Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Heritage Oaks during CMS and state inspections, most recent first.
RN Coverage Not Maintained: The facility failed to provide RN services for at least 8 consecutive hours per day on 2 days reviewed. RN time punches showed no RN hours, and the ADM, DON, and staffing coordinator confirmed there was no RN coverage when the scheduled RN called off sick and no replacement was found. The facility policy stated an RN provides services at least 8 hours every 24 hours, 7 days a week.
Cell Phone Use During Resident Care: CNAs were observed and reported using personal cell phones while providing care, including showers, in resident rooms, at nurses’ stations, in hallways, and while supervising smoking times. Nine confidential residents said the behavior made them feel ignored, embarrassed, and that their privacy was violated. The DON and ADM stated residents should receive privacy and full attention during care, and the facility policy required staff to treat residents with kindness, respect, dignity, privacy, and confidentiality.
Missing Informed Consent for Psychotropic Medications: Five residents received psychotropic meds, including antidepressants and antianxiety agents, without signed consent forms in the chart. The residents included individuals with intact cognition as well as residents with dementia or severe cognitive impairment. The DON stated the consents had not been signed, and the ADM said she was unaware the forms were missing until the day of the interview. The facility’s psychotropic medication policy did not address medication consents, and no informed consent policy was provided.
Incomplete DNR Documentation: The facility failed to ensure DNR forms were completed correctly for three residents. One resident's DNR lacked required physician and resident signature details, another was missing a witness signature, and a third was missing a dated physician signature. The SW and ADM stated the forms were not valid if not filled out correctly and that there was no system for monitoring DNR accuracy.
Inadequate Shower Function and Hot Water Temperatures: The facility failed to maintain a functioning shower in the Magnolia unit and failed to keep shower and room sink water temperatures within the expected range. A resident reported delayed showers and inconsistent warm water, while staff confirmed residents were using showers on another hall because the Magnolia shower was out of service and water pressure was poor. Observations and log review showed repeated low hot water readings in Magnolia rooms and showers, and the Wildflower shower also measured below the facility's temperature range.
A facility failed to make grievance/complaint information available to 9 of 9 residents reviewed. Residents stated they did not know they could file anonymously, where to get a grievance form, who to give it to, what happened after filing, or that they had a right to a written decision. Observations showed the prominent postings did not include grievance instructions, and the ADM stated the grievance procedure and anonymous filing process were not being discussed in Resident Council.
Meals were not consistently palatable, attractive, or served at an appetizing temperature for several residents. Residents reported cold food, bland taste, and poor texture, including mechanical meals that were not warm and a resident who said he had almost choked on a mechanical diet item. Surveyors observed sample tray items that were cold, mushy, chunky, tough, or had no flavor.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors observed unlabeled food items without use-by dates in the walk-in freezer and refrigerator, an uncovered garbage can next to the food prep table, a cook not properly wearing a hair restraint, and dirty black residue under the pot and pan sink/draining area. The cook, DM, and ADM each acknowledged the labeling, dating, sanitation, and hair restraint issues during interview.
Improper Dumpster Waste Disposal: The dumpster area behind dietary was observed with one dumpster about 3/4 full, another dumpster door left open, and bags of garbage on the ground around both dumpsters. The DM, MS, and ADM gave differing accounts of who was responsible for the area, and the MS stated he had not yet reviewed the waste disposal policy. The facility policy required waste to be properly contained with lids or otherwise covered and disposal areas kept sanitary and free from pests.
Failure to follow infection control practices during resident care was observed for two residents. One CNA provided foley catheter care to a resident with an indwelling catheter and EBP orders but did not change gloves, perform hand hygiene, or use the required PPE during dirty-to-clean tasks. Another CNA provided incontinence care to a resident with severe cognitive impairment and total incontinence, then handled a clean brief with dirty gloves without changing gloves or sanitizing hands, contrary to facility policy and staff expectations.
A cognitively intact male resident with paraplegia, dependent on staff for toileting and bathing, requested a shower during the night. A CNA, who reported being in the middle of rounds, undressed him in bed, partially attempted incontinence care, then left the room after he became verbally aggressive, without covering him, closing the door, or pulling the privacy curtain. The resident was later found by an LVN completely naked in bed with the door wide open, no privacy curtain in place, and soiled items on the bed, while his cognitively intact roommate was present. Facility leadership and policy indicated staff were expected to ensure residents were covered, safe, and afforded privacy before leaving the room, and acknowledged that this incident violated the resident’s dignity and privacy rights.
