the prior PRN instruction, and the ADON, RN, DON, and med aide all acknowledged the change-of-direction label had not been placed on the card.
Improper Hand Hygiene and Glove Use During Food Prep: The Dietary Manager and a Dietary Aide were observed handling food with gloves after touching a crate, a shelf, and clothing without changing gloves or washing hands. They continued serving breakfast and plating cheesecake, including touching plates and food with gloved hands. Both staff stated they had been in-serviced on hand hygiene, and the facility policy identified hand hygiene as the primary means to prevent the spread of infections.
Hand hygiene was not followed during wound care for two residents on enhanced barrier precautions. An RN failed to clean a bedside table before placing supplies, did not perform hand hygiene after removing gloves and gown, and did not clean her hands before changing gloves or moving between dirty and clean wound care tasks. One resident had diabetes, ESRD, and a pressure ulcer with severe cognitive impairment; the other had PVD, foot wounds, and severe cognitive impairment.
A resident with severe cognitive impairment and a Stage 3 coccyx pressure ulcer was repositioned in bed while his room door was open and the privacy curtain was not pulled. RN J exposed the resident’s buttocks and sacral wound during care while x-ray was being performed, and both CNA E and RN J acknowledged that privacy should have been maintained during the procedure.
Unlocked Housekeeping Cart With Chemicals Left Unattended: A housekeeping cart containing glass cleaner, disinfectant cleaner, tub and tile cleaner, and bio waste degrader was observed in the dining room with its chemical compartment unlocked while the housekeeper was out of view behind a wall. The housekeeper stated the cart should be locked whenever she walked away from it, and the Administrator and Housekeeping Supervisor stated carts were expected to be locked when not in use.
Failure to Care Plan Dementia Needs: A resident with dementia, depression, anxiety, and severe cognitive impairment did not have dementia included on the care plan, and the plan lacked individualized, person-centered interventions for her cognitive needs, preferences, abilities, or engagement. A psychiatric evaluation documented dementia with behavioral disturbances and recommended behavioral interventions, redirection, and supportive encouragement for socialization, but the care plan only addressed DNR status and fall risk. During observation, the resident was yelling in bed and could not answer questions about assistance or pain, and facility leadership acknowledged dementia should have been care planned.
A resident with severe cognitive impairment and a history of frequent falls was allowed to self-propel a wheelchair outside without supervision, despite hazardous conditions such as broken pavement and proximity to a busy highway. Staff and administration were aware of the resident's unsupervised outdoor activity, and the care plan lacked specific interventions for supervision. Additionally, after an unwitnessed fall, nursing staff did not promptly respond or document the incident, and required notifications were not made.
A resident with a history of falls and severe cognitive impairment was found on the floor by non-nursing staff, but nursing staff delayed their response and did not document the incident or notify the DON, physician, or resident representative. The event was dismissed as a behavioral issue, and required assessments and notifications were not completed according to facility policy.
A resident with chronic pain and multiple health conditions did not receive scheduled doses of Tylenol-codeine 3 because the medication was unavailable, resulting from delays in ordering and confusion among staff regarding pharmacy procedures and use of the emergency medication kit. Nursing staff did not notify the DON or provider in a timely manner, and documentation of refill orders was inconsistent. The resident reported pain, but alternative pain medication was not requested or administered.
Expired and opened medical supplies were found in a medication cart on the 100/200 hall, including Xeroform dressings, sterile cotton-tipped applicators, and drain sponges. Staff interviews revealed a lack of adherence to a schedule for checking expiration dates, with responsibility shared among nurses and the pharmacist. The facility's policy mandates the return or destruction of outdated supplies, but no resident complaints were recorded.
Three residents with significant physical and cognitive impairments were found to have their call lights out of reach while in bed, despite facility policy and staff expectations that all staff ensure call light accessibility. Observations showed call lights placed on the floor or on distant surfaces, and interviews revealed inconsistent staff training and care plan documentation regarding call light placement.
Persistent uncleanliness was observed in two shower rooms, two resident rooms, and multiple common areas, with soiled items, stained linens, unsanitary toilets, and foul odors present over several days. Two residents with cognitive impairments lived in rooms with ongoing hygiene issues and strong odors, and their care plans did not address these behaviors. Housekeeping staff reported insufficient hours and resources to maintain cleanliness, and facility leadership acknowledged the problem and staffing challenges.
Surveyors identified deficiencies in kitchen practices, including uncovered and unlabeled food stored in the refrigerator, personal items such as shoes stored on a utility cart in contact with hair nets, and a cook failing to follow proper hand hygiene and glove use during food preparation. These actions were confirmed by the Dietary Manager and staff, who acknowledged the lapses and the facility's policies requiring proper food storage, sanitation, and hand hygiene.
Four staff members began working with residents without documented orientation or required training on abuse, neglect, exploitation, and dementia care, as mandated by facility policy. Personnel files lacked evidence of completed orientation, and interviews with HR, DON, and ADM confirmed that the new onboarding process did not ensure staff received this training before resident contact.
Two residents did not have all of their care needs addressed in their care plans. One resident with dementia and severe cognitive impairment had a care plan for bladder continence but not for his behavior of urinating in inappropriate places, despite this being a known issue. Another resident with multiple cardiac conditions and severe cognitive impairment had deep tissue injuries on both heels, but her care plan did not address pressure injury prevention or treatment, even though she was receiving wound care. Staff interviews confirmed these omissions were due to lapses in the care planning process.
Two residents did not receive care according to physician orders and care plans: one did not have a skin tear monitored or treated after a fall and hospital readmission, and another did not have compression hose applied as ordered due to unavailability and staff oversight. Nursing staff and leadership confirmed lapses in assessment, documentation, and follow-up, contrary to facility policy.
