Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Golfcrest during CMS and state inspections, most recent first.
Incomplete Care Plans for Medications, Dental Needs, and ADL Refusals: The facility failed to keep care plans current for several residents by omitting a resident’s dental recommendations and prescribed oral treatments, not addressing anticoagulant and antiplatelet therapy in care plans, and not updating a resident’s plan for ongoing ADL refusals. Interviews, MDS data, MAR review, and observations showed the residents had significant medical and functional needs, but the interdisciplinary care plans did not consistently reflect those needs or current interventions.
The facility failed to provide needed ADL assistance for grooming, hygiene, and incontinent care for multiple residents. One resident had long, dirty fingernails, another had facial hair on her chin, a third had long fingernails and dry, flaky skin, and a fourth was found with a feces-saturated brief and soiled linens. Staff and the DON stated these tasks were part of routine shower and ADL care, but the residents’ needs were not met.
A resident with cognitive impairment and smoking limitations was observed smoking without direct supervision, and two other residents who required direct visual supervision were also left unattended during smoking. The smoking area lacked accessible ashtrays, residents were seen dropping cigarettes into a grate, and staff acknowledged the fire concern. The facility also had hot water above the stated limit in two room sinks, damaged plumbing and wall surfaces in one room, and an exit door by the laundry was repeatedly propped open by staff.
A facility exceeded the allowed medication error rate after surveyors found missed doses, an incorrect administration, and a medication documented as given when it was not. Errors involved a resident with hypokalemia who did not receive the full ordered KCl dose, a resident with COPD whose Budesonide inhalation was not actually given despite MAR initials, and two residents with dry eye syndrome who did not receive Artificial Tears as ordered. The DON and Administrator stated meds were expected to be administered timely and according to physician orders.
Kitchen sanitation, food storage, and temperature control failures: Clean bowls, cups, serving utensils, pots, pans, and equipment were observed with food particles, stains, grease, and burnt residue, and the dry storage room floor had missing tiles and dust. A bag of chicken fried steak in the freezer was unlabeled and undated, cold menu items were above the required temperature, and a dietary worker used the same gloves while touching surfaces and ready-to-eat foods without washing hands or changing gloves.
The facility had multiple infection control failures involving resident care and staff hand hygiene. An LPN did not maintain sterile technique during trach care for a resident with trach and G-tube status, another LPN did not wash or sanitize hands between two residents, and an LPN entered a room with an EBP sign without PPE and later discarded PPE improperly. Staff also failed to follow proper hand hygiene and glove practices during Foley care, while laundry room observations showed missing soap in the dirty area and a basket of clean socks placed on the floor in the clean area.
The facility failed to maintain an effective pest control program, with roaches, flies, gnats, spiders, and other pests observed in resident rooms and common areas. Surveyors found a live roach in one room, a dead bug in another restroom, and flies on a resident’s pillow, while records showed repeated pest sightings in resident rooms, kitchens, offices, and the conference room. Staff interviews confirmed the pest issue was ongoing, and an air-conditioning unit in one room had damaged plastic and gaps that the Maintenance Director said could allow bugs to enter.
A facility failed to maintain a safe, clean, comfortable, and homelike environment for 2 residents. One resident with severe cognitive impairment, total ADL dependence, and bowel/bladder incontinence had a missing hot water faucet handle in the room, preventing hot water use. Another resident’s restroom had a damaged sink, an inch-long missing chunk on the faucet with white material oozing from the gaps, and gashes in the wall behind the toilet and sink; the Mgr stated the damage was not safe and had not been reported on the maintenance log.
A resident with neurogenic bladder, urinary retention, and an indwelling Foley catheter was observed with the catheter bag, privacy bag, and tubing on the floor, and later still touching the floor while hung on the bed. Staff also failed to secure the catheter with a stat lock and performed Foley care with improper hand hygiene and glove use, including handling clean supplies after contact with a soiled sheet. The DON and staff acknowledged the catheter was not positioned or secured correctly and that the hand hygiene practices created cross-contamination.
Improper Sterile Technique During Tracheostomy Care: A resident with trach status, dysphagia, and G-tube status required scheduled trach care and suctioning. During observed care, an LVN changed gloves without hand hygiene, handled sterile suction and trach supplies with the same gloves, removed and reinserted the inner cannula, and continued using dirty gloves while opening sterile trach care items. The RT stated the technique was incorrect, and the LVN acknowledged he did not use a clean procedure.
Failure to administer ordered potassium medication: an LVN dissolved Effer-K for a resident with hypokalemia, but the resident drank only part of the dose and the remainder was discarded. The LVN knew the resident would not finish it and did not notify the ADON, DON, or MD. The resident had severe cognitive impairment and a low K level was later found.