A cognitively intact male resident with paraplegia and other comorbidities was involved in an altercation with a maintenance staff member over access to an exterior door code. The staff member reported becoming frustrated after the resident repeatedly requested the code and threatened to tell others he had provided it, and admitted telling the resident to "get the fuck out of my face," which he recognized as verbal abuse by definition. Another cognitively intact male resident with a history of CVA and epilepsy corroborated that there was bickering about the door code and heard the staff member tell the resident to get out of his face, though he did not hear profanity and stated neither resident appeared upset. This incident reflects a failure to ensure a resident was free from verbal abuse.
A resident with quadriplegia, severe cognitive impairment, and a chronic coccyx pressure ulcer was admitted with an existing wound and later received a physician order for a low-pressure airflow mattress. The MDS identified pressure ulcer risk and triggered a CAA, and clinical notes documented wound progression, infection, and use of pressure-reducing devices, as well as ongoing wound care and repositioning efforts. However, the comprehensive care plan, even after revision, did not include the ordered pressure-relieving mattress as an intervention or provide guidance on its implementation or monitoring. Observations and interviews showed that the resident and family repeatedly reported concerns about the bed’s inflation, while CNAs and some nurses reported they had not been trained on the mechanics of the mattress and were unclear who was responsible for checking it. The MDS coordinator, ADONs, and DON all acknowledged that the low-pressure mattress should have been care planned and that existing systems for updating care plans did not ensure this intervention was added, resulting in a deficiency for failure to develop and revise a complete, measurable care plan based on the resident’s assessed needs and physician orders.
A resident was found to have cigarettes and a lighter stored in a bag on their walker in their room, contrary to the facility's smoking policy requiring all smoking supplies to be kept locked at the nurse's station and only accessed under staff supervision. Staff were unaware of the presence of these supplies, did not remove them, and did not report the incident, despite being trained on the policy. The facility's policy prohibits residents from keeping smoking articles except when directly supervised.
The facility failed to inform residents about their rights to file grievances, as 19 residents reported not having access to grievance forms or knowing the procedure. The grievance policy was not posted in prominent locations, and there was no option for anonymous submissions. The Administrator confirmed the lack of accessible grievance forms and the absence of discussions in Resident Council meetings.
The facility failed to maintain effective infection control due to inadequate hand hygiene practices by staff during resident care. Staff members, including CNAs and an LVN, did not adhere to the facility's handwashing protocols, washing hands for less than the required time and failing to follow proper procedures during peri and wound care. These actions could lead to the spread of infections among residents.
A resident with multiple medical conditions was observed with an uncovered urinary catheter drainage bag, compromising their dignity and privacy. Despite the facility's policy to use privacy bags, the resident's bag was visible through an open door on two occasions. Interviews with the DON, ADON, and ADM confirmed that nursing staff were responsible for ensuring privacy bags were used, as per facility policy.
A resident with respiratory conditions did not receive proper care as the facility failed to monitor and maintain oxygen equipment according to physician orders. The resident's oxygen humidification bottle was often empty, and the nasal cannula and tubing were not changed weekly, leading to discomfort and potential health risks. Despite facility policies and staff training, these deficiencies were observed, indicating a lapse in care.
A dietary aide failed to change gloves and wash hands during food preparation, despite leaving the prep table and engaging in various tasks, leading to a deficiency in food service safety. Interviews confirmed that the facility's policy required these actions to prevent cross-contamination.
