Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Gonzales during CMS and state inspections, most recent first.
A resident with quadriplegia, total dependence for all ADLs, and documented urinary and bowel incontinence remained wet for an extended period after requesting help with toileting and incontinence care. Despite facility policies requiring timely call light response and assistance with ADLs, a CNA turned off the call light, left the room without providing care, and repeatedly delayed changing and bathing the resident while stating she needed a second staff member for a two-person transfer. Observations showed more than 30 minutes elapsed before the CNA secured help from another staff member and began incontinence care and showering, even though staff and leadership acknowledged that waits over 30 minutes for brief changes were excessive and outside facility expectations. This resulted in the resident not receiving necessary services to maintain personal hygiene and grooming in accordance with his care plan and facility policies.
The facility did not ensure RN coverage for at least eight hours daily and lacked a full-time DON for multiple days, as confirmed by staffing records and staff interviews. Leadership acknowledged the importance of daily RN presence for resident assessments, and the facility's policy requires such coverage.
A deficiency was identified when three resident rooms were found to lack a fully functional call light notification system, with dome lights either not activating or missing entirely. Facility staff confirmed that these issues prevented visual notification of care needs, and maintenance records showed no consistent log of call light checks.
A deficiency was cited when a resident's care plan did not address all identified needs and failed to include measurable timetables and specific actions, as observed in the resident's records during the survey.
The facility did not ensure RN coverage for at least 8 consecutive hours each day, as required, with staffing records confirming multiple days without any RN present. The Administrator acknowledged the gaps in coverage and cited challenges in hiring RNs, while the DON noted the absence of a policy addressing this requirement.
A medication error rate of 5 percent or greater was identified during the survey, indicating that the facility did not maintain medication administration accuracy within regulatory standards.
A resident with moderate cognitive impairment and multiple mental health diagnoses was administered several psychoactive medications without signed and dated consents from her POA. The DON confirmed that required consents were missing from both electronic and hard copy records, and the facility's policy did not address the need for obtaining consent for these medications.
A resident admitted with psychotic disorder, major depressive disorder, and anxiety disorder did not have her mental illness diagnoses reflected in the PASRR Level 1 screening due to reliance on incomplete hospital records. The MDS Nurse did not update the PASRR to prompt a Level 2 screening, resulting in mental health services not being coordinated through the local authority, despite the resident receiving psychiatric and counseling services.
An expired controlled medication, Morphine Sulfate oral suspension, was found stored in a locked medication cart for a resident with severe cognitive impairment and chronic lung disease. The LPN using the cart was unaware of the process for removing expired medications, despite having been assessed as competent in this area. The DON confirmed the medication was expired and should not have been present, in accordance with facility policy.
Surveyors found that two residents had unlabeled and undated food items in their personal refrigerators, including an opened jar of Picante Sauce and a Styrofoam cup with an unidentified white liquid. Both residents had cognitive impairments and significant medical conditions. The DON and Administrator were unable to determine how long the items had been stored, and the facility's policy requiring labeling and timely disposal of perishable foods was not followed.
A resident with an order for TED hose had daily MAR entries indicating application, but interviews and observations revealed staff never applied TED hose and instead documented the resident's use of his own compression socks as if they were TED hose. Nursing staff and the unit manager confirmed the discrepancy, and the DON noted that TED hose and compression socks are not interchangeable, resulting in inaccurate and incomplete medical records.
Surveyors found that the facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency related to infection control practices.
Nursing staff did not accurately code a resident's upper extremity functional limitation on the MDS assessment, despite the resident having documented contractures and decreased range of motion due to multiple medical conditions. The omission was confirmed through observation, interviews, and record review, with facility leadership acknowledging the importance of accurate MDS documentation.
Three residents with oxygen equipment in their rooms did not have required physician orders, care plans for oxygen administration, or oxygen safety signage posted, despite facility policy mandating these measures. In two cases, oxygen equipment was present without orders or care plans, and in the third, an order existed but no care plan or signage was in place. Staff interviews confirmed inconsistent adherence to procedures for managing oxygen therapy and safety.
Two residents with severe cognitive impairment and fall risk did not have their call lights within reach as required by their care plans and facility policy. Staff interviews confirmed that all staff were responsible for ensuring call lights were accessible, but observations found one resident's call light draped over a nightstand and another's wrapped around a wall plug, both out of reach.