Opened medications in Nurse Cart A were found without open dates, including Sodium chloride nasal spray, Fluticasone Propionate nasal spray, and a sterile normal saline bottle. An LVN said he did not know when the nasal meds were opened or which nurse opened them, and the DON stated opened meds should have an open date; the facility policy required opened multi-dose vials to be dated and discarded within 28 days unless the manufacturer specifies otherwise.
Food was observed cooking too early in the kitchen, with green beans, carrots, ham, sweet potatoes, peas, and cabbage left on the stove or grill for hours before lunch. Staff stated the vegetables were overcooked, could become mushy, lose color and nutritional value, and not look appetizing. The facility policy stated residents should receive a nourishing, well-balanced diet that considers resident preferences.
A resident who was care planned for two-person assistance during ADLs and transfers slid from an elevated bed while a CNA was changing linens with only one staff member present. The resident sustained a forehead hematoma and skin tears, was sent to the hospital after a witnessed fall, and later expired. Interviews and record review confirmed the resident required x2 assistance, but only one CNA provided care at the time of the incident.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes that affected the resident, as required by regulation.
A resident did not receive care and treatment in accordance with physician orders and their stated preferences and goals, as identified by surveyors through observation and record review.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
The facility failed to ensure that MDS assessments accurately reflected the dental and mental health status of four residents. Inaccuracies included documenting the presence of natural teeth when residents were edentulous or had significant dental issues, and omitting mental illness diagnoses despite clear evidence in clinical records and PASRR evaluations. These discrepancies were identified through interviews, observations, and review of dental and medical records.
A medication error rate of 10% was identified when staff failed to administer chewable aspirin as directed and gave an incorrect dose of Vitamin D3 to three residents, despite clear orders and ongoing staff education. Errors included not instructing residents to chew aspirin and administering a higher-than-ordered dose of cholecalciferol.
A resident with a history of hemiplegia and hemiparesis was later diagnosed with bipolar disorder and anxiety disorder and prescribed antipsychotic medication, but staff did not refer for a required PASRR Level II evaluation. The social worker and MDS Coordinator lacked formal PASRR training and were unaware of the new diagnoses, resulting in no referral or updated documentation. Facility leadership did not have clear oversight or training processes to ensure PASRR compliance.
A resident with multiple diagnoses was admitted to an LTC facility without a timely PASARR assessment, risking unmet service needs. The assessment, crucial for identifying necessary specialized services, was delayed due to the social worker's illness. Interviews revealed a lack of coordination in the PASARR process, highlighting the importance of timely assessments as per federal requirements.
A resident with major depressive disorder and intellectual disability was admitted without a timely PASRR assessment, leading to a delay in identifying necessary services. The social worker's illness contributed to the delay, and facility staff acknowledged the failure to comply with PASRR procedures.
A resident with a history of mental health disorders was subjected to mental abuse by a CNA during a nephrology appointment. The CNA allegedly used a racial slur, causing the resident to become withdrawn. The incident was reported by a Patient Affairs Specialist, but the facility failed to respond appropriately, violating the resident's right to be free from abuse.
Incomplete Care Plans for Medications, Dental Needs, and ADL Refusals
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that reflected residents’ assessed needs and current treatments for multiple residents. For Resident #127, the care plan addressed impaired dentition and oral hygiene reminders, but it did not include the dental recommendations from the telehealth dental exam. That dental exam documented discomfort when chewing in the back molars, interest in dentures, and interim instructions to avoid chewing on the left side, consider a softer diet, brush and clean the mouth and teeth 2-3 times per day, use warm saltwater rinses after meals and as needed, and take prescribed amoxicillin and chlorhexidine oral rinse. At the time of observation, Resident #127 was resting in bed, appeared comfortable, and had blackened lower molars on both sides. Staff interviews showed the resident was on a soft/puree diet and that the dental recommendations had not been incorporated into the care plan. For Resident #7, the care plan did not address the ordered anticoagulant apixaban 5 mg twice daily, even though the resident’s diagnoses included acute embolism and thrombosis of the left peroneal vein, acute embolism and thrombosis of deep veins of the lower extremities, thrombocytopenia, peripheral vascular disease, atherosclerosis of the right leg, acute kidney failure, and chronic diastolic congestive heart failure. The annual MDS coded the resident as receiving anticoagulant medication, and the MAR showed apixaban was administered during June and July 2026. The MDS nurse stated she missed doing the service plan and acknowledged the care plan had not been updated to include the anticoagulant. For Resident #97, the care plan did not address clopidogrel bisulfate 75 mg daily, despite the resident being coded on the quarterly MDS as receiving antiplatelet medication and the MAR showing the medication was administered during June and July 2026. The resident’s diagnoses included chronic venous hypertension, type 2 diabetes, peripheral vascular disease, atherosclerosis of the right leg, acute kidney failure, and chronic diastolic congestive heart failure. The MDS nurse confirmed the medication was not care planned and stated she had not followed up with the physician in time to clarify the diagnosis for the medication before updating the care plan. Resident #12’s comprehensive care plan was also not revised to reflect ongoing refusals of ADLs. The resident’s care plan still contained older interventions related to being resistive to care, but the interventions were not current despite later annual and quarterly MDS assessments. The quarterly MDS showed the resident required total assistance for toileting, bathing, dressing, and personal hygiene, was always incontinent, and had daily rejection of care necessary to achieve health and well-being goals. Observation and interviews showed the resident remained in bed much of the day, refused to walk despite being physically able to do so, and staff were providing total assistance because of repeated refusals. Staff and the MDS nurse acknowledged that no current interventions were being used to address the refusals, no assessment had been done to determine why the resident refused care, and the care plan had not been updated to reflect current needs or evaluate the effectiveness of existing interventions.