A resident with a history of falls and multiple chronic conditions was found to have a nonfunctional emergency call light in her bathroom. Instead, a squeaky toy was attached to the handrail as an alternative, but it was not audible in the hallway. Staff interviews revealed inconsistent understanding of responsibilities for monitoring call light systems, and facility policy requiring functional call lights was not followed.
The facility failed to provide adequate activities for residents, particularly on the secure unit and certain halls, leading to potential risks of boredom and depression. The Activity Director and Assistant lacked proper documentation of activities, and residents expressed dissatisfaction with the lack of group engagement.
The facility failed to provide adequate nail care for two residents, one with diabetes and another with severe cognitive impairment. Observations showed unclean and rough nails, despite care plans requiring assistance. Staff interviews revealed confusion over nail care responsibilities, with non-CNAs performing tasks against facility policy.
A resident with diabetes and severely impaired cognition was served a full-size dessert instead of the prescribed half portion, despite having an elevated blood sugar level. The facility's dietary protocol for low concentrated sweet diets was not followed, as confirmed by the dietary manager and registered dietician consultant. The oversight was acknowledged by the DON, who noted the resident's blood sugar should have warranted a sugar-free dessert.
A facility failed to document critical notifications after a resident's fall, risking inaccurate medical records and inadequate care. The resident, with cognitive impairment and a history of falls, experienced an unwitnessed fall. The nursing staff did not record whether the family, physician, or nurse practitioner was informed, as required by the facility's Fall Protocol. The Director of Nurses confirmed the lack of documentation, and attempts to contact the responsible nurse were unsuccessful. The Nurse Practitioner was notified but issued no new orders as the resident reported no pain.
A resident with severe cognitive impairment and a history of wandering eloped from a secure unit courtyard due to inadequate supervision. The resident was left unsupervised, climbed over a fence, and left the facility. Staff interviews revealed inconsistent training and protocols regarding supervision in the courtyard, contributing to the incident.
A resident at risk for falls did not have a fall mat beside their bed as required by their care plan. The resident, with a history of traumatic subdural hematoma and Alzheimer's, was observed without the mat, and the LVN was unaware of this requirement. The ADON and DON emphasized the importance of following care plans to prevent injuries.
The facility failed to provide a safe, clean, comfortable, and homelike environment for seven residents and four hallways. Observations revealed various issues, including stains, peeling paint, damaged walls, malfunctioning bathroom fixtures, and strong odors. Interviews with residents and staff confirmed that these issues had been present for a long time, and the facility had not taken adequate steps to address them.
A CNA verbally abused a resident with severe cognitive impairment by using foul language and refusing to make up her bed, causing distress. The incident was reported by two staff members, and the facility's investigation confirmed the abuse. The resident did not recall the incident due to her cognitive condition.
Care Plan Did Not Reflect Ordered Larger Meal Portions
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident that included measurable objectives and timeframes to meet identified medical, nursing, mental, and psychosocial needs. Resident #01, a [AGE]-year-old male admitted with COPD, hypertension, and lymphedema, had a BIMS score of 09, indicating moderately impaired cognition. Record review showed the resident’s comprehensive care plan dated 03/04/2026 did not address the order for larger portions at lunch and dinner. During observation on 05/20/2026 at 12:26 pm, Resident #01’s lunch tray contained 1 chopped beef sandwich, 1 serving of beans, 1 serving of corn, and 1 dessert. The surveyor compared the resident’s meal ticket with another resident’s meal ticket and found both tickets listed the same amounts of food, and both plates appeared to have the same portion sizes. Resident #01’s meal card noted 1 regular serving of food with instructions for large portions at lunch and dinner, while the other resident’s meal ticket had no such note. The MDS nurse, DON, and Administrator each stated that a doctor’s order for larger portions at lunch and dinner should be included in the care plan.
Missing Person-Centered Care Plans for Activities and ADLs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for three residents. The deficiency involved missing care plan documentation for activity preferences and interventions for two residents, and missing ADL documentation for one resident. The facility’s comprehensive care plan policy stated that each resident’s plan must include measurable objectives and timeframes, describe services to meet physical, psychosocial, and functional needs, and reflect the resident’s goals and desired outcomes. Resident #17 was admitted with diagnoses including senile degeneration of the brain, polyneuropathy, and major depressive disorder. Her admission MDS showed a BIMS score of 6, indicating severely impaired cognition, and she was assessed as feeling down, depressed, or hopeless. Her activity preferences included reading books, newspapers, and magazines; listening to music; participating in groups; doing favorite activities; going outside for fresh air when weather was good; and participating in religious services or practices. Her comprehensive care plan did not include an activity care plan related to these preferences or her ability to participate in activity programming. Resident #52 was admitted and later readmitted with diagnoses including unspecified dementia, major depressive disorder, and anxiety disorder. His MDS assessments showed BIMS scores of 3 and 4, indicating severely impaired cognition. His stated activity preferences included keeping up with the news, doing things in groups, doing favorite activities, participating in religious services or practices, and listening to music. His comprehensive care plan did not include an ADL and activity care plan related to his preferences or his ability to participate in activity programming. Resident #58 was admitted with diagnoses including unspecified dementia, muscle weakness, need for assistance with personal care, and lack of coordination. Her quarterly MDS showed she was rarely or never understood, had poor short- and long-term memory, severely impaired decision-making, and required substantial to maximal assistance with showers and was dependent for personal hygiene, upper and lower body dressing, and toileting hygiene. Her comprehensive care plan did not document her ADLs. Interviews with the Activity Director, MDS Coordinator LVN, Activity Assistant A, and the Administrator confirmed that activity preferences, 1:1 activities, and ADL needs were expected to be care planned and that staff would rely on the care plan to know what interventions to provide. The Activity Director stated all activity programs were expected to be on each resident’s care plan and that she had no explanation for why the activity care plans were missing. The MDS Coordinator LVN agreed that the three residents did not have activity care plans and stated that without ADL documentation staff would have difficulty knowing what care to provide. The Administrator stated that activity preferences, interventions, and ADLs were expected to be documented on the care plan.