Two residents requiring enhanced barrier precautions did not have care plans reflecting the need for staff to use gowns and gloves during direct care, despite having wounds and infection risks. Although signage was present, care plans were not updated to include these precautions until after surveyor intervention, contrary to facility policy and staff expectations.
The facility failed to distribute mail to residents on Saturdays, as the BOM was the only one responsible for mail distribution and only worked Monday through Friday. Despite department heads having access to the mailbox on weekends, they did not distribute mail, leading to residents expressing dissatisfaction and feeling disrespected. This practice violated the facility's policy on residents' rights to privacy in receiving mail.
The facility did not maintain the required RN coverage for 8 consecutive hours a day, 7 days a week, as evidenced by the absence of RN coverage on ten weekend dates. Interviews with the DON and Regional Nursing Consultant confirmed the lack of coverage and the absence of a policy addressing this CMS standard.
The facility reported a 10% medication error rate due to late administration of medications by a medication aide. Three residents received their medications significantly past the scheduled time, contrary to the facility's policy requiring administration within one hour of the prescribed time. The errors were confirmed through observation and interviews, with the medications marked as late in the electronic record.
The facility's kitchen failed to meet food safety standards, with expired shredded cheese found in the cooler and cleaning supplies improperly stored near food. Additionally, a sack of breadcrumbs was left open and unsealed, risking contamination. The Dietary Manager confirmed these lapses, which contravene the facility's food storage policies.
A LTC facility failed to maintain proper infection control practices, as observed in three separate incidents. A medication aide did not sanitize a blood pressure cuff between residents, a CNA did not properly sanitize her hands during incontinent care, and an LVN failed to wash her hands after touching a potentially contaminated surface before providing enteral feeding. These actions were contrary to the facility's infection control policies.
A resident's right to formulate an advance directive was not honored when her family member executed an OOH-DNR without her consent, despite her intact cognition. The facility failed to reassess her wishes upon her return from hospitalization, and the resident expressed that she did not want anyone signing on her behalf.
Two privacy breaches occurred in the facility: CNAs failed to fully close a privacy curtain during incontinent care, exposing a resident, and an LVN left a computer screen open in a hallway, displaying a resident's protected health information. Both staff members acknowledged the lapses, and the DON confirmed the breaches of privacy.
A resident with severe cognitive impairment and exit-seeking behavior was not provided with a comprehensive care plan addressing these issues. Despite having a physician's order for a wander guard, the care plan did not include this or the resident's tendency to wander. The DON and MDS coordinator acknowledged the oversight, which was contrary to the facility's policy requiring comprehensive care plans.
A resident with intact cognition and complete dependence on staff for transfers did not receive podiatry care despite a physician's order. Observations showed the resident's toenails were severely neglected, and interviews revealed a lack of regular podiatrist visits and difficulty in transporting the resident to an external provider. The facility's nail care policy was not adhered to, resulting in a deficiency in maintaining the resident's foot health.
The facility failed to maintain a safe environment on Hall 300, where a container of Sani-Cloth wipes was left unsecured on a medication cart. This posed a potential hazard, especially to residents with dementia who could access the area. LVN E and the DON confirmed the wipes should have been locked away, as per facility policy, which emphasizes minimizing accident hazards.
A medication cart was left unlocked by an LVN during a blood sugar check, leaving medications accessible and out of sight. The DON confirmed the requirement for carts to be locked, as per facility policy, to prevent drug diversion.
A facility failed to coordinate hospice care for a resident by not having the required Physician Certification of Terminal Illness. The resident, with severe cognitive impairment and COPD, was on hospice care, but the necessary documentation was missing from the facility's records. This lack of documentation could impede communication and coordination between the facility and hospice care teams, affecting the resident's end-of-life care.