Failure to Provide Needed Grooming, Hygiene, and Incontinent Care
Penalty
Summary
The facility failed to provide necessary ADL assistance for grooming and personal hygiene for four residents who were unable to complete those tasks independently. One resident with dementia, hypertension, myocardial infarction, and paraplegia had fingernails on both hands that were about 0.75 cm long with dark brown substance under them. The resident said she had asked aides to cut her fingernails, but they said they would come back and did not. Staff interviews confirmed the nails were long and dirty, and the DON stated fingernails should be cleaned daily and cut during showers or by nursing staff if needed. Another resident with dementia, hypertension, and atrioventricular block had black curled hair on her chin during observation. She said it had been a week or two since staff shaved the hair on her chin and that she wanted it shaved. Staff stated that shaving or plucking was done on shower days and as needed, and the DON and Administrator both identified facial hair removal as a dignity issue when a female resident did not want facial hair. A third resident with cerebrovascular disease, hypertension, diabetes mellitus, severe cognitive impairment, weakness, and tremors had long fingernails on both hands, with several nails about 1.5 cm long, and dry, flaky skin from below both knees to the feet. The resident said he wanted his fingernails cut and that staff had said they would get to it. Staff stated that nails were to be cut on shower days and as needed, and lotion or cream was to be applied to resident skin on shower days and as needed. The DON and Administrator stated the skin should be moisturized to prevent dryness and skin breakdown. A fourth resident with neuromuscular dysfunction of the bladder, hypertension, urinary retention, and total dependence for ADLs was observed during foley and incontinent care with a brief saturated with feces and both dry and fresh feces present. The draw sheets and bed pad had substantial feces and dry brown rings. Staff stated the resident had not been changed for hours, and the DON said aides were supposed to make rounds every two hours for incontinent care. The resident said he could not remember when staff last changed him and wanted to be changed whenever he was dirty.
Unsafe Smoking Supervision and Environmental Hazards
Penalty
Summary
The facility failed to keep the resident environment as free of accident hazards as possible and failed to provide adequate supervision for residents who smoked. Resident #57 had diagnoses including systemic lupus erythematosus, Wernicke's encephalopathy, rheumatoid arthritis, mild cognitive impairment, and tobacco use. His MDS showed a BIMS score of 12 and he required extensive staff assistance with multiple ADLs. His smoking assessment documented functional limitations, inability to independently light a cigarette, and a need for direct visual supervision while smoking. Despite this, he was observed smoking on the patio without supervision, and he told staff there was not enough staff to help with smoke breaks. Staff interviews showed that the facility knew residents were not supposed to smoke alone, but Resident #57 was still observed smoking outside without staff present. Resident #71 and Resident #7 were also observed smoking outside without adequate supervision. Resident #71 had diagnoses including dementia, hypertension, osteoporosis, epilepsy, and nicotine dependence, with a BIMS score of 12 and a smoking assessment requiring direct visual supervision because her hands shook while smoking. Resident #7 had diagnoses including dementia, hypertension, polyneuropathy, osteoarthritis, muscle wasting and atrophy, and nicotine dependence, with a BIMS score of 10 and a smoking assessment showing she needed help getting to the smoking area, could not light her cigarette, and sometimes dropped ashes on herself. During observation, CNA CT assisted both residents with lighting cigarettes and then left them unattended for about a minute. Resident #7 dropped her cigarette on the ground, and the residents reported that ashtrays were not accessible because the ones provided were either on the ground far away or nailed to a nearby tree. They were observed throwing cigarettes into a grate in the ground, and staff acknowledged that this could create a fire hazard. The facility also had environmental hazards in resident areas and common areas. The smoking area did not have ashtrays within reach for residents to use. Room B's restroom sink hot water measured 115 degrees F, and Room C's restroom sink hot water measured 114 degrees F. Room C also had a damaged faucet with a missing chunk and unknown white material oozing from the gaps, along with damaged sheetrock behind the sink and toilet. In addition, staff propped open the exit door by the laundry area on more than one occasion, including when HK Q wheeled a cart in through the open door and when Dietary Aide A propped the door open with a basin while taking trash out. Multiple staff members stated the door should have remained closed because it created a safety issue, but it was left open during the observations.