Failure to Provide Needed Grooming and Nail Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received the necessary assistance to maintain good grooming and personal hygiene. During observation and record review, Resident #17 was found sitting in the dining room with facial hair under her chin and on the side of her upper lip. She stated that she did not like hair on her face and wanted it removed. Her record showed severe cognitive impairment with a BIMS score of 6 and need for supervision or touching assistance with personal hygiene, toileting hygiene, showers, dressing, transfers, and bed mobility. Her comprehensive care plan did not document ADLs. Resident #52 was observed sitting in the dining room with blackish/brownish substance underneath the middle and ring fingernails on both hands. He had a BIMS score of 4 and required supervision or touching assistance with personal hygiene, toileting hygiene, showers, dressing, transfers, and bed mobility. His comprehensive care plan also did not document ADLs. Resident #58 was observed in the dining room with blackish/brownish substance underneath the middle and ring fingernails on the right hand. Her record showed she was rarely or never understood, had poor short- and long-term memory, severely impaired decision-making, and required substantial to maximal assistance with showers and was dependent for personal hygiene, dressing, and toileting hygiene. Her comprehensive care plan did not document ADLs. Interviews with nursing staff and the DON indicated that nail care was to be completed by CNAs for residents without diabetes and by nurses for residents with diabetes, usually on shower days and Sundays, and facial hair on female residents was to be checked on shower days and as needed. Staff also stated that any refusal of care should be documented in the medical record. The facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene, including bathing, dressing, grooming, and oral care.
Failure to Provide and Document Resident Activity Programming
Penalty
Summary
The facility failed to provide an ongoing activity program that supported residents’ choices in facility-sponsored group activities, individual activities, and independent activities for three residents reviewed for activities. The deficiency involved Resident #17, Resident #52, and Resident #58, all of whom had diagnoses including dementia or cognitive impairment, and two of whom also had depression and/or anxiety. Their records showed activity preferences such as listening to music, reading, being in groups, going outdoors, participating in religious services, and keeping up with the news, but their comprehensive care plans did not document activity plans related to those preferences and abilities. Record review showed that Resident #17 did not receive activities on multiple days in March and April 2026, and Resident #52 did not receive activities on multiple days in March 2026 and April 2026. Resident #58’s record also did not document an activity plan related to her preferences and abilities. During observation on the secure unit, the Activity Assistant was seated away from residents and was documenting participation records while residents sat at a table with activity items in front of them. Resident #17 was observed with an activity item she did not understand and stated she did not know what to do with it. The Activity Assistant stated she did not know the residents needed assistance or that they did not have all the items needed to do the activity, and said she thought the residents knew what to do with the items. The Activity Assistant stated she worked Monday through Friday, did 1:1 visits every day, and was expected to document participation records when activities occurred, but she did not always do so because she did not have enough time. She also stated she did not have participation records every day and did not have proof the residents received activities every day in March and April 2026. The Activity Director stated participation records were expected to be completed immediately after each activity and that if activities were not documented, the activity did not occur. She also stated activity preferences and plans were expected to be documented on care plans. The Administrator stated residents’ activity preferences were expected to be assessed, activities were expected to be planned according to those preferences, and independent, in-room, and group activities were expected to be documented on participation records.
Medication Label Not Updated After Order Change
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with currently accepted professional principles for one resident. Resident #36, an older male with encephalopathy, cerebellar stroke syndrome, pain, bilateral lower-limb swelling, and cognitive communication deficit, had a BIMS score of 12 indicating moderate cognitive impairment. His care plan included interventions to administer pain medications per order, and physician orders showed hydrocodone-acetaminophen 5-325 mg changed from an as-needed order to a scheduled order of 1 tablet by mouth three times a day. The medication label in the medication cart was not updated to reflect the change in frequency. Review of the medication administration record showed the medication had been administered as a scheduled medication, but staff interviews confirmed the card still reflected the prior as-needed direction and that a change-of-direction label had not been placed on the medication card. The ADON, RN, DON, and medication aide all acknowledged that the nurse receiving the order was responsible for updating the label, and staff stated that a medication error could occur if the label was not changed.
Improper Hand Hygiene and Glove Use During Food Preparation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During breakfast service, the Dietary Manager wore gloves while serving from the steam table but handled a red crate with both hands, moved it to another area, and then returned to the steam table without changing gloves. She then touched inside a divided plate with her right hand and placed food where she had touched, walked away from the steam table to obtain a pitcher, and when she handled the pitcher from a shelf, her fingers touched the shelf. She returned to the steam table again without changing gloves and continued serving food, including placing oatmeal in a bowl and touching the oatmeal with her fingers before continuing meal service. Dietary Aide G was also observed wearing gloves while cutting cheesecake and placing slices on dessert plates at the food prep table. She left the food prep area, touched her shirt in the left shoulder area with her right hand, and then returned to continue cutting and plating cheesecake without changing gloves. She touched the side of two cheesecake pieces and touched inside four dessert plates before placing the cheesecake slices on them. The Dietary Manager and Dietary Aide G both stated they had been in-serviced on hand hygiene and glove changes, and the facility policy stated hand hygiene is the primary means to prevent the spread of infections.
