Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Grand Saline during CMS and state inspections, most recent first.
The facility failed to ensure safe food handling by not consistently monitoring and documenting cooking and holding temperatures, and by lacking effective dietary oversight. Review of temperature logs showed many missing or incomplete entries for multiple meals, and on numerous days no logs were available at all, despite written standards specifying required internal cooking and holding temperatures. A complaint alleged that a resident was served raw chicken, and a family member reported that chicken had been served undercooked. The new DM acknowledged that she had not verified that cooks were completing temperature logs and had not trained a newly hired cook on the logging process. The cook stated he was unaware of the temperature log, did not document temperatures, and knew only the poultry temperature requirement, not other food or holding standards. These actions and inactions conflicted with the facility’s own dietary policies and job descriptions, which required temperature control, recordkeeping, and investigation of food quality complaints.
Kitchen Surfaces and Food Storage Equipment Not Kept Clean: The pantry freezer, pantry coolers, bulk dry-food bins, milk box, stove area, and deep fryer vent hood were observed with food debris, dried liquid splatters, fingerprints, and greasy build-up. The DM said the vent hood had been deep cleaned by a vendor and that routine light cleaning was not part of the current process she was aware of.
Incorrect PASRR Level I Mental Illness Screenings: PASRR Level I screenings for four residents were marked negative for MI even though the records showed diagnoses including delusional disorder, PTSD, mood disorder, schizoaffective disorder, and bipolar disorder. The MDS nurse and MDS Coordinator stated the forms were incorrect, and the DON, SW, Interim Administrator, and ADM acknowledged that residents with MI, ID, or DD should be marked positive on the PASRR Level I screening.
Lack of Scheduled Activities in Secure Unit: A secure unit had no ongoing activities during multiple observations, and the posted calendar was outdated and initially missing for the new month. The Activity Director was also working as a med aide, did not yet have access to activity materials, and staff reported that aides had been informally responsible for activities for years with no set schedule. The DON and Administrator stated they were responsible for ensuring activities were scheduled and followed.
Incomplete narcotic counts and unsecured cart keys were found on two medication carts. Staff gave conflicting accounts about who counted the controlled substances and when, and records showed missing signatures and no entries for some shifts. The DON reconstructed multiple handoffs involving medication aides, LVNs, and an RN, with several missing narcotic count signatures. The facility policy required the oncoming and off-going nurse to count controlled meds together and document the count.
Unqualified Activity Director: The facility failed to ensure the activities program was directed by a qualified professional. Record review showed the current AD was not certified and no one was listed as the official activity director on the staffing roster. Interviews confirmed the AD had been hired as a medication aide, had not applied for the AD certification course, and had little to no experience as an AD. The Administrator stated the AD lacked the required certification and the facility did not have a policy on AD requirements.
Failure to use EBP PPE during resident care: two CNAs prepared a resident for transfer with a Hoyer lift and adjusted his foley catheter drainage bag without wearing gowns, despite an EBP sign posted outside the room and PPE available nearby. The resident had an open sacral wound, a foley catheter, and diagnoses including heart disease, CKD, influenza A, and sepsis; staff later stated they either missed the sign or forgot the required gown use.
Failure to Notify Resident Representative of Hospital Transfer: A resident with severe cognitive impairment, Parkinsonism, dementia, and frequent falls was sent to the hospital after a change in condition when he was found on the floor with altered responsiveness, clammy skin, and jerking movements. The NP and DON were notified, but the RP was not notified at the time of transfer, and the record only showed undocumented attempts to call the RP. The RP later stated he was not informed until the hospital contacted him.
A resident with severe cognitive impairment and a Wanderguard bracelet exited the facility unsupervised after staff failed to conduct a proper census check when a door alarm sounded. The resident was not discovered missing until contacted by police, who found him over a mile away. Staff had received training and had protocols in place, but these were not followed at the time of the incident.
The facility did not consistently develop or implement baseline care plans within 48 hours of admission for three residents with complex medical needs. In some cases, care plans were incomplete, lacked required signatures, or were not made available to nursing staff, resulting in inadequate documentation and communication about residents' immediate care needs.
A resident with diabetes and her responsible party were not informed in advance about changes to her insulin dosing and blood glucose monitoring orders after re-admission. The nurse practitioner altered the orders without documented notification to the resident or her representative, and the responsible party only learned of the changes after questioning staff. Facility staff confirmed that notification should have occurred, but it was missed in this case.