Failure to Provide Timely Toileting and Hygiene Assistance to a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with toileting and incontinence care to a dependent resident, as required by the resident’s care plan and facility policies. The resident was an adult male with cerebral infarction, quadriplegia, and muscle wasting/atrophy, admitted with total dependence for all ADLs, including toileting hygiene, transfers, and personal hygiene. His MDS and care plan documented that he was cognitively intact (BIMS 14), used a wheelchair, was always incontinent of urine and frequently incontinent of bowel, and required two-person assistance and a mechanical lift for transfers and toileting. The care plan also identified him as at risk for impaired skin integrity and pressure ulcers due to moisture, with goals for intact skin and interventions including assistance with movements/tasks and total dependence for toilet use. On the day of the incident, the resident reported that he had been wet for about an hour and stated that a CNA did not want to change or bathe him. At 12:48 PM, he was observed in his wheelchair, appropriately dressed, holding his call light, and expressing anger about being left wet. At 12:50 PM, CNA A entered his room in response to the call light, turned it off, told him she was waiting for additional staff to help with his brief change, and left the room quickly without allowing him to fully explain his needs. At 1:06 PM, the resident stated he was still waiting to be changed. CNA A entered again, placed wipes, gloves, and changing pads on the bed, commented that the resident was impatient, and left the room, stating she needed another staff member to assist, but did not provide care at that time. Subsequent observations showed that CNA A did not secure a second staff member and initiate care until more than 30 minutes after the resident’s request. At 1:19 PM, CNA A was observed asking a Med Tech to assist with a two-person brief change, and at 1:21 PM they entered the room to provide incontinence care, then exited quickly. At 1:24 PM, CNA A wheeled the resident to the shower area, again stating that the resident was impatient and that she needed another staff member to help clean, change, or bathe him. At 1:28 PM, the Med Tech entered the shower area to assist with toileting hygiene and showering. Interviews with CNAs, an LVN, the Regional Nurse Consultant, and the Administrator confirmed facility expectations for call light response (generally within 5–10 minutes), two-hour rounding, and that waiting more than 30 minutes for a brief change was considered excessive and unacceptable. CNA A acknowledged that the resident waited more than 30 minutes for toileting hygiene, that a 40-minute wait was excessive, and that she had difficulty obtaining help from other staff, resulting in the resident remaining soiled for an extended period despite being totally dependent for ADLs. Facility policies on Resident Rights, ADL support, and the call system required that residents be treated with respect and dignity, receive necessary services to maintain grooming and personal hygiene when unable to perform ADLs independently, and have calls for assistance answered timely. The resident’s documented dependence for toileting and hygiene, combined with his incontinence and risk for skin breakdown, required prompt assistance with elimination and hygiene. Despite these requirements, the resident remained wet for more than 40 minutes after his second verbal request to CNA A, with delays attributed by staff to difficulty obtaining a second person for transfer and care. Staff interviews consistently described that more than 30 minutes for toileting hygiene was outside facility protocol and could be considered neglectful, and leadership confirmed that a wait time exceeding 35 minutes for a total-care, alert resident to have his brief changed was unacceptable. These observations and interviews demonstrate that the facility did not ensure the resident received timely assistance with ADLs necessary to maintain good grooming and personal hygiene as outlined in his care plan and facility policies.
Failure to Provide Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight hours each day and did not have a full-time Director of Nursing (DON) present for eight specific days in November 2025. Record review showed that on these days, there was no RN or DON working at the facility during the 24-hour period. The absence of RN coverage was confirmed by both the Corporate RN and the Human Resources Director, who stated that the previous DON, who had provided daily RN coverage, was last employed on October 31, 2025. After this date, the Corporate RN attempted to visit the facility as much as possible but was not present daily, resulting in gaps in required RN coverage. Interviews with facility leadership, including the Administrator and Assistant Director of Nursing (ADON), acknowledged the necessity of having a DON or RN present to provide licensed nursing assessments of resident care needs and behaviors on a daily basis. The facility's own policy requires that an RN provide services at least eight hours every 24 hours, seven days a week. The deficiency was identified through observation, interviews, and record review, with no mention of specific residents or their medical conditions at the time of the deficiency.
