Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Hillsboro during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, incontinence, and total dependence on staff for toileting hygiene was observed receiving perineal care while fully exposed from the lower body, with the room door open and no privacy curtain in use. Despite two knocks from the surveyor, the CNA continued care without closing the door or pulling the curtain, only stating "resident care" in response. The resident later reported that the door is usually closed during such care and that the lack of privacy did not make her feel good. The CNA, DON, and ADM all acknowledged that facility expectations and policies on dignity, resident rights, and perineal care require closing doors and/or using curtains and draping to protect bodily privacy during personal care.
Meal timing failed to meet the required overnight interval because the posted dinner and breakfast schedule created a 14.25-hour gap for all residents reviewed. Residents said they were not involved in choosing mealtimes and wanted dinner later, while the ADM, DM, and RD acknowledged the timing issue and referenced the 14-hour requirement and bedtime snack expectations.
Kitchen sanitation and alternate meal service concerns: Surveyors found a freezer with a yellow sticky spill on the bottom shelf beneath frozen food items, and the DM said the spill was about to be cleaned and likely happened overnight. Interviews also showed that alternate meals were inconsistently handled, with staff using frozen ham for sandwiches, PB&J and ham and cheese used as common alternates, and no prepared alternate items on the steam table during observation. The DON and ADM described ongoing issues with residents not consistently receiving requested menu substitutions and items such as bacon and salads not being regularly available.
Insufficient Emergency Water Supply: Surveyors found that the facility’s only emergency water supply was 23 gallons of bottled water and one 5-gallon jug stored in the kitchen pantry for a census of 61 residents. The DM stated she was not aware of any additional water on site and did not think the facility had enough to supply all residents during a water emergency. The ADM confirmed the pantry water was the only emergency supply in the building and was not enough to continue daily operations if a water outage occurred; she also stated prior emergency water had expired and had not yet been restocked.
Failure to Provide Anonymous Grievance Access: Surveyors found no blank grievance forms available for residents or representatives to obtain or submit anonymously, and no grievance information was prominently posted. Six residents stated they did not know how to file grievances anonymously, had to ask the AD for forms, and had no place to submit complaints on their own, including on weekends or holidays. The AD said she wrote grievances during resident council or morning rounds, while the ADM and DON said anonymous filing was possible but forms were only available if requested from staff.
Failure to Prevent Resident-to-Resident Abuse: The facility failed to keep residents free from abuse when one cognitively impaired resident physically assaulted two other residents and later was found unclothed with another resident in a room while they were attempting a sexual act. The involved residents had severe cognitive impairment and dementia-related diagnoses, and staff statements described the resident as aggressive and uncooperative during the incidents.
A resident with intact cognition and a history of malnutrition was not consistently provided the meat sandwich she requested and was often offered only PB&J when she asked for something different. The RD had recommended snacks, supplements, and food preferences due to severe malnutrition risk, but the care plan did not address her dietary preferences or desire to gain weight. Staff and other residents also reported repetitive breakfast menus, cold room trays, and inconsistent access to always-available menu items.
A resident with heart failure and intact cognition was discharged home with home health while Medicare Part A skilled days remained, but the facility did not provide a NOMNC. Records showed the resident’s skilled episode ended with benefit days left, the discharge paperwork was incomplete, and the ADM could not confirm the discharge circumstances or locate the required notice. The physician note reflected the resident wanted to return home, therapy expected readiness in 7-10 days, and no discharge order was in place until a verbal order was obtained later.
Employment of Individual With Disqualifying Criminal History: The facility employed a Maintenance Director despite a background check showing a 3rd degree felony conviction for credit or debit card abuse elderly. HR stated the individual had been approved by the previous ADM and that the facility did not want to terminate him, while the ADM stated the criminal history report had been run before hire. Facility policy stated unsatisfactory background reports would result in rescinding the offer or termination, and the Abuse Prevention Program stated the facility would not knowingly employ anyone convicted of abusing, neglecting, or mistreating individuals.
MDS assessments for two residents were inaccurately coded for high-risk drug classes. One resident had an active aspirin order and no anticoagulant medication, yet the MDS showed anticoagulant use and did not mark antiplatelet use; the other resident also had aspirin ordered with no anticoagulant medication, but the MDS again showed anticoagulant use and did not mark antiplatelet use. Both residents had severe cognitive impairment, and neither care plan reflected the antiplatelet use or monitoring.
A resident with HTN, kidney failure, stroke, hemiplegia, chronic pain, and other diagnoses was dependent on staff for bathing, but staff did not follow his shower schedule and he reportedly went months without a bed bath or shower. He had intact cognition, yet his care plan only directed staff to encourage bathing despite documented refusals, pain with touch to his legs and feet, and verbal abuse toward staff. Surveyors observed heavy dead skin buildup on his face, feet, and bed, while a CNA and an LVN confirmed he mostly received bed baths and that his feet and legs were painful to touch.
Failure to provide in-room activities based on resident preferences. A resident with CHF, HTN, DM, anxiety, depression, schizophrenia, morbid obesity, UTI, constipation, and severe cognitive impairment spent most of her time in her room and required a mechanical lift and about 5 staff to transfer her. Her care plan noted she enjoyed TV, reading, snack cart, and 1:1 visits, but no recent Resident Preference Assessment was completed, and the AD confirmed she had not done one. The resident stated she was not given books, cards, or puzzles, and none were observed in her room aside from a TV.