Hand Hygiene Not Followed During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program when RN J did not follow hand hygiene procedures during wound care for two residents. Resident #10 had diagnoses including type 2 diabetes mellitus, stage 3 pressure ulcer of the sacral region, end stage renal disease, and dependence on renal dialysis. His quarterly MDS showed a BIMS score of 5, indicating severe cognitive impairment, and his care plan identified enhanced barrier precautions with directions for staff to use gown and gloves during high-contact care and to wash hands or use alcohol-based gel when entering and exiting the room. During observation of wound care for Resident #10, RN J failed to clean the bedside table before placing wound care supplies on it. After completing care to the left lateral great toe wound, she removed her gloves and gown but did not perform hand hygiene before leaving the room to get more supplies. When she returned, she again did not perform hand hygiene before putting on a new gown and gloves. She then performed wound care to the right medial foot, changed her gloves, and again failed to perform hand hygiene. Resident #24 had diagnoses including peripheral vascular disease, an open wound to the right foot, and a non-pressure chronic ulcer of the left foot. His annual MDS showed a BIMS score of 3, indicating severe cognitive impairment, and his care plan also included enhanced barrier precautions with directions for gown and glove use and hand hygiene when entering and exiting the room. During observation of wound care for Resident #24, RN J failed to perform hand hygiene after completing care to the left heel wound and beginning care on the right lateral ankle. She also failed to perform hand hygiene or change gloves after cleaning the right lateral ankle wound before dressing it. At the end of the procedure, she washed her hands in the sink with soap and water for less than 10 seconds.
Failure to Maintain Resident Privacy During Repositioning
Penalty
Summary
The facility failed to ensure a resident was treated with respect, dignity, and privacy during repositioning care. Resident #10, a severely cognitively impaired male with depression, anxiety disorder, and a sacral pressure ulcer, was dependent on staff for multiple ADLs and required substantial to maximal assistance with bed mobility. His care plan identified a Stage 3 coccyx pressure ulcer and included interventions for skin breakdown prevention and treatment. During observation, Resident #10 was in bed receiving x-ray while RN J repositioned him with the room door open and the privacy curtain not pulled. RN J moved him toward the window and held him while his buttocks remained exposed, and an open area to his sacrum was visible. CNA E observed the exposure and stated the curtain should have been pulled and the door closed during care. RN J later stated she knew privacy was required during care and acknowledged Resident #10’s buttocks were exposed and visible from the hallway, but said she did not think about pulling the curtain until she saw the surveyor.
Unlocked Housekeeping Cart With Chemicals Left Unattended
Penalty
Summary
The facility failed to ensure Housekeeping Cart #1, which contained chemicals in its compartments, was locked when it was left unattended. On 04/21/2026 at 9:30 a.m., Housekeeping Cart #1 was observed in the dining room with the chemical storage compartment unlocked. The cart contained glass cleaner, disinfectant cleaner, tub and tile cleaner, and bio waste degrader. Housekeeper H was not standing near the cart and was behind a wall in the dining room, unable to view it, while no other staff were near the cart. During interview, Housekeeper H stated the cart was expected to be locked anytime the housekeeper walked away from it and said she could not see the cart from where she was standing. She also stated she had a key but it was difficult to lock the cart. The Administrator and Housekeeping Supervisor both stated housekeeping carts were expected to be locked when not being accessed, and both noted that if a resident swallowed chemicals, the resident could become ill and may need hospital evaluation. The report also notes that the facility’s Safety and Supervision of Residents policy addressed poison control, and requested records related to chemical storage on housekeeping carts were not provided prior to exit.
Failure to Care Plan Dementia Needs
Penalty
Summary
The facility failed to ensure a resident with dementia received necessary care and services to support the highest practicable level of physical, mental, and psychosocial well-being. Resident #2 was a female with diagnoses including unspecified dementia, major depressive disorder, anxiety, hypothyroidism, and a history of hyperosmolality and hypernatremia. Her quarterly MDS assessment showed she was unable to complete the BIMS interview because she was rarely or never understood, and the staff mental status assessment indicated severely impaired cognitive skills. Review of the resident’s comprehensive care plan showed only two focus areas: DNR status and fall risk related to balance problems. The care plan did not include dementia as a focus area and did not contain individualized, person-centered interventions addressing her cognitive needs, preferences, abilities, or need for engagement. A psychiatric evaluation noted moderate dementia with behavioral disturbances, delusional disorders, generalized anxiety disorder, major depressive disorder, and insomnia, and recommended behavioral interventions, redirection as needed, and supportive encouragement to increase interaction and socialization. During observation, the resident was heard yelling while in bed and was unable to answer questions about whether she needed assistance or was in pain. Interviews with the DON, RNC, MDS Coordinator, and Administrator confirmed that dementia should have been included on the care plan when a diagnosis was present, but it was not. The facility’s dementia clinical protocol stated that the IDT would identify a resident-centered care plan to maximize remaining function and quality of life and document the resident’s condition and level of support needed during care planning, and the comprehensive person-centered care plan policy required measurable objectives and services to meet the resident’s physical, psychosocial, and functional needs.
Failure to Prevent Accident Hazards and Ensure Timely Response to Falls
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision or assistance devices to prevent accidents for a resident with a history of frequent falls and severe cognitive impairment. The resident, who had diagnoses including repeated falls, impulse disorder, cerebral infarction, muscle weakness, unspecified lack of coordination, bipolar disorder, and chronic kidney disease requiring dialysis, was allowed to self-propel in a wheelchair outside the facility without supervision. The area outside included hazards such as broken pavement, exposed dirt and rocks, and was adjacent to a busy highway. Staff and administration were aware that the resident was allowed outside unsupervised, and there were no care plan interventions specifying the type or frequency of supervision required for outdoor activities, despite the resident's high fall risk and severe cognitive impairment as indicated by a BIMS score of 7. Multiple staff interviews confirmed that the resident was permitted to go outside alone, and that staff would intermittently check on him, with intervals ranging from every 10 minutes to every hour or two. Observations documented the resident navigating hazardous outdoor areas without staff present. Staff acknowledged that the resident had a history of unwitnessed falls both inside and outside the facility, and that he was difficult to redirect and lacked safety awareness. Despite these known risks, the care plan did not include specific interventions for outdoor supervision, and staff relied on the resident's ability to follow instructions, even though his cognitive status was severely impaired. Additionally, the facility failed to ensure prompt and appropriate response to an unwitnessed fall. On one occasion, the resident was found on the floor in his room by a staff member and a visitor, who reported a delay in nursing response. The fall was not documented, nor were notifications made to the DON, physician, or resident representative. Staff interviews revealed confusion about whether the resident's behavior of placing himself on the floor should be treated as a fall, leading to inconsistent documentation and reporting. The lack of immediate assessment and failure to follow facility policy for fall response and documentation placed the resident at risk for harm.