Failure to Maintain Functional Call Light System in Resident Rooms
Penalty
Summary
The facility failed to ensure that a fully functional call light notification system was available in three resident rooms across three hallways. During observation rounds with the Maintenance Director and Activity Director, it was found that the dome lights outside the entrances to two rooms did not activate when the call light was engaged, and the dome light apparatus was missing from the entrance of another room. The Maintenance Director, who had been in the position for about a month, was unaware of how long these issues had persisted and had not maintained a written log of call light checks, only checking them as needed. Record review indicated that maintenance repairs, including call light notification repairs, had been completed previously, but these deficiencies were still present at the time of the survey. Interviews with facility staff confirmed that the lack of an operating dome light hindered staff's ability to receive visual notifications of residents' care needs. The facility's policy required that the resident call system remain functional at all times, but this standard was not met in the identified rooms. The deficiency was identified through observation, interview, and record review, and it was acknowledged by both the Maintenance Director and Activity Director that the absence of a working call system could impede timely staff response to resident needs.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process and was based on a review of the resident's records, which did not contain a comprehensive or measurable care plan as required.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Review of RN staffing records showed that there was no RN coverage on thirteen specific dates between March and July 2025. During interviews, the Administrator confirmed the lack of RN coverage on these dates and attributed the issue to difficulties in hiring enough RNs, particularly for weekend shifts in a rural setting. The Director of Nursing (DON) also confirmed that there was no facility policy addressing the requirement for 8-hour daily RN coverage, stating that this was a CMS standard.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct observation and calculation of medication error rates during the survey process.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident's right to be informed in advance of the risks and benefits of proposed care, treatment alternatives, and to choose preferred options was upheld. Specifically, for one resident with a history of psychotic disorder, major depressive disorder, and anxiety disorder, there were no signed and dated consents from the resident's Power of Attorney (POA) for the use of multiple psychoactive medications, including Seroquel, Buspar, Zoloft, Trazodone, and Depakote. Record review showed that the resident had moderate cognitive impairment and was prescribed these medications for her mental health conditions. The resident was not aware of the medications she was taking, and the electronic health record did not contain any consents for these psychoactive medications. During interviews, the DON confirmed that no consents were found in the electronic or hard copy records, except for an unsigned and undated consent for Seroquel. The DON acknowledged responsibility for ensuring medication consents were obtained prior to administration and was unable to explain why the consents were missing. Additionally, the facility's policy on antipsychotic medication use did not include information regarding the need to obtain consent for psychoactive medications.
Failure to Coordinate PASRR Assessments for Resident with Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for a resident admitted with multiple mental health diagnoses, including Psychotic Disorder with delusions, Major Depressive Disorder, and Anxiety Disorder. Upon admission, the resident's PASRR Level 1 screening did not reflect her mental illness diagnoses, as the MDS Nurse relied primarily on hospital records, which did not indicate mental illness or dementia. The MDS Nurse later acknowledged that she used poor judgment by not updating the PASRR to reflect the resident's mental health conditions, which would have triggered a Level 2 PASRR screening by the local mental health authority. The resident was admitted with moderate cognitive impairment and was receiving antipsychotic, antianxiety, and antidepressant medications. Despite being seen by a mental health counselor and psychiatric provider shortly after admission, the lack of a Level 2 PASRR referral meant that these services were not coordinated through the local authority as required. The DON confirmed that the resident's PASRR should have indicated her mental illness diagnoses upon admission and acknowledged the absence of a facility policy regarding PASRR services, relying instead on state guidelines.
Expired Controlled Medication Found in Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored in accordance with professional standards, as evidenced by the presence of an expired controlled medication, Morphine Sulfate 20mg/5ml oral suspension, in the Hall 300 Nurse's medication cart. The medication, prescribed for a female resident with chronic obstructive pulmonary disease and severe cognitive impairment, had an expiration date of 12/28/2024 but was still found in the locked controlled medication storage during an observation. The nurse present at the time, who had been working at the facility for three weeks, acknowledged the medication was expired but was unaware of whose responsibility it was to remove expired medications from the cart. The Director of Nursing confirmed that the expired medication should not have been stored in the medication cart and stated that it was the responsibility of the nurse using the cart to remove expired medications. Review of the nurse's competency checklist indicated she had been assessed as competent in areas including checking medication expiration dates. The facility's policy required contacting the dispensing pharmacy for instructions regarding the return or destruction of discontinued or outdated medications.