A resident with multiple chronic conditions and moderate cognitive impairment, along with her representative, was not informed of or included in the development or review of her person-centered care plan. There was no documentation of invitations to care plan meetings or provision of care plan summaries, and the representative confirmed she was not consulted or given a copy of the care plan, contrary to facility policy.
A comprehensive MDS assessment was not completed within the required 14-day timeframe for a newly admitted resident with multiple complex medical conditions. Key sections of the assessment remained incomplete, and the MDS Coordinator acknowledged the delay, citing inexperience and workload as contributing factors.
A resident with severe cognitive impairment and multiple medical conditions was admitted, but the facility did not complete a comprehensive, person-centered care plan within the required 21-day period. Staff interviews revealed that the MDS Coordinator, DON, and ADON shared responsibility for care planning, but due to new staff and organizational challenges, the care plan was not developed on time as required by policy and federal regulations.
The facility did not report to the state agency an allegation of physical abuse made by a resident against two CNAs, nor did it report a serious injury involving a subdural hematoma following an unwitnessed fall by another resident. In both cases, the required notifications were not made despite facility policy and regulatory requirements.
A resident at risk for pressure injuries developed a DTI to the right heel after staff failed to consistently perform required skin assessments and follow the care plan, particularly during a period without a treatment nurse. Nursing staff did not regularly inspect the resident's skin, and the injury was only identified after it had developed, despite facility policy and care plan directives.
Staff failed to perform proper hand hygiene between glove changes and after handling contaminated materials during incontinent care for two residents. In both cases, CNAs did not follow hand hygiene protocols as outlined in facility policy, despite having received training. Interviews revealed inconsistent understanding of hand hygiene requirements among staff and leadership.
The facility's kitchen failed to maintain sanitary conditions, with a scoop left in a flour bin, raw cabbage stored on the floor, and several food items unlabeled or undated. The dietary manager acknowledged the issues, noting that new staff were still learning procedures. These actions violated facility policy and FDA guidelines, potentially risking foodborne illness for residents.
A long-term care facility failed to maintain an effective infection control program, as staff did not adhere to Enhanced Barrier Precautions (EBP) and proper PPE disposal protocols. An LVN did not wear a gown while administering medication to a resident with a gastrostomy tube, and rooms of residents on contact isolation lacked bio-hazard containers for PPE disposal. These lapses in infection control practices could increase the risk of cross-contamination and disease spread.
A facility failed to ensure proper EBP training and implementation, as observed when an LVN did not don a gown while administering medication to a resident with a gastrostomy tube. Despite EBP signage and available PPE, the LVN only wore gloves, indicating a lack of training upon hire. Interviews confirmed that new hires were not trained on EBP, and observations showed other rooms with EBP signage lacked PPE supplies, highlighting systemic issues in infection control measures.
Failure to Monitor and Document Food Temperatures and Oversee Safe Food Handling
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the only kitchen reviewed. Surveyors’ record review of March 2026 food temperature logs showed that on multiple dates where logs were available, the facility did not document final internal cooking temperatures for breakfast, lunch, and dinner meals. For those same dates, required holding temperatures for breakfast and lunch had multiple blank or slashed entries, indicating that required temperature monitoring was not performed or recorded. On numerous additional dates in March 2026, there were no food temperature logs available at all, indicating that required temperature monitoring was not conducted or maintained on those days. The facility’s own temperature log form contained reference standards for safe food handling, including internal cooking temperatures and hot and cold holding parameters, but these standards were not consistently documented as being followed. A complaint investigation intake documented an allegation that the facility’s food was of poor quality and that a resident was served raw chicken on a specific date, which the resident did not eat. During dinner meal service observation and interview, a resident’s family member reported that kitchen staff had served chicken that was not fully cooked. The Dietary Manager (DM), who had been in her position for about one month and had previously worked as a cook for about one year, stated that cooks were responsible for