Failure to Respond and Document Unwitnessed Fall
Penalty
Summary
A deficiency occurred when nursing staff failed to respond appropriately to an unwitnessed fall involving a male resident with a history of repeated falls, severe cognitive impairment, and multiple comorbidities including impulse disorder, cerebral infarction, muscle weakness, bipolar disorder, and chronic kidney disease requiring dialysis. The resident was found on the floor in his room by a maintenance director and a visitor, who reported the incident to nursing staff at the nurse's station. Despite being notified, the nursing staff delayed their response, with reports indicating a wait of several minutes before the resident was assisted. During this time, the resident was observed face down on the floor with a pillow under his head, calling for help, and his call light was not within reach. The incident was not documented in the resident's medical record, progress notes, or incident reports. There was no evidence that the fall was reported to the DON, physician, or the resident's representative. Interviews with staff revealed inconsistent accounts regarding the response time and actions taken following the report of the fall. Some staff dismissed the event as a behavioral issue, referencing the resident's care plan, which noted a tendency to self-transfer and lie on the floor, but did not include specific interventions for supervision or documentation of such events. The lack of documentation and notification was contrary to facility policy, which requires all falls, including unwitnessed ones, to be assessed, documented, and reported. Further review of the resident's care plan and fall risk assessments showed a pattern of previous falls, but no interventions addressing supervision outside or specific documentation protocols for unwitnessed falls. The facility's policies define a fall as any unintentional change in position to the floor and require immediate assessment, documentation, and notification of appropriate parties. The failure to follow these protocols resulted in the event not being properly managed or communicated, as required by professional standards of practice.
Failure to Ensure Timely Administration of Scheduled Narcotic Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs for a resident with multiple diagnoses, including atherosclerotic heart disease, dementia, chronic pain, and anxiety disorder. The resident had a physician's order for Tylenol-codeine 3 to be administered every 8 hours, but the medication was not given at two scheduled times due to it being unavailable. Documentation on the Medication Administration Record (MAR) indicated the medication was not administered at midnight for an unspecified reason and at 8:00 AM due to the drug being unavailable. Interviews with nursing staff revealed that the medication was not available in the facility because the pharmacy was closed and the refill had not been ordered in time. Staff indicated that narcotics required a provider to call in refills, and there was confusion about the use of the emergency kit (e-kit), with some staff believing it was tied to a specific pharmacy. The Director of Nursing (DON) clarified that the e-kit was available for any resident and that staff should have notified her or the provider about the missed dose. The DON also stated that medications should be ordered 5-7 days before running out, and that documentation of refill orders was inconsistent. The resident reported running out of Tylenol 3 earlier in the week and experienced pain related to chronic back and sciatic nerve issues. Staff interviews indicated that the resident did not display obvious signs of pain at the time the medication was missed, and alternative pain medication was available but not requested. The nurse practitioner (NP) was notified after the fact and expressed minimal concern, stating the resident had access to regular Tylenol and did not consider the situation an emergency. Facility policy required medications to be administered as ordered unless a provider specified otherwise.
Expired Medical Supplies Found in Medication Cart
Penalty
Summary
The facility failed to ensure pharmaceutical services were provided to meet the needs of each resident by storing expired or opened medical supplies in one of the two medication carts on the 100/200 hall. During an observation, it was found that the medication cart contained several expired items, including Xeroform dressings, sterile cotton-tipped applicators, drain sponges, hydrogel saturated dressings, and silicone composite dressings. Additionally, an opened package of rolled gauze bandage was found, which compromised its sterility. These findings were confirmed through interviews with various staff members, including LVN E, LVN C, the ADON, the DON, and the ADM, who all acknowledged the responsibility of checking expiration dates and the potential ineffectiveness of expired supplies. The staff interviews revealed a lack of adherence to a schedule for checking expiration dates, as mentioned by LVN E, who noted that the schedule had not been seen in a long time. The DON and ADM both stated that the pharmacist checked the carts monthly and provided reports, but the responsibility for removing expired supplies was shared among the staff. The facility's policy on the storage of medications, revised in November 2020, mandates the return or destruction of outdated or deteriorated drugs or biologicals. Despite these policies, the facility's record review of grievances indicated no complaints or concerns from residents about expired medications or supplies being administered.