Failure to Label and Date Resident Food Items in Personal Refrigerators
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in personal refrigerators in residents' rooms, as required by facility policy. During observations, one resident's refrigerator contained an opened glass jar of Picante Sauce with a 'Best Use By' date but no indication of when it was opened. Another resident's refrigerator contained a Styrofoam cup with a white liquid, possibly milk, covered with plastic wrap, but lacking any label or date to identify its contents or when it was placed there. Both items were not labeled or dated as required for safe storage and handling. Record reviews revealed that one resident had severe cognitive impairment and the other had mild cognitive impairment, with both having significant medical conditions such as dementia, muscle wasting, chronic kidney disease, and diabetes. Interviews with the DON and Administrator confirmed that they could not determine how long the food items had been in the refrigerators and acknowledged that outdated food should be discarded. The facility's policy required that food brought by family or visitors be labeled and stored appropriately, and that nursing staff are responsible for discarding perishable foods by their use-by or expiration dates. However, these procedures were not followed for the residents in question.
Failure to Accurately Document and Administer Ordered TED Hose
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who had a physician's order for TED hose to be applied in the morning and removed at bedtime for edema. Review of the Medication Administration Record (MAR) for the month showed that staff documented the application of TED hose every morning, but night shift documentation was inconsistent, with most entries indicating to 'see progress note' and only two entries marked as 'off' or 'N/A.' Interviews with the resident and a family member revealed that staff had never applied TED hose, and the resident always wore his own black compression knee-high socks, which he put on himself daily. The family member confirmed never seeing staff apply TED hose. Further interviews with nursing staff and the unit manager confirmed that the resident wore compression socks, not TED hose, and that day shift staff were documenting the use of compression socks as if they were TED hose on the MAR. The DON clarified that TED hose and compression socks are not the same and should not be substituted for each other. The facility's policy requires that treatments and services performed be documented objectively, completely, and accurately in the medical record, which was not followed in this case.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection prevention and control measures were not established or maintained as expected. The report specifically notes the absence of a comprehensive program designed to prevent and control infections within the facility.
Failure to Accurately Reflect Resident's Functional Limitation in MDS Assessment
Penalty
Summary
Nursing staff failed to accurately code Section GG of the MDS Comprehensive assessment for a resident with multiple diagnoses, including myopathy, rheumatoid arthritis, osteoarthritis, osteoporosis, osteopenia, contractures, chronic pain, and muscle atrophy. Despite documentation in the care plan and physician's progress notes indicating the resident had contractures and decreased range of motion in the upper extremities, the MDS assessment did not reflect any impairment in the resident's upper extremity function. Observations and interviews confirmed the resident had visible hand contractures and required staff assistance for transfers. The MDS Coordinator acknowledged that the assessment did not capture the resident's limited range of motion due to contractures. Both the DON and Administrator stated that accurate MDS records are essential for proper care planning and regulatory compliance. Facility policy requires comprehensive assessments to be conducted according to established criteria and timeframes.
Failure to Ensure Safe and Appropriate Respiratory Care and Oxygen Safety Measures
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who had oxygen equipment in their rooms. For two residents, there were no physician orders for oxygen administration, no care plans addressing oxygen use, and no oxygen safety signs posted on their room doors, despite the presence of oxygen concentrators or cylinders. In both cases, the oxygen equipment was not in use at the time of observation, but staff interviews confirmed that the equipment was available for use as needed, particularly for residents on hospice care. For the third resident, although there was a physician order for oxygen to be administered as needed for shortness of breath, there was no care plan addressing oxygen administration and no oxygen safety sign on the room door. The oxygen cylinder was present in the room but had not been used since admission. Staff interviews indicated that hospice provided the oxygen equipment for potential use, and that nursing staff were responsible for obtaining orders, updating care plans, and ensuring appropriate signage. Facility policy required a physician order, review of the care plan, and placement of 'No Smoking/Oxygen in Use' signs when oxygen equipment is present. However, these procedures were not followed for the three residents identified. Staff and administration interviews confirmed that the required orders, care plans, and safety signage were not consistently in place for residents with oxygen equipment in their rooms, regardless of whether the oxygen was actively being used.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that two residents had access to their call lights, as required by their care plans and facility policy. For one resident with severe cognitive impairment and a high risk for falls, observations revealed that both his push button and soft touch call lights were draped over a nightstand and not within his reach while he was seated in his recliner. This resident was unable to answer questions about his call light due to his cognitive status and was observed attempting to get up from his recliner without assistance. Another resident, also with severe cognitive impairment and a history of falls, was found asleep in bed with her call light cord wrapped around the call light plug on the wall behind her bed, making it inaccessible. Staff interviews confirmed that call lights should be within reach of residents at all times, and that all staff members, including CNAs, nurses, housekeeping, and the Administrator, were responsible for ensuring proper placement. The resident denied moving the call light herself and stated that she relied on it to call for assistance. Both residents had care plans specifying that call lights should be kept within reach and that staff should educate and encourage their use. Facility policy also required that call lights be within easy reach of residents in bed or confined to a chair. Interviews with staff and administration revealed uncertainty about recent training on call light placement and issues with broken call light clips, but confirmed the expectation that call lights be accessible to residents at all times.