obtaining and documenting food temperatures for all meals and that logs were kept on a clipboard in the kitchen. However, she acknowledged that several March 2026 food temperature logs were incomplete or not completed and that she could not confirm whether food temperatures were consistently taken. She also stated she was not aware that cooks were not completing the logs until the survey interview and that she had not followed up to ensure the logs were being completed. A cook who began working in the last week of February 2026 reported that he knew food temperatures were to be taken but said he was not instructed to document them and was unaware of the existence of a food temperature log. He stated that no one had shown or reviewed the temperature log with him, and while he knew poultry must reach 165°F, he could not identify required temperatures for other foods or the minimum holding temperatures for hot or cold items. The DM confirmed she had not trained or reviewed the food temperature log process with this cook and had assumed another cook had done so. The DM reported that she was notified on a specific date about residents’ complaints regarding uncooked chicken and received a picture showing chicken that was not fully cooked; she stated it was possible food temperatures were not taken that day and did not check the temperature log at that time. The cook initially denied but later admitted he was the cook who prepared the chicken on the date in question, stated he took the temperature but did not document it, and acknowledged that some chicken may not have been properly prepared. The DM’s job description and the facility’s Food Preparation and Service Policy both required oversight of dietary operations, investigation of food quality complaints, maintenance of dietary records, and adherence to specific cooking and holding temperatures, but the documented practices and interviews showed these requirements were not consistently implemented or monitored. The facility’s written Food Preparation and Service Policy, revised in November 2022, defined the temperature danger zone, identified potentially hazardous foods, and specified required internal cooking temperatures and holding parameters for various food items, including poultry and reheated foods. It also required that food thermometers be clean, sanitized, and calibrated, and that food and nutrition services staff monitor temperatures of foods held in steam tables throughout meal service. The policy further required that proper hot and cold temperatures be maintained during food distribution and service, and that foods held in the danger zone beyond specified time limits be discarded. Despite these detailed policy requirements, the lack of complete temperature logs, the absence of logs on multiple days, the DM’s lack of verification of staff practices, and the cook’s lack of training and knowledge about documentation and holding temperatures collectively demonstrate that the facility did not ensure that food was prepared and served in accordance with its own professional standards and safe food handling practices. The DM’s job description, signed earlier in the year, required her to evaluate and monitor all aspects of dietary operations, maintain high-quality food, plan and conduct training and in-service education for dietary personnel, investigate and resolve food quality and service complaints, and prepare routine reports and maintain all dietary records in accordance with policies and procedures. The cook job description required inspection of food and food preparation to maintain quality standards, temperature standards, and sanitation regulations. Interviews with the DM and the cook, combined with the incomplete and missing temperature logs and the complaint about undercooked chicken, show that these responsibilities were not fully carried out. The Administrator confirmed that the DM and the cook were both new and that the DM was responsible for training dietary staff and ensuring adherence to facility policies and procedures, but the evidence in the report shows that this oversight and training did not occur as required, contributing to the identified deficiency in food safety practices.
Kitchen Surfaces and Food Storage Equipment Not Kept Clean
Penalty
Summary
The facility failed to keep kitchen equipment and food storage areas sanitary. On observation, the pantry freezer, pantry cooler, and the cooler between the pantry and meat freezer had food debris, dried liquid splatters, fingerprints, and soiled shelves and door sills. The bulk sugar, flour, and cornmeal bins had dirty lids with built-up debris and dried food splatters, and the outside of the refrigerated milk box had dried liquid drips. The area above the oven doors on the 6-burner stove had a deep golden-brown greasy film that could be scraped with a fingernail, and the vent hood above the deep fryer had a light build-up of golden-brown greasy film. The DM stated the vent hood had been deep cleaned in December 2025 by a vendor and that the maintenance supervisor also deep cleaned it sometimes, but she was not aware of routine light cleaning to keep surfaces free of grease build-up.