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors identified 4 medication errors out of 30 opportunities, resulting in a 13% error rate, involving 3 residents and 3 staff members reviewed for medication administration practices. The errors included failure to administer ordered medications, administration of the wrong dose, and documentation of a medication as given when it was not administered. For one resident with hypokalemia and severe cognitive impairment, the ordered Potassium Chloride/Effer-K was dissolved in water, but the resident drank only part of the dose and the remainder was discarded. The nurse did not notify the ADON, DON, or physician that the resident had not taken the full dose or that the medication might need to be changed to liquid. The resident’s potassium level was later found to be low at 3.1 mEq/L. For another resident with COPD and moderate cognitive impairment, Budesonide inhalation was ordered daily, but the nurse did not administer it during the observed medication pass even though the MAR was initialed as given. For a resident with severe cognitive impairment and dry eye syndrome, Artificial Tears Ophthalmic Solution was ordered for both eyes, but the nurse administered a different amount than ordered. A similar error occurred with another resident who also had dry eye syndrome, when Artificial Tears Ophthalmic Solution was not administered as ordered during observation. The DON and Administrator stated that medications were expected to be given timely, correctly, and according to physician orders.
Kitchen sanitation, food storage, and temperature control failures
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the kitchen. During observation on 06/30/2026, bowls, plates, cups, and serving utensils with dried food particles, food stains, and water stains were stored with clean items in the dish room. The oven racks and doors had brown greasy stains and burnt food particles, and a nonfunctioning oven had an accumulation of a brown greasy substance on the racks. The dry storage room floor had missing tiles next to the back of the walk-in freezer and dust was observed in the area. On 06/30/2026, a plain plastic bag of chicken fried steak in the walk-in freezer was observed without a label or date. On 07/02/2026, lunch items including cold marinated mixed vegetables with mayonnaise at 55 degrees F and marinated cooked mixed vegetables at 45 degrees F were observed, although the menu items were supposed to be chilled to 41 degrees F and below. During the same meal observation, [NAME] A was seen touching the counter, picking up a bag with carrots, plating food, and picking up rolls with the same gloves without changing gloves or washing hands. The Dietary Manager and Administrator stated the expectation was for staff to follow sanitation policies, maintain sanitary food storage and preparation, and follow the cleaning schedule.
Infection Control Failures During Resident Care and Laundry Handling
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for multiple residents and staff. The report identified failures involving tracheostomy care, hand hygiene between resident contacts, PPE use during care for a resident with an EBP sign posted on the door, laundry room sanitation, Foley care, and glove and hand hygiene practices when exiting a resident room. The cited events involved Resident #150, Resident #53, Resident #138, Resident #48, Resident #1, and staff including LVN BK, LVN ED, LVN CO, HK H, CNA NH, the Staffing Coordinator, and CNA Y. During tracheostomy care for Resident #150, who had dysphagia, tracheostomy status, and gastrostomy status and was documented as totally dependent for all ADLs, LVN BK performed care using clean and dirty gloves in a manner that did not maintain sterile technique. He changed gloves without washing or sanitizing his hands, handled sterile supplies with dirty gloves, touched the inner cannula and other sterile items without proper hand hygiene, and continued the procedure while using contaminated gloves. The respiratory therapist observed the care and stated he should not have touched the inner cannula with a clean glove and should have used proper sterile technique. LVN BK stated he had recent trach care training and acknowledged that trach care was a sterile procedure and that he did not use a clean procedure. For Resident #53 and Resident #138, LVN ED administered oral medications to Resident #53 and then moved to Resident #138 to administer eye drops without washing or sanitizing her hands between residents. LVN ED stated she was nervous and knew the action could cause cross contamination. For Resident #48, who had severe cognitive impairment and was totally dependent for bed repositioning and personal hygiene, LVN CO entered the room with an EBP sign posted on the door without PPE or gloves and assisted the resident with clothing and brief care. Later, LVN CO donned PPE and gloves for G-tube feeding, then went to the medication cart with the same PPE and gloves and administered eye drops. He discarded the PPE and gloves at the medication cart trash instead of the hazardous box in the resident’s restroom. Additional infection control failures were observed in the laundry room and during Foley care for Resident #1. The dirty section of the laundry room did not have handwashing soap, and HK H washed her hands using sanitizer at the sink, then turned off the faucet with wet hands. A basket of clean socks was also observed on the floor in the clean section of the laundry room. During Foley care for Resident #1, CNA NH changed gloves multiple times without sanitizing her hands before donning clean gloves and used sanitizer from her uniform pocket before placing it back in the pocket. The Staffing Coordinator handled a top sheet with feces on it, discarded it, and continued care while using dirty gloves to pull wipes from a clean container and hand them to CNA NH. CNA Y was also observed leaving Room G with gloves on, closing the door with the same gloves, discarding the gloves at the medication cart, and taking new gloves without washing or sanitizing her hands.