Two CNAs failed to perform proper hand hygiene during incontinence care for residents with cognitive impairments and incontinence issues, risking infection spread. One CNA did not wash hands between glove changes or before leaving a resident's room, while another did not wash hands before, during, or after care, handling clean items with dirty gloves. Interviews revealed a lack of awareness about infection control roles and recent training, despite facility policies emphasizing hand hygiene.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 2 of 30 days reviewed for RN coverage. Record review of RN time punches provided by the facility showed no RN hours for 4/24/2026 and 4/25/2026, and the facility failed to maintain RN coverage of eight hours on those dates. During interviews on 5/06/2026, the ADM stated there was no RN coverage for those two days and explained that the staffing coordinator and the DON were responsible for scheduling RN coverage. The DON stated the RN scheduled for that weekend called off sick and a replacement could not be found, and that agency was used for LVN nurses only, not RN coverage. The staffing coordinator stated she did not look for a replacement and believed the DON would do so because the RN had called in to the DON. The facility policy titled, Staffing, Sufficient and Competent Nursing, revised 08/22, stated that a registered nurse provides services at least eight hours every 24 hours, seven days a week.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and care in a manner that promotes quality of life and recognizes each resident’s individuality for 9 confidential residents. The deficiency was based on resident interviews and record review showing that CNAs were using personal cell phones while providing care, including assisting with showers, performing care in resident rooms, and supervising residents during supervised smoking times. Residents stated staff texted and talked on their phones while walking in hallways, at nurses’ stations, and while performing care in their rooms, and they reported that this occurred on every shift and often in the facility. The residents also stated they did not know the names of the CNAs involved. The 9 confidential residents stated the cell phone use made them feel ignored, not a priority, embarrassed, and concerned that a CNA could make a mistake because of distraction. They also stated their privacy was violated. During interviews, the DON and ADM stated residents should receive privacy and full attention during care, and both stated staff were trained on privacy, resident rights, dignity, and cell phone usage. The record review included the facility policy titled Resident Rights, dated February 2021, which stated employees shall treat all residents with kindness, respect, and dignity and that residents have the right to a dignified existence, to be treated with respect, kindness, and dignity, and to privacy and confidentiality.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that five residents were fully informed and had signed informed consent for psychotropic medications before those medications were administered. Residents #30, #32, #93, #127, and #130 were each receiving antidepressant and/or antianxiety medications, and record review showed no signed consent documents in their electronic medical records for the ordered psychotropic drugs. Resident #30 was admitted with diagnoses including cerebral infarction and depression, had a BIMS score of 13, and was receiving duloxetine and mirtazapine. Resident #32 had dementia, depression, and anxiety, had a BIMS score of 03, and was receiving Paxil. Resident #93 had cerebral infarction, depression, and anxiety, had a BIMS score of 05, and was receiving buspirone and citalopram. Resident #127 was admitted with depression and anxiety, had no completed MDS assessment in the record reviewed, and was receiving duloxetine. Resident #130 was admitted with depression and anxiety, had a BIMS score of 14, and was receiving clonazepam, escitalopram, and Wellbutrin XL. During interview, the DON stated the consents had not been signed and that nursing staff were responsible for obtaining consent when the order was received. The ADM stated she was not aware the consents were not signed until the day of the interview and that staff had been trained to obtain consent when medication was ordered. The facility’s psychotropic medication policy did not include information related to medication consents, and no informed consent policy was provided when requested.
Incomplete DNR Documentation
Penalty
Summary
The facility failed to ensure that advance directive and DNR documentation was completed accurately for 3 of 6 residents reviewed for advance directives. Resident #1 had a DNR order on the face sheet, physician order summary, and care plan, but the DNR form was incomplete because the resident's signature was not dated, the physician did not print his name after signing, the physician's signature was not dated, and the physician's license number was missing. Resident #5 also had DNR status documented on the face sheet, physician order summary, and care plan, but the DNR form was missing a witness signature. Resident #6 had DNR status documented on the face sheet, physician order summary, and care plan, but the DNR form was missing the physician's dated signature. During interviews, the SW and ADM stated the DNRs were not valid if not filled out correctly and verified the missing information for Residents #1, #5, and #6. They stated there was no system for monitoring DNRs for accuracy, and the ADM identified human error as the reason the forms were incomplete.
Inadequate Shower Function and Hot Water Temperatures
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff, and the public by not maintaining functioning showers and adequate hot water temperatures in resident rooms and shower areas. The deficiency involved 2 of 3 showers, identified as Magnolia and Wildflower, and 2 of 12 rooms. The Magnolia shower had been out of order for approximately 4 months, with an undated sign on the shower door stating, "DO NOT USE." During observation, the Magnolia shower had inconsistent water pressure and the handheld shower head only trickled water. Staff interviews confirmed the shower had been out of service since at least February 2026 and that residents were being directed to use another unit's shower instead. Resident and staff interviews described ongoing problems with shower access and water temperature. A resident stated the Magnolia shower had not been working for a while, showers were sometimes delayed, and the water was not always warm because other residents had used the same shower. CNA and LVN interviews confirmed residents on Magnolia were using showers on another hall and that hot water had been an issue throughout the facility. The DON stated the importance of hot water and a functioning shower was for residents to be comfortable, clean, and to decrease infection risk. The ADM stated the hot water concerns had started the prior week and that the facility had approved repair of the tankless water heater. Record review showed repeated water temperature readings below the facility's stated range for resident rooms and shower areas. In Magnolia unit rooms, documented hot water temperatures included readings such as 93.6 F, 92.4 F, 86.2 F, 83.4 F, 89.6 F, 83.7 F, and 90.3 F. In the Magnolia shower, documented temperatures included 95.1 F, 99.6 F, 93.8 F, 95.4 F, and 93.7 F, and later observation showed 70.4 F. In the Wildflower shower, observation showed 95.3 F. A confidential resident council interview included 9 residents stating the water did not get hot enough during showers. Facility policy stated water heaters serving resident rooms, bathrooms, common areas, and tub/shower areas were to be set to no more than 110-115 F or the maximum allowable temperature per state regulation, and maintenance staff were responsible for checking and recording water temperatures.