Incorrect PASRR Level I Mental Illness Screenings
Penalty
Summary
The facility failed to ensure PASRR Level I screenings accurately reflected residents’ mental health status for four residents reviewed. Resident #64’s PASRR Level 1 screening dated 9/15/25 indicated no primary diagnosis of dementia or mental illness, although the resident had a diagnosis of delusional disorder documented in the record, along with anxiety and mild dementia with agitation. The physician’s orders also included Depakote related to delusional disorder, and the care plan described delusional behavior and medication use for delusional disorder/behaviors. Resident #9’s PASRR Level 1 screening dated 9/11/25 marked mental illness as no, even though the resident’s diagnoses included delusional disorder and he received routine antipsychotic medication. Resident #20’s PASRR Level 1 screening dated 11/01/25 also marked mental illness as no, although the resident had a diagnosis of post-traumatic stress disorder at admission. Resident #47’s PASRR Level 1 screening dated 12/11/25 marked mental illness as no and indicated primary dementia, while the record showed diagnoses of mood disorder, schizoaffective disorder, and bipolar disorder, with mood disorder listed as the primary diagnosis. During interviews, the MDS Coordinator stated the PASRR Level 1 forms for Residents #9, #20, and #47 were incorrect and should have been marked yes for mental illness. The MDS nurse stated Resident #64’s screening was marked wrong and should have been positive for mental illness. The DON, SW, Interim Administrator, and ADM all stated that residents with MI, ID, or DD should be marked positive on the PASRR Level 1 screening, and the VPCO stated the facility did not have a PASRR policy and followed state and federal guidelines.
Lack of Scheduled Activities in Secure Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities to support residents in the secure unit in their choice of facility-sponsored group, individual, and independent activities. On 02/02/26, residents in the secure unit were observed sitting in the dining room watching TV, with some asleep in wheelchairs or couches and others wandering the hall. At that time, there was no activity ongoing in the unit, and the posted activity schedule was still for January; there was no February schedule posted. Later that same day, residents again were observed after lunch with no activity ongoing, while some sat in the dining room watching TV and others wandered the unit. The Activity Director stated she was on her third full day in the role, was still required to administer medications as a medication aide, did not yet have access to the activity director computer or materials, and did not have a February activity schedule for the secure unit. On 02/03/26, the Activity Director provided a February schedule for the secure unit, which listed activities such as music, arranging flowers, Bible study, and TV. During subsequent observations on 02/03/26, the Activity Director conducted a coloring activity at 10:18 AM, but no activity was being conducted at 1:01 PM, 1:13 PM, or 1:20 PM. CNA staff stated the Activity Director did not conduct activities in the secure unit on 02/02/26 and that aides had been responsible for activities for the last 2 years, with no set schedule because they were busy with resident care tasks. The Activity Director later confirmed she did not conduct any activities in the secure unit on 02/02/26 and said she had not yet been able to work full time as Activity Director because she was still required to work as a medication aide. The DON and Administrator stated they were responsible for ensuring activities were scheduled and followed, and the Administrator said he expected the Activity Director to keep the activity schedule like medication.
Incomplete narcotic counts and unsecured medication cart keys
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate control of narcotics on Medication Cart Hall 2 and Medication Carts Halls 1 & 3. During observation, MA-B was standing at Medication Cart Hall 2 with the top drawer open and the key ring lying on top of the cart, and she stated she had obtained the keys from MA-C. MA-B said she counted the narcotics with MA-C when she took control of the keys that morning, but also said she forgot to sign the narcotic count record. Interviews with MA-C, MA-B, and LVN-E showed conflicting accounts about who counted the narcotics and when the counts occurred. MA-C first said she counted the narcotics with MA-B before giving her the keys, then later said she counted with LVN-E, and later stated she did not count with anyone when she obtained the keys from the notebook and counted the narcotics by herself. LVN-E denied counting narcotics with MA-C or MA-B. MA-C also stated that the keys to Hall Cart 2 and Hall Carts 1 & 3 were left unsecured inside the narcotic count book on top of Hall Cart 2. Record review showed missing and incomplete narcotic count documentation for both carts. The Controlled Substances Count sheet for Hall Cart 2 had a missing signature for the 6 PM to 6 AM shift on 02/02/2026 and no entries for 02/03/2026. The Controlled Substances Count sheet for Hall Cart 1 & 3 had an undated entry below 02/02/2026 with no corresponding signature from oncoming staff. The DON reconstructed the exchange of control for Hall Cart 2 and identified 8 handoffs involving 2 medication aides, 4 LVNs, and 1 RN, resulting in 13 missing signatures for narcotic counts from 07:00 AM on 02/02/2026 through 07:00 AM on 02/03/2026. The facility policy stated controlled medication inventory is to be counted at the end of each shift and the nurse coming on duty and the nurse going off duty are to make the count together and document it.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional. During record review, the current Activity Director was found to be not certified, and the staffing roster did not list anyone as the official activity director. The report states this deficiency could affect any resident and could result in residents not receiving activities individualized to match their skills, abilities, and interests/preferences. Interviews confirmed that the facility did not have a qualified Activities Professional directing the program. The HR Coordinator stated the Activity Director was not certified. The Activity Director said she had been hired as a medication aide and had not applied for the AD certification course, and she stated she did not really have any experience as an AD. The Administrator stated the current AD had started as a medication aide and did not have the required AD certification, and he acknowledged it was his responsibility to ensure enrollment in an AD program. He also stated the facility did not have a policy on the requirements for an AD, and the Regional Director stated the facility did not have a policy on Activity Director.