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program and was not free of pests and rodents in multiple resident areas. Survey observations found a live roach in Room A near the restroom, a dead brown bug in Room B’s restroom, and two flies landing on a resident’s pillow in another room. The report also noted that Room E had an air-conditioning unit with damaged plastic and quarter-inch gaps, and the Maintenance Director stated that the gaps could allow bugs to enter the room. Record review showed repeated pest sightings over several months in resident rooms, kitchens, offices, the beauty salon, the conference room, and other areas. The pest control binder and the facility’s pest observation log documented gnats, roaches, spiders, ants, and flies on multiple dates, including live roaches, dead German roaches, and ongoing sightings in resident rooms and staff areas. Staff interviews confirmed that pests were still being seen in the building, including in the front lobby, nurse’s station area, and resident rooms. During interviews, staff described the pest issue as ongoing. The Activities Director said she had recently seen roaches in the front lobby and believed flies came in when residents opened the patio door to smoke. The Receptionist said she had seen roaches and baby roaches after pest control visits and thought pests entered when the door was opened for smoke breaks. The DON stated the facility had a binder for pest sightings and that pest control came promptly, but also acknowledged the building was older and the pest issue was ongoing. The facility policy stated that the building should be kept free of insects and rodents and that windows are screened at all times, but the Maintenance Director said he was not aware of the window-screen policy and noted the Room E unit remained in place.
Damaged Resident Bathroom Fixtures and Room Surfaces
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for 2 residents reviewed for resident rights. One resident, an older male with diagnoses including iron deficiency anemia, blurred or impaired vision, anxiety disorder, hypertension, heart failure, hyperlipidemia, and type 2 diabetes mellitus, had a significant change MDS indicating severe cognitive impairment, total dependence on staff for bed repositioning and personal hygiene, and incontinence of bowel and bladder. During observation of his room, the hot water faucet handle on the left side was missing and the hot water could not be turned on. The resident did not answer questions about the faucet during interview and changed the subject often. A second resident’s restroom was observed with a damaged wall and sink. The Maintenance Director observed an inch-long missing chunk on the lower left side of the faucet near the sink bowl with an unknown white material appearing to ooze from the gaps, along with one gash of missing sheetrock behind the toilet and one behind the sink. He stated the gashes in the wall were not safe for residents and said he was not aware of the damaged sink and bathroom wall because no staff had reported it on the maintenance log. The facility policy titled Safety and Supervision of Residents did not address how to manage damaged resident equipment.
Improper Foley Catheter Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling Foley catheter and failed to provide appropriate catheter care and hand hygiene during catheter care. The resident was admitted from the hospital with diagnoses including neurogenic bladder, hypertension, and urinary retention. The admission MDS indicated a BIMS score of 12, total assistance with ADLs, and the presence of an indwelling Foley catheter. The care plan directed staff to position the catheter bag and tubing below bladder level. On observation, the resident’s Foley bag, privacy bag, and tubing were found on the floor. The DON stated the bag and tubing should not have been on the floor and that staff should have raised the bed slightly to prevent the Foley from touching the floor. A later observation showed the Foley bag hung on the bed, but the bag, privacy bag, and tubing were still touching the floor. During the same observation, the resident’s Foley catheter care was provided by a CNA and the Staffing Coordinator, and the catheter was not secured with a stat lock. Staff stated the catheter tubing could be pulled during care and could be pulled out, causing harm. During Foley care, the CNA changed gloves multiple times without sanitizing or washing her hands before donning clean gloves, and she kept sanitizer and gloves in her uniform pocket. The Staffing Coordinator removed a top sheet that had bowel movement on it, placed it in a trash bag, and then continued handling wipes with dirty gloves before handing them to the CNA. Both staff members acknowledged the hand hygiene and glove practices were improper and that the wipes were contaminated. Facility policy required catheter tubing and drainage bags to be kept off the floor, the drainage bag to remain below bladder level, the catheter to be secured with a leg strap, and hand hygiene to be performed before touching a resident and after glove removal.