Failure to Develop and Implement Care Plans for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing enhanced barrier precautions for two residents. For one resident with chronic obstructive pulmonary disease and severe cognitive impairment, there was no care plan in place to address the need for staff to use gowns and gloves during direct care, despite the presence of a wound requiring dressing and an enhanced barrier precautions sign posted outside the room. The resident's care plan only addressed a laceration from a fall, omitting the required infection control measures. Another resident, who had chronic venous hypertension, a colostomy, and no cognitive impairment, also lacked a care plan for enhanced barrier precautions at the time of review. This resident was dependent on staff for multiple activities of daily living and had active wound care and colostomy management orders. Although an enhanced barrier precautions sign was posted, the care plan was not updated to reflect these precautions until after surveyor intervention. Interviews with staff, including an LVN, a CNA, the Administrator, and the DON, confirmed that care plans should include enhanced barrier precautions to inform staff of required infection control measures. The facility's policy requires comprehensive care plans with measurable objectives and timetables, and ongoing assessment and revision as resident conditions change. The lack of timely care plan updates for enhanced barrier precautions constituted the identified deficiency.
Failure to Distribute Mail on Saturdays
Penalty
Summary
The facility failed to uphold residents' rights to receive mail in a timely manner, as observed during a survey. It was found that the facility staff did not distribute mail received on Saturdays to the residents. This practice was confirmed during a confidential group meeting with residents, who expressed their dissatisfaction and confusion about not receiving mail on Saturdays. They felt that this practice was disrespectful and diminished their quality of life. Interviews with facility staff, including the Business Office Manager (BOM) and the Administrator, revealed that the BOM was solely responsible for distributing mail from Monday to Friday, leaving Saturday's mail undelivered until the following Monday. Despite department heads rotating as managers on duty during weekends and having access to the mailbox, they did not distribute the mail. The facility's policy on resident rights, which includes the right to privacy in sending and receiving mail, was not adhered to, as the practice of not distributing mail on Saturdays had been in place since 2018.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to comply with the requirement of having a registered nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency was identified during a review of the facility's RN hours record, which revealed a lack of RN coverage on ten specific dates, all of which were weekends, between March 1, 2024, and May 31, 2024. Interviews with the Director of Nursing (DON) and the Regional Nursing Consultant confirmed the absence of RN coverage on these dates. The facility had two RNs, one full-time and one part-time, who worked different shifts, but there was no RN coverage on the specified dates. Additionally, the Regional Nursing Consultant acknowledged that there was no nursing policy in place to address the requirement for RN coverage for 8 hours per day, as it was a CMS standard.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate based on 3 errors out of 30 opportunities. These errors involved three residents who did not receive their medications within the prescribed time frame. Medication Aide D administered hydrocodone to a resident 1 hour and 20 minutes late, duloxetine to another resident 1 hour and 42 minutes late, and metoprolol to a third resident 1 hour and 55 minutes late. These delays were observed and confirmed during interviews, and the medications were marked in red in the electronic medication administration record, indicating they were administered past the allowable time window. The residents involved had various medical conditions, including myopathy, atrial fibrillation, depression, rheumatoid arthritis, hypertension, chronic obstructive pulmonary disease, anxiety disorder, type 2 diabetes mellitus, major depressive disorder, hyperlipidemia, hypokalemia, dementia, osteoarthritis, and chronic venous hypertension. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not adhered to in these instances. The Director of Nursing confirmed that medications should be administered within one hour of the scheduled time, either one hour before or after, and acknowledged the errors.