Grievance Procedure Information Not Made Available to Residents
Penalty
Summary
The facility failed to make information on how to file a grievance or complaint available to residents for 9 of 9 confidential residents reviewed for grievances. During interviews, all 9 residents stated they did not know they could file a grievance anonymously, that the grievance procedure had never been discussed in Resident Council, and that they had not seen a posting of the grievance procedure in prominent locations. The residents also stated they did not know where to obtain a grievance form, who to submit it to, what happened after a grievance was filed, or that they had the right to receive a written decision once the grievance was resolved. Observation of prominent postings showed the facility did not include instructions regarding the grievance procedure with the postings. The ADM stated she was the grievance officer and that grievance forms were available on a shelf by the piano, but she did not know there were no forms available there. She stated the Activities Director completed grievance forms during monthly Resident Council meetings when concerns were voiced, and staff also completed forms for some face-to-face complaints. The ADM stated grievances were assigned to the appropriate department, addressed with the complainant, resolved, and documented on the grievance form, which was then reviewed and kept in a notebook for 3 plus years. The ADM also stated she was responsible for staff training on the grievance process and agreed the availability of grievance forms, the grievance procedure, and the process for submitting an anonymous grievance should be explained at admission and continually discussed in monthly Resident Council meetings.
Meals Served Cold and Poor in Texture and Flavor
Penalty
Summary
Food and drink were not provided in a palatable, attractive, and safe appetizing temperature for five residents, including Residents #8, #60, #99, #101, and one confidential resident. Several residents voiced concerns that meals were cold, lacked flavor, or had poor texture. Resident #99 said some foods were not really good and had no flavor or taste. Resident #101 reported that mechanical meals were not even warm and said he had almost choked once about a month earlier. The confidential resident stated that eggs were very cold in the mornings, lunch tasted like old food, and the meat was particularly poor. Resident #60 said the food did not look or taste good, was sometimes cold, and that the meat served at lunch was tough. Resident #8 stated that the food was bland, cold most of the time, and that spaghetti was sometimes not drained enough and vegetables were not drained well.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During a kitchen tour, surveyors observed an uncovered garbage can next to the food prepping table, a cook not properly wearing a hair restraint to cover the mustache area, and dirty black food residues under the pot and pan sink/draining area. These observations were made in the facility kitchen that was reviewed for food safety. Surveyors also observed food items in the walk-in freezer and walk-in refrigerator that were not labeled and did not have use-by dates. In the walk-in freezer, items that resembled chicken breasts, hashbrowns, breast sticks, and sausages were stored in clear plastic bags with no labels or use-by dates. In the walk-in refrigerator, items that resembled lettuce, sausages, tortillas, and ground beef were also stored in clear plastic bags with no labels or use-by dates. During interviews, the cook stated he was responsible for labeling and dating food items but had forgotten to do so because he was busy with other kitchen tasks, and he acknowledged he had been trained on labeling, dating, and kitchen sanitation policies. The DM stated she was responsible for monitoring labeling and dating of food items and also acknowledged that the uncovered garbage can, improper hair restraint use, and dirty residue under the pot and pan draining area were not in compliance with facility expectations. The ADM stated kitchen staff were responsible for dating and labeling food items, that the garbage can should have been covered when not in use, and that the dirty residue needed to be cleaned.