Failure to Use EBP PPE During Resident Transfer and Catheter Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program when CNA G and CNA H did not don gowns before providing direct care to a resident on Enhanced Barrier Precautions. The resident was an older male with diagnoses including heart disease, chronic kidney failure, influenza A, and sepsis. His quarterly MDS indicated a BIMS of 14, showing intact cognition. His care plan dated 02/01/2026 indicated he required Enhanced Barrier Precautions to prevent the spread of multidrug-resistant organisms. During an observation on 02/02/2026 at 1:15 PM, CNA G and CNA H were seen preparing the resident for transfer from bed to a shower bed using a Hoyer lift. A sign indicating the need for EBP was posted on the wall to the left of the outer doorway, and PPE was available in a plastic 3-drawer container inside the doorway. The CNAs turned the resident from side to side to place the Hoyer sling under him while he had an open wound to his sacrum. CNA H used his gloved right hand to reposition the resident's foley catheter drainage bag from underneath the bed to the foot of the bed. Neither CNA was wearing a disposable gown during the care. In interviews, CNA G said she did not see the EBP sign and forgot to wear gowns and gloves for residents with wounds, g-tubes, and foley catheters. CNA H said he did not know what conditions required EBP but understood the sign meant gown and glove use for direct care, and he did not see the sign outside the room. The DON stated she expected staff to follow EBP for residents with foley catheters and that she was responsible for ensuring staff adhered to EBP.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the resident’s representative when the resident was transferred from the facility to the hospital for a change in condition. Resident #95 had diagnoses including Parkinsonism, striatonigral degeneration, dementia without behavioral disturbance, vascular dementia, Parkinson’s disease, visual hallucinations, and high blood pressure. His admission assessment showed a BIMS score of 06, indicating severely impaired cognition, and he required assistance with toileting and showering, supervision with dressing, and had intermittent bladder incontinence. The record showed that Resident #95 had a pattern of frequent falls and progressive decline. His care plan identified multiple falls over several months, including falls with no major injuries noted, and progress notes documented repeated incidents such as being found on the floor, bruising to the face and eye, agitation after a room change, and continued neuro checks after falls. On 01/14/2026, he was found on the floor on his hands and knees, only responding with moans and groans, with cold and clammy skin, jerking movements to both upper extremities, and bruising from prior incidents. 911 was called, and the NP and DON were notified. The transfer documentation for that hospital send-out indicated the NP and DON were notified at the time of transfer, but the primary responsible party had not been notified at the time of transfer. The incident report stated that the charge nurse attempted to call the responsible party three times with no response, but there were no documented times for those attempts. Hospital records later showed the responsible party was contacted by phone after the transfer and was aware the resident was in the hospital. During interview, the responsible party stated he was not notified when the resident was sent to the hospital and did not learn of the transfer until the hospital called him later. The facility policy stated that a nurse will notify the resident’s representative when it is necessary to transfer the resident to a hospital or treatment center.
Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple psychiatric diagnoses, who was wearing a Wanderguard bracelet, was able to leave the facility unsupervised. The resident was last seen by staff in the morning, and although the front door alarm sounded, the charge nurse assumed it was triggered by other residents accompanied by family members and did not conduct a facility-wide check to account for all residents with Wanderguard devices. The resident was not discovered missing until the local police contacted the facility after finding him approximately 1.3 miles away. The resident's care plan had previously identified a risk for wandering, and a Wanderguard had been placed after a prior incident where the resident was found outside the facility. Despite this, staff did not follow procedures to verify the whereabouts of all residents at risk when the door alarm was activated. Interviews with staff revealed that although they had received training on elopement procedures and the use of a binder listing residents with Wanderguards, the protocol was not followed at the time of the incident. The charge nurse did not initiate a sweep or census check to ensure all at-risk residents were present after the alarm sounded. The facility's failure to provide adequate supervision and to respond appropriately to the door alarm resulted in the resident leaving the premises undetected for approximately one hour. The resident was eventually located by law enforcement and returned to the facility without injury. The incident demonstrated a lapse in the implementation of established elopement prevention protocols, specifically in monitoring and accounting for residents identified as being at risk for wandering or elopement.