Improper Sterile Technique During Tracheostomy Care
Penalty
Summary
The facility failed to ensure tracheostomy care and suctioning were provided according to professional standards for a resident with dysphagia, tracheostomy status, and gastrostomy status who was totally dependent for all ADLs. Physician orders required Shiley inner cannula changes every 6 hours and as needed, trach tie changes as needed, trach care every 6 hours, and tracheal suction every 6 hours for a patent airway. The treatment record showed tracheal suctioning was provided on 6/20/2026, and the resident was observed later lying in bed with oxygen at 3.5 L/min and, on another observation, with audible moist breath sounds. During the observed tracheostomy care, the LVN did not maintain proper sterile technique. He changed gloves without washing his hands or using hand sanitizer, handled the sterile suction catheter kit and saline, removed the inner cannula, suctioned the tracheostomy tube, and then used the same gloved hands to open and insert the sterile inner cannula. He also picked up the trach care kit without changing dirty gloves, opened sterile supplies with the same gloves, and handled sterile gloves, gauze, and a bottle of normal saline while continuing the procedure. The respiratory therapist observed the care and stated the LVN should not have touched the inner cannula with a clean glove, should have sanitized or washed his hands and changed gloves, and should not have used dirty gloves inside a sterile tracheostomy kit. The LVN stated trach care was a sterile procedure, that he should have washed his hands before doing anything, and acknowledged he did not use a clean procedure and touched sterile items with dirty gloves. The facility policy stated residents needing respiratory care, including tracheal suctioning, are to receive such care consistent with professional standards of practice.
Failure to Administer Ordered Potassium Medication
Penalty
Summary
The facility failed to ensure that a resident with hypokalemia received Potassium Chloride as ordered. The resident was an elderly female admitted with diagnoses including shortness of breath, pneumonitis due to inhalation of food and vomit, hypoxemia, restlessness and agitation, mixed hyperlipidemia, essential hypertension, other intervertebral disc displacement in the lumbar region, muscle wasting and atrophy, and hypokalemia. Her admission MDS showed a BIMS score of 3, indicating severe cognitive impairment. Her care plan identified hypokalemia and directed staff to give Potassium Chloride medications as ordered, and the physician ordered Potassium Chloride 10 mEq by mouth once daily for hypokalemia. During observation, an LVN dissolved an Effer-K 10 mEq tablet in 4 ounces of water with other medications, but the resident drank only 2 ounces and the LVN discarded the remainder. The LVN stated he knew the resident was not going to drink the full dose because she always complained of being too full, and he had not informed the ADON, DON, or the physician that the resident was not taking all of the medication or that the medication should be changed to liquid. The DON later stated the facility was not aware of the issue and that potassium blood work would be started; the potassium level was 3.1 mEq/L. The facility policy stated medications are to be administered in accordance with the prescriber's order.
Opened Medications in Nurse Cart A Were Not Dated
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, including the required accessory and cautionary instructions and expiration dates when applicable, for 1 of 4 medication carts reviewed, Nurse Cart A. During observation of the cart, opened medications were found without dates showing when they had been opened, including Sodium chloride 0.65% nasal spray, Fluticasone Propionate nasal spray, and a sterile 0.9% normal saline 100 ml bottle. During interview, the LVN said he was not aware when the nasal medications were opened and stated the resident always refused the Fluticasone Propionate nasal spray and Sodium chloride nasal spray. He also did not know which nurse opened those medications. The DON stated that opened eye drops should have an open date and that the medicines would not be effective for treatment after 30 days. Record review of the facility policy stated that multi-dose vials that have been opened or accessed should be dated and discarded within 28 days of opening or initial access unless the manufacturer specifies a different date.
Food Left Cooking Too Early and Vegetables Overcooked
Penalty
Summary
The facility failed to ensure food was prepared by a method that conserved nutritive value, flavor, and appearance in the kitchen. On 6/30/2026 at 9:05 a.m., cooked green beans, carrots, ham, and whipped sweet potatoes were observed on the stove cooking for lunch, and two pans of pureed green beans and pureed ham were also on the grill, which was hot. During an interview, the dietary staff member stated she was preparing those menu items for lunch. On 7/4/2026 at 9:10 a.m., green peas and cabbage were observed cooking on the stove for lunch, with the peas olive green in color and the cabbage bright green. In interviews, the dietary manager stated that overcooked vegetables could be mushy, would not look good, and could lose nutritional value, and she said vegetables would be cooked a few minutes before meal service so they would not be overcooked. The foodservice district manager also stated she would be in-servicing staff on food service sanitation, food preparation, and ware washing. The facility policy stated that each resident is provided with a nourishing, well-balanced diet that meets daily nutritional and special dietary needs, taking into consideration resident preferences.