Improper Dumpster Waste Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (#1 and #2). During observation on 05/04/2026 at 10:21 a.m., the dumpster area behind the dietary department was found with a commercial-size dumpster about 3/4 full of garbage, dumpster #2 left open, and bags of garbage on the floor around dumpsters #1 and #2. The report states the area was not kept clean and waste was not properly contained in the dumpsters with lids or otherwise covered. During interviews, the DM stated that everyone in the facility was responsible for keeping the dumpster area clean and closing the door, and that all staff members were responsible for monitoring the task. The MS stated he and his assistant were responsible for keeping the dumpster area clean and closing the door, but said the task was overlooked and that he had not yet come across the waste disposal policy. The ADM stated maintenance personnel were responsible for keeping the dumpster area clean and closing the door, with the MS monitoring the task, and also stated she did not know why the area was littered with garbage or why the door was not closed. Record review of the facility policy titled Sanitation, revised November 2022, stated garbage and refuse containers are to be in good condition, waste properly contained in dumpsters/compactors with lids or otherwise covered, and garbage disposal areas maintained to prevent pests.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 of 6 residents reviewed for infection control. During observation, CNA D provided foley catheter care to a resident with a history of cerebral infarction, obstructive and reflux uropathy, benign prostatic hyperplasia, moderate cognitive impairment, and an indwelling catheter. The resident had Enhanced Barrier Precautions ordered for high-contact care activities, including hygiene, incontinence care, and catheter care. CNA D washed her hands and put on gloves, but during the care she did not change gloves or perform hand hygiene when moving between dirty and clean tasks, and she also did not wear the appropriate PPE for EBP. During the same survey, CNA E provided incontinence care to another resident with dementia, muscle weakness, severe cognitive impairment, and total bowel and bladder incontinence. CNA E cleaned the resident’s buttocks, removed the soiled brief, and then grabbed a clean brief with dirty gloves and placed it on the resident without changing gloves or performing hand hygiene before touching the clean brief. The resident’s care plan identified incontinence care needs, and the facility policy for perineal care required discarding soiled gloves, sanitizing hands, and re-gloving before touching clean linens or an adult brief. The DON stated she was the infection preventionist and that staff are trained on hand hygiene, glove changes, and EBP quarterly, with infection control training done monthly. She stated staff are expected to follow all infection control policies, including wearing a gown, gloves, and mask for EBP, and that not following these practices could spread infection. The ADM also stated staff are expected to follow infection control training and use the appropriate PPE and hand hygiene protocols. The observations showed CNA D and CNA E did not follow those practices during the resident care events.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
The deficiency involves a failure to ensure personal privacy and dignity for a cognitively intact male resident with chronic kidney disease, malignant neoplasm of the spinal cord, and paraplegia, who was dependent on staff for toileting hygiene and required substantial assistance for showers. According to his care plan, he required staff assistance with ADLs, including toilet and personal hygiene. On the night in question, the resident returned late from a pass and initially fell asleep after being put to bed. In the early morning hours, he used his call light and requested a shower from a CNA who reported she was in the middle of rounds and could not provide the shower at that time. During this interaction, the resident became verbally aggressive and used profanity toward the CNA. The CNA stated she placed him in bed, removed his bottoms, and attempted to complete incontinence care, but reported that he stopped cooperating and refused to turn, preventing her from completing his brief change. She told him she would step out and that someone else would finish his care, then left the room. The CNA acknowledged that the resident was left with only a shirt and half a brief on, and she was unsure whether the door was left open. She did not cover him with a sheet or otherwise ensure he was not exposed before leaving, and she did not return to the room or follow up on whether his care was completed, instead notifying her charge nurse that he had been cursing at her and that she had stepped out to let him calm down. Another nurse later received a call from the resident asking for help and went to his room, where she found the door wide open, the privacy curtain between the two roommates not pulled, and the resident completely naked on the bed with a soiled brief and dirty wipes present. The roommate, who was also cognitively intact and paraplegic, recalled that the CNA had undressed the resident in bed, left the door open, and then left, and that some time passed before another nurse came to finish the resident’s care. Facility leadership, including the LVN charge nurse, the administrator, and the DON, stated that staff were expected to ensure residents were safe, covered, and provided privacy before leaving a room, even when stepping out due to resident behavior, and acknowledged that leaving the resident exposed in bed with the door open and without privacy curtains constituted a violation of his dignity and privacy. The facility’s resident rights policy required employees to treat residents with kindness, respect, and dignity, and to protect their privacy and confidentiality.