Failure to Develop and Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, as required by policy. For one resident with Alzheimer's disease, dementia, aortic stenosis, and osteoporosis, the electronic baseline care plan was completed but lacked signatures from the resident, the resident's representative, and the staff who developed the plan. The document was not properly signed or made available to the nursing staff, and the process for obtaining signatures was inconsistently followed. Another resident with a principal diagnosis of COPD, emphysema, dementia, and diabetes mellitus did not have their baseline care plan updated to address the principal diagnosis or the identified risks for hypoglycemia and hyperglycemia. The care plan was a revision of a previous stay's plan and did not include goals or interventions for the current admission's primary health concerns. Additionally, there was no documentation that the resident or their representative had been informed or included in the care planning process. A third resident with multiple diagnoses, including cerebral atherosclerosis, major depression, diabetes, and dysphagia, had an incomplete and undated baseline care plan in the electronic record, and the signed paper copy was not scanned into the electronic health record. As a result, the baseline care plan was not accessible to nursing staff and could not be updated to reflect changing needs. The facility's process for managing baseline care plans was inconsistent, leading to incomplete documentation and lack of communication among staff regarding residents' immediate care needs.
Failure to Notify Resident and Representative of Changes in Insulin Orders
Penalty
Summary
The facility failed to inform a resident with diabetes mellitus and her responsible party in advance about changes made to her physician orders regarding insulin dosing and blood glucose monitoring. Upon re-admission from the hospital, the resident's orders were changed by the nurse practitioner from a sliding scale insulin regimen with blood glucose checks four times daily to a reduced frequency of two times daily and discontinuation of the sliding scale insulin. There was no documented evidence that either the resident or her responsible party was notified of these changes, as required by facility policy and regulatory standards. The responsible party only became aware of the changes several days after admission when the resident reported not receiving her insulin shots. Upon inquiry, the responsible party learned of the order changes from nursing staff and subsequently had the original orders reinstated after discussing with the nurse practitioner. Interviews with staff, including the charge nurse and DON, confirmed that notification of such changes is expected practice, but in this instance, the notification was missed. Facility policy also requires prompt notification of residents and their representatives regarding changes in care or treatment.
Failure to Include Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and her representative were informed of and included in the development and implementation of a person-centered care plan. Record review showed that during the resident's stay, there was no documentation indicating that either the resident or her representative had been invited to participate in care planning meetings, had been consulted about the care plan, or had received a copy of the care plan. The resident, who had a history of COPD, emphysema, dementia, and diabetes mellitus, was moderately cognitively impaired and ambulatory with a walker. Despite these needs, there was no evidence in the medical record of any communication or invitation to the care planning process for the resident or her representative. Interviews with the resident's representative confirmed that she was not consulted or included in the care planning process, was never asked to attend a care plan meeting, and was not provided with a copy of the care plan. The DON, who was not employed at the facility during the resident's stay, was unable to find any documentation of care plan meetings or invitations for the resident or her representative. Facility policy required that residents and/or their representatives be provided with a written summary of the baseline care plan and be informed of their right to participate in care planning, but this was not followed in this case.
Failure to Complete Timely Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a newly admitted resident within the required 14-day timeframe, as specified by the CMS Resident Assessment Instrument (RAI) User Manual. Record review showed that the resident, a male with multiple diagnoses including cerebral atherosclerosis, major depression, diabetes mellitus, anxiety, sleep apnea, atrial fibrillation, dysphagia, arthritis, ataxia, and a history of repeated falls, was admitted to the facility and had an incomplete admission MDS assessment. Key sections of the MDS, such as identification information, preferences, functional abilities, health conditions, special treatments, participation in assessment, and care area assessment summary, were not completed, and the assessment was not signed as completed by the required date. During an interview, the MDS Coordinator acknowledged the assessment was overdue and could not provide a reason for the delay. She stated she was still learning the process and had not completed the assessment within the regulatory timeframe. The facility's policy, based on the RAI Version 3.0 Manual, requires comprehensive assessments to be completed by the end of day 14 following admission, but this was not met for the resident in question.