Failure to Provide Two-Person Assistance During Bed Care
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices were provided to prevent an accident for a resident who required two-person assistance for ADLs and transfers. The resident’s record showed diagnoses including heart failure, thrombocytopenia, intracranial hemorrhage, hemiplegia, hemiparesis, and deep vein thrombosis. The annual MDS coded the resident as severely impaired and dependent for two-person assistance with showers, toileting, hygiene, and bed transfers. The care plan identified the resident as at risk for falls related to poor safety awareness and poor balance and directed that a mechanical lift with staff x2 be used for transfers and that total assistance x2 staff be provided for ADLs. During linen change and ADL care, only one CNA was present even though the resident required two-person assistance. The CNA reported that he requested help from two other CNAs, but assistance was not immediately available, so he began changing the bed linen while waiting. He stated the bed was elevated and the resident slid from the bed to the floor, landing face down. A progress note documented that staff found the resident on the floor face down, with a raised area to the forehead and open skin sites to the right arm. The resident was nonverbal but responded to verbal stimulus by nodding. Nursing staff performed an assessment, applied ice to the forehead, initiated neuro checks, and called 911. The EMS report documented transport to a local hospital for a witnessed fall with a forehead hematoma. The facility’s incident investigation described the event as a witnessed fall during linen change when the resident slid out of bed. Interviews with the DON, Administrator, CNA, and LVN confirmed that the resident was care planned for two-person assistance, but only one staff member provided care at the time of the incident. The report also states that the resident expired in the hospital the following day.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of records, which indicated that care provided did not align with the documented orders or the expressed wishes and objectives of the resident. Specific details regarding the nature of the treatment or the resident's medical history and condition at the time of the deficiency are not provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Inaccurate MDS Assessments for Dental and Mental Health Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the current status of four residents. For one resident, the annual MDS assessment indicated the presence of all natural teeth without problems, despite dental records and direct observation confirming the absence of natural teeth and the presence of inflamed, swollen, and bleeding gums. This resident was observed on a pureed diet and verbally confirmed having no teeth during an interview. Another resident's annual MDS assessment also inaccurately documented the presence of all natural teeth without problems, even though the resident reported ongoing dental pain, loss of teeth, and the use of oral gel for pain relief. The resident had not communicated the specific nature of his dental pain to staff, and the nursing and MDS staff were unaware of his dental issues at the time of assessment. The resident's care plan was later updated to reflect dental concerns, but the original MDS did not capture these issues. A third resident's MDS assessment failed to document a mental illness condition, leaving the relevant section blank, despite the resident having diagnoses of bipolar disorder and schizophrenia, and a PASRR evaluation confirming serious mental illness. For a fourth resident, the MDS assessment indicated edentulism (no natural teeth), but the resident reported having several teeth remaining, and dental records supported the presence of non-restorable teeth recommended for extraction. These inaccuracies in the MDS assessments were identified through record review, observation, and interviews, and were not consistent with the residents' actual conditions as documented in other clinical records and direct statements.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration Errors
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, as evidenced by a 10% error rate observed during medication administration. Specifically, three out of thirty medication administration opportunities resulted in errors involving three residents and two staff members. For two residents with severe cognitive impairment, staff administered chewable aspirin tablets without instructing or ensuring the residents chewed them, resulting in the tablets being swallowed whole. In another instance, a resident was given a higher dose of cholecalciferol (Vitamin D3) than ordered, receiving 125 mcg (5000 IU) instead of the prescribed 50 mcg (2000 IU). Record reviews confirmed that the medication orders were clear regarding the form and dosage to be administered, and medication administration records matched these orders. Observations showed that staff did not follow the specific administration instructions, and interviews with facility leadership and staff confirmed ongoing education and competency checks related to medication administration. However, these measures did not prevent the observed errors, which were directly related to staff actions during medication pass.