Food Safety Violations in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. A bag of shredded Cheddar cheese was found in the reach-in cooler, past its use-by date, which was not discarded as per the facility's food storage policy. The Dietary Manager (DM) confirmed that the cheese had been opened on 05/07/2024 and should have been discarded to prevent potential foodborne illness. Additionally, cleaning supplies, including a broom, plunger, and mop heads, were improperly stored in the dry storage area alongside food staples, which is against the facility's storage guidelines. Furthermore, a 25-lb. sack of Japanese-style breadcrumbs was found open and unsealed in the dry storage room, lacking a label and use-by date, which could lead to contamination from pests. The DM acknowledged that the breadcrumbs should have been properly sealed and labeled. The facility's dietary policies are based on the Texas Food Establishment Rules, 2015 edition, and the U.S. FDA Food Code, 2022, which require proper labeling, dating, and storage of food to prevent contamination and ensure safety.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. A medication aide did not sanitize a blood pressure cuff between using it on two residents, despite being aware of the need to prevent cross-contamination. This oversight occurred during medication administration for residents with various medical conditions, including hypertension and diabetes. The aide admitted to not having sanitizing wipes available on her cart and acknowledged the lapse in protocol. Another deficiency was observed when a CNA did not properly sanitize her hands while providing incontinent care to a resident with severe cognitive impairment and multiple health issues, including Alzheimer's disease and diabetes. The CNA used hand sanitizer but failed to rub it between her fingers, which is necessary to ensure complete hand hygiene. The CNA recognized the mistake and confirmed having received training on proper hand hygiene techniques. Additionally, an LVN failed to sanitize her hands after touching a potentially contaminated surface before providing enteral feeding to a resident with brain cancer and other serious health conditions. The LVN moved a bedside table without sanitizing it and then proceeded to provide care without washing her hands. This action was contrary to the facility's hand hygiene policy, which requires hand sanitization after contact with objects in the resident's environment. The LVN acknowledged the error and confirmed having received infection control training.
Failure to Honor Resident's Advance Directive Rights
Penalty
Summary
The facility failed to honor a resident's right to request, refuse, and/or discontinue treatment and to formulate an advance directive. A resident, who was cognitively intact with a BIMS score of 14, was unable to make her wishes known regarding her code status. Her family member executed an Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) order without her consent or knowledge, following a physician's recommendation during a hospitalization when the resident was near death. The facility did not reassess the resident's cognitive status or her wishes regarding the DNR upon her return to the facility. Interviews revealed that the resident was not informed about the DNR status and expressed that she did not want anyone signing documents on her behalf. The family member, who signed the DNR, wished to respect the resident's wishes and have the DNR removed, restoring her status to full code. The facility's policy required the Interdisciplinary Care Planning Team to review advance directives with residents during quarterly care planning sessions, which was not adhered to in this case.
Privacy Breaches During Resident Care
Penalty
Summary
The facility failed to ensure personal privacy for two residents during care activities. For one resident, CNAs did not completely close the privacy curtain while providing incontinent care, leaving the resident exposed and visible from the room's door. The curtain rods were too far apart, preventing the curtains from closing fully. Both CNAs acknowledged the issue and confirmed they had received training on resident rights but had not reported the malfunctioning curtain rods. The Director of Nursing (DON) confirmed that privacy should have been maintained and that staff had received training on resident rights. In another instance, an LVN left a computer screen open on a medication cart in the hallway, displaying a resident's protected health information, including their medication administration record and insulin order. This information was visible to other staff and residents. The LVN admitted the oversight and confirmed she had received training on resident rights. The DON also confirmed that the medication administration record is protected information and should have been secured. The facility's policy requires staff to have in-service training on resident rights, including confidentiality of protected health information.
Failure to Address Exit-Seeking Behavior in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and a history of exit-seeking behavior. The resident, who was admitted with diagnoses including diabetes mellitus, cognitive communication deficit, dementia with psychotic disturbance, and heart failure, had a BIMS score indicating severe cognitive impairment. Despite having a physician's order for a wander guard to be checked every shift, the resident's care plan did not address his exit-seeking behavior or the use of the wander guard. Observations and interviews revealed that the resident had a wander guard taped to his wheelchair, but this was not reflected in his care plan. The Director of Nursing acknowledged the care plan's inaccuracy, and the MDS coordinator admitted that the resident's wandering behavior was overlooked in the care plan. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan with measurable objectives and timeframes, which was not adhered to in this case.