Failure to Complete Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident within the required timeframe. Specifically, a female resident with diagnoses including Alzheimer's disease, dementia, aortic stenosis, and osteoporosis was admitted, and her records showed a severely impaired cognitive status with a BIMS score of 6. Despite these needs, a comprehensive care plan had not been completed within 21 days of admission, as required by both federal regulations and the facility's own policy. The MDS Coordinator confirmed that the comprehensive MDS assessment and subsequent care plan were not completed on time, attributing the delay to efforts to get caught up with new admissions. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that responsibility for care plan development was shared among the MDS Coordinator, DON, and ADON. The DON and other key staff were new to the facility and acknowledged they were still organizing processes and were unaware that the resident's care plan was overdue. Review of the facility's policy and the CMS RAI Manual confirmed the requirement for care plan completion within 21 days of admission, which was not met in this case.
Failure to Timely Report Alleged Abuse and Serious Injury
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse and serious injury to the state agency as required by regulations. In one instance, a male resident with dementia and physical impairments reported to the DON that two CNAs were rough with him during care, including an allegation that one CNA struck him with a rolled-up rag and knocked a scab off his foot. Although the Administrator conducted an internal investigation and determined the accused CNAs were not present at the time of the alleged incident, the facility did not report the allegation to the state agency as required, since the Administrator believed reporting was unnecessary if the accused staff were not present. In a separate case, another male resident with dementia and a history of falls experienced an unwitnessed fall resulting in a head injury. The resident was found on the floor with a hematoma and was transported to the hospital, where he was diagnosed with a subdural hematoma. Despite the serious nature of the injury, the facility did not report the incident to the state agency. The DON, who was present at the time of the fall, confirmed that the Administrator was responsible for reporting such incidents, but the required report was not made. Review of the facility's own policy confirmed that all allegations of abuse, neglect, exploitation, or injuries of unknown source must be reported immediately to the Administrator and to authorities, with specific timelines based on the severity of the incident. The facility's failure to report both the abuse allegation and the serious injury was not in accordance with their policy or regulatory requirements.
Failure to Prevent Pressure Injury Due to Inconsistent Skin Assessments
Penalty
Summary
A deficiency occurred when a resident, who was at risk for pressure injuries due to conditions such as dementia, diabetes, incontinence, and limited mobility, developed a deep tissue injury (DTI) to her right heel. The resident's care plan required skin assessment and inspection every shift, with particular attention to the heels, but this was not consistently implemented. The facility's policy also required daily skin inspections during personal care and weekly risk assessments, but these were not reliably performed. Nursing staff interviews revealed that skin assessments were primarily the responsibility of the treatment nurse, and when the facility was without a treatment nurse, other nurses did not assume this responsibility. Several staff members, including RNs and LVNs, stated they had not recently assessed the resident's feet or performed skin assessments, despite the care plan's requirements. The DON confirmed that skin assessments should be performed on admission and weekly, and that if a care plan called for assessments every shift, this should be done, but was unaware of any such care plans being in place. Documentation showed that the resident had no skin issues noted in assessments prior to the discovery of the DTI. The injury was first identified by an RN who noticed a dark area with surrounding redness on the resident's right heel and subsequently notified the physician and responsible party. Observations at the hospital confirmed the presence of a DTI on the right heel. The facility's failure to ensure consistent skin assessments and adherence to the care plan led to the development of the pressure injury.
Failure to Perform Proper Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene practices among staff during incontinent care for two residents. In one instance, a CNA performed multiple glove changes while providing care, including opening a wet brief, wiping the resident's vaginal area and bottom, applying lotion, and putting on a clean brief, but did not perform hand hygiene between glove changes. Although the CNA had previously been checked off on proper handwashing techniques, she stated that hand hygiene was not necessary between glove changes. In another instance, a CNA disposed of a dirty wipe after receiving it from another CNA during incontinent care, but did not change gloves or perform hand hygiene before handing over clean wipes and a clean brief. The CNA acknowledged the lapse, attributing it to nervousness. Interviews with the DON and Administrator revealed differing expectations regarding hand hygiene, with the DON expecting hand hygiene before care, between dirty and clean tasks, after care, and between glove changes, while the Administrator emphasized hand hygiene before and after glove use and when hands are visibly soiled. The facility's policy indicated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and outlined specific indications for hand hygiene.