Failure to Protect Resident From Verbal Abuse by Staff Member
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from abuse and/or neglect when a maintenance staff member (MM A) used profane language toward a resident. Resident #1, a cognitively intact male with chronic kidney disease, malignant neoplasm of the spinal cord, and paraplegia, was involved in an interaction with MM A related to the exterior door code. According to MM A’s interview, he had recently changed the exterior door codes and went outside to smoke when Resident #1 approached and repeatedly asked for the code. MM A stated he refused to provide the code due to facility policy, and Resident #1 continued to pressure him and said he would tell others that MM A had given him the code. MM A reported that he became frustrated and told Resident #1 to “get the fuck out of my face,” acknowledging he was irritated and believed, by definition, his statement constituted verbal abuse. Resident #1 later told surveyors he did not recall anything happening between him and MM A, stated they had always gotten along, and denied hearing MM A say anything to him, though he confirmed the DON had spoken to him about the incident. Resident #2, also cognitively intact with a history of cerebral infarct, hemiplegia, and epilepsy, reported overhearing bickering between Resident #1 and MM A about the door code. Resident #2 stated he heard Resident #1 say he would tell others that MM A gave him the code, and then heard MM A say “get out of my face,” without cursing or yelling. Resident #2 reported that both he and Resident #1 were laughing, did not feel upset, and he did not hear MM A use the word “fuck.” Despite differing accounts regarding the exact wording, the report identifies that MM A directed an inappropriate, potentially abusive statement toward Resident #1, constituting a failure to protect the resident from verbal abuse.
Failure to Include Ordered Pressure-Relieving Mattress in Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise a comprehensive care plan to include a physician-ordered pressure-relieving mattress for a resident with a significant pressure ulcer. The resident, an older male with quadriplegia and severely impaired cognition, was admitted with a coccyx pressure ulcer that was present on admission and greater than three months in duration. The comprehensive MDS identified the resident as at risk for pressure ulcers, with a triggered CAA for pressure ulcers that should have been care planned, and documented the use of a pressure-reducing device for the bed. Physician orders included a pressure-reducing mattress to the bed with a start date in November and detailed wound care orders for an unstageable coccyx pressure ulcer. Despite these orders and the resident’s high-risk condition, the written care plan did not include the low-pressure airflow mattress as an intervention. Record review showed that the resident’s care plan, last revised in early January, contained a focus on wound management with goals for wound improvement and freedom from infection, and interventions such as administering antibiotics as prescribed, notifying the provider if there was no improvement, and providing wound care per treatment orders. Another care plan focus addressed the resident’s resistance to repositioning due to anxiety, with interventions including education about noncompliance and praise for appropriate behavior. However, the care plan lacked any reference to the ordered pressure-relieving mattress, did not provide clear guidance for staff on implementation or monitoring of the mattress, and did not outline expectations for pressure injury management related to the specialized bed. Progress notes over several months documented the presence and progression of the coccyx wound, including staging changes from Stage 2 to unstageable, wound measurements, infection, antibiotic use, and additional care such as turning/repositioning and pressure-reducing devices, but did not include progress notes specifically addressing the pressure-relieving mattress. Interviews and observations further demonstrated gaps in care planning and staff knowledge related to the low-pressure airflow mattress. On observation, the resident was seen lying on a low-pressure airflow mattress with the static button turned on, and the resident and a family representative reported repeated concerns that the bed was not properly inflated, with staff appearing unsure how to manage or check the bed. Multiple CNAs and an agency nurse reported they had not received instruction or individualized training on low-pressure airflow mattresses and were unclear about who was responsible for checking them. The MDS Coordinator, ADONs, and DON all stated that the low-pressure airflow mattress should have been care planned as an intervention, and acknowledged that it was not included in the resident’s care plan. Leadership interviews revealed confusion and inconsistency about who was responsible for ensuring such interventions were entered into care plans, especially after the facility no longer had a designated wound care nurse, and there was no specific policy for low-pressure airflow mattresses. The DON stated that the care plan should have reflected the implementation of the low-pressure airflow bed at admission and acknowledged that the omission could result in worsening wounds or increased infection, confirming that the ordered pressure-relieving mattress was not incorporated into the comprehensive care plan as required. The facility’s own staff described the care plan as the primary guide for all staff to know residents’ active issues, conditions, and required interventions, and recognized that missing interventions could place residents at risk for decline. Despite this, the system described for monitoring and updating care plans—baseline care plans within 48 hours, discussion in morning meetings, and quarterly or change-in-condition reviews—did not result in the inclusion of the low-pressure airflow mattress for this resident. The MDS Coordinator indicated that, historically, the wound care nurse would have ensured wound-related interventions were added to care plans, but after that role was vacated, no clear reassignment of those duties occurred. The DON and administrative staff acknowledged overall responsibility for ensuring interventions were included in care plans, yet they were unaware that this resident’s mattress intervention was missing until it was identified during the survey. This combination of incomplete care planning, lack of documented guidance on the mattress, and staff uncertainty about mattress operation and monitoring led to the cited deficiency for failure to develop and revise a comprehensive care plan consistent with the resident’s assessed needs and physician orders.