Failure to Ensure Call Lights Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents had their call lights within reach while lying in bed, as observed during multiple surveyor visits. For one resident with a history of cerebral infarction, hemiplegia, and severe cognitive deficits, the call light was found on the floor between the bed and the wall, out of reach. Another resident, who had aphasia, hemiplegia, and memory problems, was observed with the call light on the floor near the head of the bed, next to a fall mat, trash can, and enteral feeding pole. A third resident, with diagnoses including cerebral infarction and respiratory failure, had the call light placed inside a water basin on top of the nightstand, approximately four feet away from the bed. Record reviews revealed that care plans for two of the residents did not address call light accessibility, and the care plan for the third resident only included a general approach to encourage use of the call light without specific interventions to ensure accessibility. Staff interviews indicated that all staff were expected to ensure call lights were within reach, but one housekeeper was unaware of what a call light was and had not been trained on its placement. Other staff, including CNAs, LVNs, the ADON, DON, and the administrator, confirmed that ensuring call lights were within reach was a shared responsibility and part of daily checks. The facility's policy required that call lights be plugged in, functioning, and within easy reach of residents in bed or confined to a chair. Despite this policy, observations and interviews demonstrated that staff did not consistently ensure call lights were accessible to residents, and there were no grievances or complaints related to call lights documented in the facility's records.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by persistent uncleanliness in two shower rooms, two resident rooms, and several common areas over a three-day period. Observations revealed that shower rooms contained soiled items such as a first aid bandage, hair, a disposable glove, and an open jug of body soap without a lid. The toilets in these rooms had brown substances caked on them, overflowing trash cans, and unsanitary conditions that were not addressed over multiple days. Mirrors were spattered with white specks, and the floors had dried fluids and visible tracks of dirt, indicating a lack of regular cleaning and sanitation. Two residents' rooms were also found to be in unsanitary conditions. One resident, with intellectual disabilities and a history of urinary tract infection, was observed to have an unmade bed with stained sheets and a bathroom with thick brown streaks on the toilet and a persistent unpleasant odor. The other resident, with dementia and behavioral disturbances, had a room with an overwhelming foul odor, a bathroom with white flecks on the mirror, brown crusted substances on the toilet, and a wastebasket containing standing yellow liquid. The floor around the toilet was not tiled and had a dark crust, and these conditions persisted over several days. Neither resident had care plan items addressing behaviors related to poor hygiene or inappropriate urination. Throughout the facility, foul odors, particularly of urine, were present in most areas except the secure unit and dining room, with the strongest smells in two specific halls and the rotunda. Interviews with housekeeping staff revealed that they were not provided with sufficient hours or resources to complete their cleaning duties, and that there was no specific cleaning procedure taught. Staff reported being unable to clean all assigned areas or revisit problematic rooms as needed. The DON and ADM acknowledged the ongoing odor and cleanliness issues, attributing them to staffing shortages and turnover, and confirmed that the facility's environment did not meet policy standards for cleanliness and comfort.
Deficiencies in Food Storage, Sanitation, and Hand Hygiene in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage, sanitation, and hand hygiene. A large pan of fruit cobbler was found in the refrigerator without a cover, label, or date, despite being prepared the previous day for future service. The Dietary Manager confirmed that the cobbler should have been covered, labeled, and dated, and acknowledged the risk of contamination if staff or their clothing came into contact with the uncovered food. Additionally, a pair of shoes was found stored on a kitchen utility cart, in direct contact with hair nets used by staff. The Dietary Manager identified the shoes as belonging to a cook and stated that storing personal items, especially shoes, in the kitchen was unsanitary and could lead to contamination of kitchen surfaces and items. The cook admitted to leaving her shoes in the kitchen to prevent her dogs from chewing them at home and acknowledged she had been previously in-serviced not to leave personal items in the kitchen. Further, a cook was observed pureeing food for residents without following proper hand hygiene protocols. After removing gloves, the cook did not wash or sanitize her hands before donning new gloves and touched various potentially contaminated surfaces before handling food. The cook admitted to these lapses and recognized that she could have contaminated the food. The facility's policy and the FDA Food Code require handwashing before putting on new gloves and after touching contaminated items, but these procedures were not followed during the observed food preparation.
Failure to Provide Required Abuse, Neglect, and Dementia Training Prior to Resident Contact
Penalty
Summary
The facility failed to provide required orientation and training on abuse, neglect, exploitation, misappropriation of resident property, and dementia management to four staff members prior to their working with residents. Personnel files for these staff did not contain documentation of completed orientation, as required by facility policy. The HR, DON, and ADM confirmed that orientation was not conducted before these staff began working, and that the new onboarding process implemented by the owners did not include provisions for orientation. The HR believed staff had received some computer-based training after starting, but acknowledged that the lack of orientation meant staff were not trained in abuse and neglect prevention before resident contact. Review of facility policies and orientation checklists showed that mandatory in-services on abuse prevention, resident rights, and related topics were required before staff began work. The facility's policy specified that orientation and ongoing training must cover abuse/neglect prohibition practices, reporting requirements, and prevention. The absence of orientation and training documentation for the identified staff members was confirmed through personnel file review and staff interviews.
Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in unmet care needs. For one male resident with dementia and severely impaired cognition, the care plan addressed decreased bladder continence but did not include his known behaviors of urinating in inappropriate places such as wastebaskets and piles of clothing. Observations confirmed the presence of a foul odor in his room and evidence of urination in the wastebasket, which staff acknowledged was a well-known behavior but was not reflected in his care plan. For a female resident with multiple cardiac conditions, dementia, and severely impaired cognition, the care plan did not address her bilateral heel deep tissue injuries (DTIs), despite documentation of these injuries in her medical record and ongoing wound treatment orders. Observations showed the resident had visible DTIs on both heels, and staff interviews confirmed that the injuries were not included in her care plan due to oversight. Interviews with facility staff, including the care plan coordinator, DON, and ADM, revealed that the omissions were due to lapses in the care planning process, such as reliance on MDS triggers and staff being assigned to other duties. Staff acknowledged that these care needs should have been included in the residents' care plans, as their absence could result in staff not knowing how to address the residents' specific needs.
Failure to Provide Wound Care and Compression Hose as Ordered
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the care plan, and resident preferences for two residents. For one male resident with a history of cellulitis, muscle weakness, and a recent arm fracture, there was a failure to follow up on a skin tear sustained during a fall after his readmission from the hospital. Although the skin tear was documented on the admission assessment, no physician orders were written for its treatment, and there was no ongoing monitoring or documentation of the wound in the following days. Nursing staff were unaware of the skin tear, and the resident had a dressing with an outdated date, indicating a lack of proper wound care and monitoring. For a female resident with multiple cardiac conditions, dementia, and a history of deep tissue injury, the facility did not ensure that compression hose were applied to both legs as ordered by the physician. The medication administration record showed that the compression hose were not administered on two consecutive days due to unavailability, and on another day, the nurse did not apply them due to being behind in duties. There was also an issue with the correct size of compression hose not being available, and it was unclear if nurse managers had been notified about the sizing issue. The resident was dependent on staff for lower body dressing and was receiving diuretic medication, making the application of compression hose a necessary part of her care plan. Interviews with nursing staff and facility leadership confirmed that required assessments, documentation, and follow-up actions were not consistently performed. The facility's own policy required care and services to be provided in accordance with professional standards and the resident's care plan, but these standards were not met in the cases described. The failures placed residents at risk of not receiving necessary medical care, as directly stated in the report.