Sanitation Deficiencies in Kitchen Food Storage and Labeling
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. A scoop was left inside a bulk flour bin in the dry pantry, which was later removed by the dietary manager (DM) who acknowledged that new kitchen staff had not yet learned all procedures. Additionally, a box of raw cabbage was improperly stored on the floor in front of a reach-in cooler, and several food items in the coolers were not labeled or dated, including a resealable bag of breadsticks, a large plastic container with an unknown orange-brown substance, and various nectar-thickened juices. The DM admitted to not knowing the contents of the plastic container and confirmed that thickened liquids should be dated when opened. The facility's policy on food storage, dated 12/01/11, requires that scoops be stored in a protected area near food containers, all items be stored at least six inches above the floor, and refrigerated foods be dated, labeled, and tightly sealed. The Food and Drug Administration Code, 2013, also mandates that food be stored in a clean, dry location, protected from contamination, and at least six inches above the floor. The facility's failure to adhere to these standards could place residents at risk of foodborne illness.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) by staff. Specifically, LVN A did not wear the required gown while administering medication to a resident with a gastrostomy tube, despite the presence of signage indicating the need for Enhanced Barrier Precautions (EBP). LVN A admitted to forgetting to don a gown and acknowledged that she had not received training on EBP at the facility. Interviews with other staff, including LVN B and the Director of Nursing (DON), confirmed that the facility's policy required the use of gloves and gowns for residents with indwelling devices, such as feeding tubes, to prevent cross-contamination and the spread of infections. Additionally, the facility failed to provide appropriate containers for the disposal of contaminated PPE in the rooms of residents requiring contact isolation. Observations revealed that rooms of residents on contact isolation did not have lined bio-hazard containers for doffed PPE. Staff interviews indicated that PPE was improperly disposed of in regular trash cans or removed from the room in plastic bags. The DON confirmed that bio-hazard boxes should have been placed in the rooms for proper disposal of PPE, and it was the responsibility of medical services to ensure their presence. The facility's policies and CDC guidelines emphasize the importance of using PPE, including gloves and gowns, for high-contact resident care activities and proper disposal of PPE to contain pathogens. The lack of adherence to these protocols and the absence of necessary disposal containers highlight significant lapses in the facility's infection control practices, potentially increasing the risk of cross-contamination and the spread of communicable diseases among residents.
Deficiency in EBP Training and Implementation
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care, specifically in the context of Enhanced Barrier Precautions (EBP). This deficiency was observed when LVN A did not don a gown before administering medication to a resident with a gastrostomy tube, who was under EBP due to the presence of an indwelling device. Despite the presence of EBP signage and available personal protective equipment (PPE) at the resident's room, LVN A only wore gloves and neglected to wear a gown, which is a requirement for EBP to prevent cross-contamination and the spread of infections. Interviews with LVN A revealed that she was aware of the EBP requirements but admitted to forgetting to don a gown during the procedure. Further investigation showed that LVN A had not received any EBP training upon her hire at the facility, which was confirmed by the Director of Clinical Operations (DCO) and the Director of Nursing (DON). The lack of initial EBP training was a systemic issue, as the Business Office Manager (BOM) also confirmed that new hires were not trained or checked off on EBP, and the facility's new hire orientation and training checklists did not address EBP. Additionally, observations indicated that other rooms with EBP signage lacked PPE supplies at or near the entrances, suggesting a broader issue with the facility's implementation of EBP protocols. The facility's policy on EBP, which aligns with CDC guidelines, mandates the use of gowns and gloves for high-contact resident care activities, such as those involving feeding tubes. However, the absence of training and proper PPE setup compromised the facility's ability to adhere to these infection control measures.
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.
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What surveyors actually found near you
We read the 83 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grand Saline
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Azalea Trail Nursing And Rehabilitation Center | 0.5 mi | ★★★★★ | 1 | 0 |
| Avir At Bradburn | 0.8 mi | ★★★★★ | 7 | 2 |
| Van Healthcare | 11.7 mi | ★★★★★ | 9 | 0 |
| Avir At Mineola | 13.2 mi | ★★★★★ | 22 | 1 |
| Canton Oaks | 13.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.