Failure to Enforce Smoking Policy and Control Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for one resident who was reviewed for smoking. According to the resident's care plan and the facility's smoking policy, all cigarettes and lighters were to be kept locked at the nurse's station, and residents were only permitted to smoke during scheduled times under staff supervision. However, during observation and interview, it was found that the resident kept cigarettes and a lighter in a black bag attached to his walker, which was stored in his room. The resident confirmed that he kept his smoking supplies in his room and was not told he could not do so. Staff interviews revealed that multiple staff members, including the DON, MA, ADM, and SW, were not aware that the resident had smoking supplies in his room. Although all staff reported being trained on the smoking policy, which prohibits residents from keeping smoking supplies in their rooms or on their person, the supplies were not removed when discovered, and the incident was not reported to supervisory staff. The resident was observed accessing his cigarettes and lighter from his walker and later smoking outside under staff supervision, with the blue smoking supply box present. The facility's policy, dated October 2022, clearly states that residents may not have or keep any smoking articles except when under direct supervision. Despite this, the resident was able to retain smoking supplies in his room, and staff did not enforce the policy or report the violation. The lack of adherence to the policy was confirmed through interviews and observations, with staff acknowledging the potential for residents to obtain smoking supplies from a nearby store and the inability to search residents' belongings.
Failure to Provide Grievance Information to Residents
Penalty
Summary
The facility failed to provide information to residents and their representatives on their rights related to filing grievances or concerns. This deficiency was identified during a Resident Council meeting where 19 out of 22 confidential residents reported they did not have access to the grievance form, were unaware of the option to file grievances anonymously, and had not seen the grievance procedure posted in prominent locations. The residents also expressed that the grievance procedure had never been discussed in Resident Council meetings, and they were unaware of how to acquire a grievance form, who to submit it to, and the process that follows once a grievance is filed. The facility's grievance policy, last updated in 2023, mandates that information on how to file a grievance should be made available to residents, family, and staff. However, observations revealed that the facility did not include instructions regarding the grievance procedure in any prominent postings, and grievance forms were not readily accessible. The Administrator, who is the grievance officer, stated that grievance forms were kept at the Nurses' Station and in the Administrator's office, and residents could not obtain a form without asking. Additionally, there was no procedure for submitting grievances anonymously, and the grievance process was not being discussed in Resident Council meetings.
Inadequate Hand Hygiene Practices in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple instances of staff not adhering to hand hygiene protocols during resident care. Specifically, CNA H did not follow proper handwashing procedures while providing peri care to a resident with multiple infections and an indwelling catheter. Despite wearing personal protective equipment (PPE), CNA H washed her hands for only 10 seconds, contrary to the facility's policy of 30-60 seconds, and failed to rinse the urinal before placing it back on the nightstand. LVN E also did not adhere to hand hygiene protocols while providing wound care to two residents. During wound care for a resident with a stage 4 pressure ulcer and a suprapubic catheter, LVN E washed her hands for only a few seconds at various points, instead of the required 20 seconds. Similarly, while attending to another resident with multiple pressure ulcers, LVN E repeatedly washed her hands for less than the required time and did not lather soap properly. CNA I, while providing peri care to a resident with cognitive impairment and incontinence, washed her hands for only nine seconds and failed to wash her hands after disposing of trash. These lapses in hand hygiene could potentially lead to the spread of infections among residents, as acknowledged by the staff during interviews. The facility's policies on hand hygiene, enhanced barrier precautions, and perineal care were not followed, contributing to the deficiency in infection control.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity and privacy of Resident #98, who was observed with an uncovered urinary catheter drainage bag on two separate occasions. The resident, a male with multiple medical conditions including osteomyelitis, pathological fracture, and neuromuscular dysfunction of the bladder, was found lying in bed with the room door open, exposing the urinary catheter drainage bag to view. The resident expressed that he was unaware of the option to have the drainage bag covered with a privacy bag and stated a preference for it. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator (ADM) revealed that it was the facility's policy to provide privacy bags for urinary catheter drainage bags unless a resident specifically requested otherwise. The DON and ADM acknowledged that the responsibility for ensuring the use of privacy bags lay with the nursing staff, who were trained to monitor and provide catheter care. The facility's policy on dignity emphasized the importance of maintaining resident privacy and preventing practices that compromise dignity, such as failing to cover urinary catheter bags.