Nonfunctional Emergency Call Light in Resident Bathroom
Penalty
Summary
A deficiency was identified when a resident's bathroom emergency call light system was found to be nonfunctional. The resident, an older adult with a history of falls, muscle weakness, unsteady gait, and multiple chronic conditions including diabetes, hypertension, and heart disease, reported that the call light in her bathroom was not working. Instead, the facility had attached a squeaky toy to the bathroom handrail as an alternative alert system, but both the resident and staff confirmed that the sound produced by the toy was barely audible, even with the bathroom door open, and not audible at all in the hallway with the door closed. Direct observation by surveyors confirmed that pulling the call light cord did not activate any lights or alarms in the room, bathroom, or hallway. Interviews with facility staff revealed a lack of clarity and consistency regarding responsibility and procedures for ensuring the functionality of call light systems. The CNA stated that both CNAs and maintenance staff were responsible for checking call lights and that she would notify the DON if a call light was not working, but was unsure about the existence of random checks. The maintenance staff member, who had only recently started working at the facility, reported conducting random weekly checks of call lights and encouraged staff to use an online tracking system for repair requests. However, he relied on staff to verbally report nonfunctioning call lights. The ADON, DON, and administrator all stated that maintenance was responsible for ensuring call lights worked, but none could describe a systematic process for monitoring their functionality. Review of the resident's care plans indicated that keeping the call light within reach was a documented intervention due to her fall risk and use of anticoagulant therapy. Facility policy required that call lights be plugged in and functioning at all times, and that defective call lights be promptly reported to the nurse supervisor. Despite these policies, the nonfunctional call light in the resident's bathroom was not addressed, and no grievances or complaints related to call lights were found in facility records.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide an ongoing activities program that met the needs and interests of residents, particularly those residing on the secure unit, 100 hall, 500 hall, and 600 hall. For the month of January 2025, no activities were provided on the secure unit, and activities were absent for 25 out of 31 days on the other halls. In February 2025, activities were not provided for 13 out of 20 days. This lack of activities placed residents at risk for boredom, depression, increased behaviors, and diminished quality of life. Interviews and record reviews revealed that the Activity Director, who worked only on Mondays and Tuesdays, left activity items for residents but did not ensure their use or document participation. The Activity Assistant, hired on February 10, 2025, was responsible for activities on the secure unit and sometimes covered other halls but lacked participation records. The Director of Nurses and other staff acknowledged the importance of activities for residents' well-being but did not have documentation to support that activities occurred as planned. Residents expressed feelings of boredom and a lack of group activities, which they desired for social interaction and engagement. Management staff occasionally held parties, but these were not documented in the activity calendar or participation records. The facility's Activity Documentation Policy required maintaining attendance records, activity evaluations, and other documentation, which were not adequately kept, leading to the deficiency.
Failure in Nail Care for Residents
Penalty
Summary
The facility failed to ensure that two residents received necessary services to maintain good personal hygiene, specifically regarding nail care. Resident #1, a male with type 2 diabetes and other significant health issues, was observed with unclean and uneven fingernails. His care plan indicated he required assistance with personal hygiene, but observations showed that his nails were not properly maintained, which could lead to hygiene and dignity issues. Resident #2, a female with severe cognitive impairment and other health conditions, was also found with unclean and rough fingernails. Her care plan specified that she required substantial assistance with personal hygiene, including scheduled nail care. However, observations revealed that her nails were not properly cared for, indicating a failure to adhere to her care plan. Interviews with facility staff revealed confusion and inconsistency regarding responsibility for nail care, particularly for residents with diabetes. The Activity Assistant and Director, who were not CNAs, were performing nail care, contrary to facility policy, which stated that only CNAs and nurses should perform this task. This miscommunication and lack of adherence to protocol contributed to the deficiency in providing adequate nail care for the residents.
Failure to Provide Appropriate Diabetic Diet
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of a resident with diabetes. The resident, who had a severely impaired cognition and required supervision with eating, was observed receiving a full-size serving of dessert, contrary to the physician's order for a diabetic diet. The resident's meal ticket indicated a low concentrated sweet diet, which should have included only a half portion of dessert. However, the resident was served a full portion of gingerbread, which he consumed entirely. The dietary manager and registered dietician consultant confirmed that the facility's protocol for residents on a low concentrated sweet diet is to receive half portions of dessert. They also stated that if a resident's blood sugar is elevated before a meal, they should not receive a regular dessert but rather a sugar-free option. On the day of the observation, the resident's blood sugar was recorded at 231 mg/dl, which is considered elevated, yet he was still served a full portion of dessert. The Director of Nurses acknowledged the oversight in allowing the meal tray to be delivered without considering the resident's elevated blood sugar and the dessert portion size. The facility's policy for a low concentrated sweets diet specifies reduced portions of regular desserts and sugar-free options for residents with controlled blood sugar levels. The failure to adhere to this policy placed the resident at risk for altered nutritional status and decreased quality of life.