Failure to Provide Podiatry Care
Penalty
Summary
The facility failed to provide proper foot care for a resident, leading to a deficiency in maintaining mobility and good foot health. The resident, who had intact cognition and was completely dependent on facility staff for transfers, had not received podiatry care since admission. Despite a physician's order indicating the need for podiatry care, there was no documentation of such care being provided. Observations revealed the resident's toenails were overgrown, thick, curved, ragged, chipped, uneven, cracked, and yellowish, with a thick growth underneath some toenails. Interviews with the resident, a CNA, the Ombudsman, the DON, and the regional nurse consultant highlighted the lack of podiatry care. The CNA incorrectly stated that the podiatrist had attended to the resident's feet, while the Ombudsman had previously reported the issue to the administrator. The DON acknowledged the absence of a regular visiting podiatrist and the difficulty in transporting the resident to an external provider. The facility's policy on nail care emphasized regular cleaning and trimming, with specific instructions for residents with circulatory impairments, but these guidelines were not followed for the resident in question.
Unsafe Storage of Hazardous Materials on Hall 300
Penalty
Summary
The facility failed to ensure the resident environment on Hall 300 was free from accident hazards, as observed on 06/06/2024. A container of Sani-Cloth, a germicidal wipe with precautionary statements indicating potential eye damage, was found on the medication cart in the open. This was confirmed by LVN E, who acknowledged that the wipes could pose a hazard if handled improperly, especially since there were multiple residents with dementia who could access the area. The facility's policy emphasizes making the environment as free from accident hazards as possible, yet this incident demonstrated a lapse in maintaining a safe environment. During an interview with the DON on 06/07/2024, it was confirmed that the Sani-Cloth containers should be kept out of residents' reach, particularly for those with dementia, as they could pose a risk of injury. The DON also confirmed that staff had been trained in handling hazardous products, indicating a failure in adherence to the facility's safety protocols. The facility's policy on safety and supervision of residents highlights the importance of identifying safety risks and environmental hazards through employee training and monitoring, yet this incident revealed a gap in the implementation of these safety measures.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with one of the medication carts (Hall 300 Medication Cart). During a medication administration session, LVN C left the medication cart unlocked on one occasion while checking a resident's blood sugar in their room. This oversight left blister packs, bottles, and vials of medications accessible and out of sight, which could lead to misappropriation or accidental ingestion of medications. In an interview, LVN C acknowledged leaving the cart unlocked and admitted to forgetting the requirement to keep it locked. The Director of Nursing (DON) confirmed that the medication cart should have been locked and that the nursing staff had been trained on drug diversion prevention, including the importance of keeping medication carts locked. The facility's policy mandates that medication carts must be securely locked when out of the nurse's view, which was not adhered to in this instance.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified during a review of records and interviews, where it was found that the facility did not have the most recent Physician Certification of Terminal Illness for a resident. The absence of this critical document could hinder the communication and coordination of care between the facility's care team and the hospice care team, potentially affecting the quality of end-of-life care provided to the resident. The resident in question was admitted to the facility with multiple diagnoses, including a cognitive communication deficit and chronic obstructive pulmonary disease (COPD), and was on hospice care. Despite the resident's care plan indicating hospice care due to COPD, the facility's clinical records and hospice binder lacked the necessary physician certification from the time of admission. During an interview, the nurse consultant acknowledged the absence of the document, which should have been included in the hospice binder to ensure proper coordination of care. The facility's policy on hospice care coordination, revised in July 2017, mandates obtaining such documentation to facilitate effective communication and care planning.
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 89 citations issued within 25 miles in the last 12 months — including the 3 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 Gonzales
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Heights Of Gonzales | 0.6 mi | ★★★★★ | 9 | 0 |
| Diversicare Of Luling | 15.6 mi | ★★★★★ | 0 | 0 |
| Shiner Nursing And Rehabilitation Center Inc | 17.5 mi | ★★★★★ | 13 | 0 |
| Avir At Magnolia | 17.5 mi | ★★★★★ | 21 | 2 |
| Avir At Luling | 17.7 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Gonzales.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.