Failure to Maintain Oxygen Equipment for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in monitoring and maintaining oxygen equipment as per physician's orders. The resident, a male with a history of acute respiratory failure with hypoxia, pulmonary embolism, and other respiratory conditions, was observed with an empty oxygen humidification bottle and undated nasal cannula and oxygen tubing. The resident reported that the oxygen tubing and nasal cannula were not changed weekly as required, and the humidification bottle was often empty, causing discomfort. Interviews with the Director of Nursing (DON) and other staff revealed that the facility's policy required oxygen tubing to be changed weekly and humidification bottles to be monitored and refilled every shift. However, these procedures were not consistently followed, as evidenced by the lack of dates on the equipment and the resident's statements. The DON acknowledged that the failure to maintain the humidification bottle could lead to dryness and discomfort, and that not changing the tubing regularly could increase the risk of infection. The facility's policy on oxygen administration emphasized the importance of adhering to physician orders and maintaining equipment to prevent complications. Despite regular in-service training for staff, the deficiency in following these protocols was evident. The administration and nursing management were responsible for ensuring compliance, but the oversight led to a lapse in care for the resident, potentially compromising their respiratory health.
Failure in Hand Hygiene and Glove Use During Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene and glove use, during the preparation of snack sandwiches. On the observed date, a dietary aide (DA A) was seen preparing sandwiches while wearing gloves. However, DA A did not change gloves or wash hands after leaving the prep table multiple times, touching various surfaces, and engaging in different tasks. These actions included walking to the dry storage room, opening a bag of potato chips, using a sharpie marker from a pocket, and interacting with other staff members, all without changing gloves or washing hands. Interviews with DA A, the dietary manager (DM), and the administrator (ADM) confirmed that the facility's policy required changing gloves and washing hands when leaving the prep table, changing tasks, or touching unsanitized items. Despite being trained on these procedures, DA A did not follow them, which was acknowledged as a problem by both the DM and ADM. The facility's policy on handwashing and glove use was reviewed, highlighting the need for proper hand hygiene to prevent cross-contamination during food preparation.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper hand hygiene practices observed during incontinence care for two residents. A certified nursing assistant (CNA) providing care to a female resident with dementia, anxiety disorder, and hypertension did not perform hand hygiene between glove changes or before exiting the resident's room. This resident was always incontinent of bladder and bowel, requiring the use of briefs, and the CNA's failure to follow proper hand hygiene protocols during care posed a risk of infection and cross-contamination. Another CNA was observed providing incontinence care to a male resident with COPD, hypertension, atrial fibrillation, and cognitive communication deficit. The CNA did not perform hand hygiene before donning gloves, during care, or after completing the care. The CNA handled clean briefs and other items in the resident's room without changing gloves or washing hands, further increasing the risk of spreading infections. This resident also required the use of briefs due to incontinence, and the lack of proper hand hygiene during care was a significant lapse in infection control practices. Interviews with the CNAs revealed a lack of awareness about the infection preventionist and insufficient recent training on infection control. The facility's administration, including the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and an educator, were unaware of the staff's non-compliance with infection control protocols. The facility's policies on infection control and hand hygiene emphasized the importance of handwashing to prevent the spread of infections, but these were not adhered to during the observed incidents.
What surveyors are citing around you — mapped
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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 135 citations issued within 25 miles in the last 12 months — including the 14 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.
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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 Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Rehabilitation And Care Center | 2.5 mi | ★★★★★ | 7 | 0 |
| Lubbock Health Care Center | 2.6 mi | ★★★★★ | 6 | 0 |
| Hansford County Hospital District Dba Lakeridge Nu | 2.7 mi | ★★★★★ | 12 | 0 |
| Southern Specialty Rehab & Nursing | 2.7 mi | ★★★★★ | 13 | 2 |
| Mesquite Post Acute Care | 2.8 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.