Failure to Document Notifications After Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced a fall. The resident, an elderly female with multiple diagnoses including cognitive communication deficit and vitamin D deficiency, had a history of falls and required substantial assistance with daily activities. After an unwitnessed fall, the nursing staff did not document whether the resident's family, physician, or nurse practitioner was notified, nor were any new orders recorded. This lack of documentation was confirmed by the Director of Nurses, who stated that the absence of such records indicated that notifications were not made. The facility's Fall Protocol requires notifying the resident's attending physician and family within an appropriate time frame, especially if the fall results in significant injury or condition change. However, the nurse assigned to the resident did not document any notifications following the fall, and attempts to contact the nurse for further clarification were unsuccessful. The Nurse Practitioner later confirmed that she was notified of the fall but did not issue any new orders, as the resident reported no pain. This failure to document critical notifications placed residents at risk of not receiving proper care and having inaccurate medical records.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident identified as an elopement risk. The resident, who had severe cognitive impairment and a history of wandering, was left unsupervised in the secure unit courtyard. On the day of the incident, the resident climbed over the fence and left the facility, which was not immediately noticed by the staff. The resident was later found and returned to the facility without any visible injuries. The resident's care plan indicated that he required supervision when outside and had a known history of wandering and poor safety awareness. Despite these documented needs, the resident was allowed into the courtyard without direct supervision, leading to his elopement. The staff member responsible for letting the resident into the courtyard left to assist another resident, assuming the resident would remain within the secure area. This lapse in supervision allowed the resident to climb over the fence and leave the premises. Interviews with staff revealed that there was a lack of consistent training and protocols regarding supervision in the secure unit courtyard. Staff were not required to accompany residents outside before the incident, and there was no specific orientation training on elopement. The facility's policies on wandering and elopement were not effectively implemented, contributing to the resident's ability to leave the secure area unobserved.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically by not having a fall mat in place beside the resident's bed as per the care plan. The resident, a male with a history of traumatic subdural hematoma, muscle weakness, lack of coordination, and Alzheimer's disease, was identified as being at risk for falls due to decreased safety awareness. The care plan indicated that a fall mat should be placed next to the bed to mitigate this risk. During an observation, it was noted that the resident's bed was in a low position with a half side rail up, but no fall mat was present. Interviews with the LVN, ADON, DON, and ADM revealed that the LVN was unaware of the requirement for a fall mat and had not reviewed the care plan. The ADON and DON stated that the expectation was for nurses to be aware of and implement care plan interventions, including the use of fall mats, to prevent potential injuries.
Facility Fails to Provide Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for seven residents and four hallways. Observations revealed various issues, including a large light brown stain of pooled and dried liquid on the ceiling tiles of the 600 hall and a coating of black dust collecting around the air conditioner vent nearby. Resident #1's room had peeling and chipping paint and texturing plaster on the ceiling, a black substance inside the air conditioning vent, and rust on the grate. Resident #2's room had large patches on the wall that were scratched, torn, and scuffed down to the drywall. Resident #3's room had a large area where the paint and texturing plaster had been scraped and torn away, exposing the drywall. Residents #4 and #5's bathroom door did not close properly, the floor was peeling off, and the insect screen on their window had several holes. Resident #6's room had a loose bathroom light switch, a hanging air vent, and missing drawer fronts. Resident #7's room had stains and black dust around the air conditioning vent, a flickering bathroom light, and a strong smell of stale urine in the bathroom, which also had feces that did not flush down the pipe. Interviews with the residents revealed that these issues had been present for a long time, and the facility had not taken adequate steps to address them. Resident #1 stated that the ceiling in his room had been in disrepair for months, and he had refused a room change. Resident #5 mentioned that the facility was aware of the bathroom issues but had not fixed them, and there was no maintenance director in the building. The ADM confirmed that there had been no maintenance director since November 2023, and the regional maintenance director visited the facility once per week. The ADM also stated that the facility had been trying to hire a maintenance director but faced difficulties in finding a suitable candidate. The regional maintenance director (RMAINT) stated that he had visited the facility the day before and noted the issues with sheetrock and drywall on a spreadsheet. He mentioned that a drywall contractor would visit the facility the next day to repair the issues. The ADM confirmed that the contractor would fix the sheetrock, drywall, and painting starting the next day. However, the ADM was not aware of the ceiling damage or the dust on the 600 hall. The AADM, who would be covering for the ADM during a leave of absence, observed the failures and noted the potential negative outcomes for the residents. The facility's policy on providing a homelike environment emphasized the importance of a clean, sanitary, and orderly environment, which was not upheld in this case.
Verbal Abuse and Neglect of Resident by CNA
Penalty
Summary
The facility failed to ensure that residents were free from abuse and neglect, specifically in the case of a resident with severe cognitive impairment and multiple medical conditions. On the specified date, a CNA was reported to have verbally abused the resident by using foul language and refusing to make up her bed, which the resident needed due to incontinence issues. The incident was reported by two staff members who overheard the CNA's abusive language and refusal to provide care. The resident, who has a history of memory problems and requires extensive assistance with activities of daily living, was left without proper bedding, causing her distress. The facility's investigation revealed that the CNA had indeed used inappropriate language and refused to assist the resident. Witnesses, including a housekeeper and a transport aide, confirmed the CNA's behavior. The resident, due to her severe cognitive impairment, did not recall the incident when interviewed later. The CNA claimed to have been busy with another resident who was allegedly bleeding, but this was not corroborated by other staff or the resident's medical records. Interviews with other staff members indicated that the resident was generally cooperative but needed frequent reminders and assistance. The facility's policy on abuse and neglect was reviewed, and it was found that verbal abuse would be substantiated if overheard by other staff or residents. The CNA involved had been educated on the prevention of resident abuse and had no prior reported issues. The facility's failure to protect the resident from verbal abuse and neglect was identified as a deficiency in their care standards.
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 47 citations issued within 25 miles in the last 12 months — including the 6 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 Giddings
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harmony Care At Giddings | 0.1 mi | ★★★★★ | 13 | 5 |
| Towers Nursing Home | 17.9 mi | ★★★★★ | 3 | 0 |
| Care Inn Of La Grange | 20.1 mi | ★★★★★ | 12 | 0 |
| Monument Rehabilitation And Nursing Center | 21.5 mi | ★★★★★ | 8 | 0 |
| Windsor Nursing And Rehabilitation Center Of Bastr | 24.3 mi | ★★★★★ | 1 | 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.