Failure to Refer for PASRR Level II Evaluation After New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer a resident for a Level II PASRR (Preadmission Screening and Resident Review) evaluation after new mental health diagnoses were identified. The resident, a female with a history of hemiplegia and hemiparesis following a cerebral infarction, was admitted with no documented mental illness at the time of her initial PASRR Level I screening. However, subsequent medical records showed new diagnoses of bipolar disorder and anxiety disorder, and the resident was prescribed antipsychotic medication for bipolar disorder with psychotic features. Despite these new diagnoses, the facility did not initiate a referral for a Level II PASRR evaluation as required. The social worker responsible for the initial PASRR Level I screening stated that she was unaware of the need for further evaluation and had not received formal PASRR training at the time. The MDS Coordinator also indicated a lack of familiarity with the PASRR process, including when to use specific forms, and had not received formal PASRR training during her tenure. Both staff members were unaware of the updated mental health diagnoses and did not complete the necessary documentation or referrals. Interviews with facility leadership revealed that there was no clear oversight or training structure in place to ensure staff responsible for PASRR were adequately trained or aware of their responsibilities. The Director of Nursing and Administrator were not aware of the changes in the resident's diagnoses or the requirements for PASRR referrals following new mental health findings. Facility policy required PASRR Level I completion prior to admission and Level II evaluation for residents with mental illness, but this was not followed in the case of the resident with new psychiatric diagnoses.
Failure to Timely Complete PASARR Assessment
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident, resulting in a deficiency. The resident, a female with multiple diagnoses including major depressive disorder, moderate intellectual disabilities, and Parkinson's disease, was admitted to the facility without a PASARR assessment completed within the required 20 days. This oversight could potentially place newly admitted residents at risk of not receiving necessary services to meet their needs. The resident's records indicated a PASARR Level 1 Screening was completed, identifying intellectual developmental disability and recommending specialized services such as physical and occupational therapy. However, the PASARR evaluation was not completed in a timely manner due to the social worker's illness, leaving no one else at the facility to perform the assessment. The social worker acknowledged the importance of completing the PASARR assessment promptly to ensure residents receive the services they need. Interviews with facility staff, including the social worker and MDS coordinators, revealed a lack of coordination and communication regarding the PASARR process. The MDS Coordinator, who had been at the facility for only a month, stated that the PASARR should be completed within 20 days to identify residents' needs accurately. The facility's handbook outlines the federal requirements for PASARR, emphasizing the necessity of timely assessments to ensure appropriate services for residents with mental illness, intellectual disabilities, or developmental disabilities.
Failure to Complete Timely PASRR Assessment
Penalty
Summary
The facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the status of a resident with a diagnosis of major depressive disorder and intellectual disability. The resident did not receive a PASRR Level II assessment or evaluation within the required timeframe. This oversight was identified for one of the twelve residents reviewed for PASRR assessments. The resident, a female with multiple diagnoses including major depressive disorder, intellectual disability, and Parkinson's disease, was admitted to the facility without a completed PASRR assessment within 20 days of admission. The resident's baseline plan of care was incomplete, lacking focus, goals, and interventions. The PASRR Level I screening was conducted by the social worker, who confirmed the presence of intellectual disability, but the assessment was not completed in a timely manner due to the social worker's illness and absence. Interviews with facility staff, including the social worker and MDS coordinators, revealed a lack of compliance with PASRR assessment procedures. The social worker acknowledged the delay in completing the PASRR assessment and its importance in ensuring residents receive necessary services. The MDS coordinators confirmed the facility's failure to complete the PASRR assessment within the required timeframe, which could result in residents not receiving the services they are entitled to.
Resident Subjected to Mental Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from mental abuse during a nephrology appointment at a hospital. A Certified Nursing Assistant (CNA) allegedly yelled at the resident and used a racial slur, which is a violation of the resident's right to be free from abuse. The incident was reported by a Patient Affairs Specialist who witnessed the CNA's behavior and noted that the resident became quiet and withdrawn after the incident. The resident involved in the incident is a male with a history of major depressive disorder, bipolar disorder, obesity, type 2 diabetes mellitus, and anxiety disorder. His cognitive abilities are mildly impaired, and he requires assistance with various daily activities. During an interview, the resident confirmed the use of the racial slur by the CNA, although he did not report the incident to anyone at the time. The facility's policy on abuse prohibition states that residents have the right to be free from verbal, sexual, physical, and mental abuse. The policy also requires that all alleged violations be reported immediately to the administrator or designee. However, the report indicates that the facility did not respond appropriately to the incident, as the Patient Affairs Specialist's attempt to report the incident was met with rudeness, and no follow-up was conducted by the facility.
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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.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Courtyard | 0.5 mi | ★★★★★ | 1 | 0 |
| Afton Oaks Nursing And Rehabilitation Center | 1.1 mi | ★★★★★ | 14 | 1 |
| Golfcrest Nursing And Rehabilitation | 2.5 mi | ★★★★★ | 8 | 0 |
| Paradigm At Faith Memorial | 5 mi | ★★★★★ | 16 | 0 |
| Richard A. Anderson (state Of Texas Veterans Land | 5.7 mi | ★★★★★ | 0 | 0 |
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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 October 2026) and official state health department websites.