Failure to maintain clean and properly stored oxygen equipment: A resident with dementia, HF, and HTN required supplemental O2 via nasal cannula, but surveyors observed an undated cannula, a concentrator filter packed with dust and debris, and tubing left open and wound around the concentrator and wheelchair armrest instead of being bagged when not in use. The DON stated the tubing should have been dated and bagged and that nurses were responsible for keeping the concentrator, filter, and tubing clean.
A resident with DM2, CKD, cellulitis, and moderate cognitive impairment received Amoxicillin-Pot Clavulanate for cellulitis without a documented stop date. The MAR and physician order summary showed the antibiotic was given for multiple days, and the DON stated all antibiotics should have a stop date and that charge nurses were responsible for obtaining it by contacting the ordering physician.
Infection control failures occurred during medication pass and wound care. A medication assistant used an electronic BP cuff on one resident and then on another without cleaning it between uses, and an LVN performing wound care for a resident with a diabetic foot ulcer did not don the gown required for EBP and did not perform hand hygiene after removing soiled gloves before applying clean gloves. The residents involved had significant medical histories including HTN, AFib, Alzheimer’s disease, CKD, and diabetes.
A resident with multiple chronic conditions, including COPD and dementia, was admitted and only received a baseline care plan, with no comprehensive care plan developed within the required timeframe. Staff interviews revealed a lack of awareness of the 21-day requirement for comprehensive care plan completion, and facility records confirmed the omission.
A resident with COPD was observed using oxygen therapy without a corresponding physician's order or care plan documentation. Staff interviews confirmed that oxygen use was not reflected in the care plan and that no current order existed, despite the resident's documented use of oxygen and the facility's policy requiring such orders and assessments.
A resident with a history of rash and pruritus did not receive the prescribed triamcinolone acetonide cream for itching over several months. Despite having a physician's order, the medication was not administered or documented, leading to ongoing discomfort and sores from scratching. Facility staff, including the ADON and DON, were unaware of the medication's availability and did not ensure its use, resulting in a deficiency in care.
A resident with dementia and lower extremity impairments was injured during a transfer from a shower chair to a bed using a mechanical lift. The shower chair was lifted along with the resident, causing the resident to grab it, leading to the chair falling and a wheel hitting the resident's toe, resulting in a cut and bruise. The facility's policy emphasizes safety, but this incident indicates a failure in ensuring safe resident transfers.
A resident with moderate cognitive impairment and multiple medical conditions was found with an unreported and unassessed bruise on her forearm. Facility staff, including the DON and LVN, were unaware of the bruise, and there was no documentation or treatment orders addressing it. Interviews revealed a lack of communication and awareness among staff, and facility records showed no recent training on injury of unknown origin.
A storage room door in a hallway was found open, exposing residents to potential hazards like razors and chemicals. Staff interviews confirmed that such doors should remain closed and locked to prevent resident access to dangerous items. The facility's policy mandates secure storage of hazardous materials, but this was not followed.
The facility failed to administer medications on time for 18 residents, with scheduled 9:00 AM doses given after 11:00 AM. This affected residents with conditions like epilepsy, diabetes, and Parkinson's disease. The DON noted the delays, and some physicians were informed, but not all residents or their responsible parties were notified.
A facility experienced a 15% medication error rate due to late administration of medications, affecting multiple residents with serious conditions. The deficiency was linked to staffing issues, as a scheduled medication aide did not report for duty, leaving only one aide to cover multiple hallways. This led to significant delays in medication administration, despite efforts by the ADON and other staff to manage the situation.
The facility failed to provide palatable food, as evidenced by undercooked rice served to residents. Residents expressed dissatisfaction with the food quality, noting improper cooking and overcooked vegetables. A test tray sampled by surveyors contained rice with hard bits, confirmed by the Dietary Manager as undercooked. Residents did not consume much of the rice due to its hardness, highlighting the importance of palatable food to prevent weight loss. The facility's policy mandates nourishing and palatable meals, with staff responsible for inspecting trays.
A LTC facility failed to maintain an effective infection control program, with staff neglecting hand hygiene while serving meals and assisting residents. CNAs were observed not sanitizing hands or equipment between uses, posing a risk of infection spread. Interviews revealed staff awareness of their lapses, despite existing policies and training on standard precautions.
The facility failed to maintain an effective pest control program, resulting in flies in two halls and the kitchen. Residents reported flies in their rooms, with one resident noting flies on her hydration cup. In the kitchen, flies were observed near meal prep areas, with an open door and fan potentially allowing entry. Staff interviews revealed a lack of awareness and communication about the pest issue, despite a policy requiring ongoing pest control.
A resident in a memory care unit was not treated with dignity during feeding, as both an LVN and a CNA were observed standing while assisting the resident with meals. The resident, who requires assistance due to severe memory loss and other conditions, was not fed at eye level, contrary to facility policy. Staff interviews confirmed the expectation for staff to sit at eye level to ensure a dignified dining experience.
A facility failed to assess and document the use of bed rails for a resident, lacking informed consent and a physician's order. The resident, with multiple medical conditions, had bed rails installed without a safety assessment or care plan inclusion. Staff interviews revealed inconsistencies in understanding the risks, highlighting a deficiency in compliance with facility policies.
A resident with multiple medical conditions did not receive his preferred breakfast of toast and was instead given pancakes, despite his documented preferences. The facility's dietary staff failed to consistently provide meals that matched residents' preferences, leading to dissatisfaction and potential risk of weight loss. Other residents also reported similar issues with meal tickets not matching the meals served.
A resident with multiple medical conditions sustained a wrist fracture and other injuries after being left unsupervised by a CNA, leading to a fall from the bed. The facility failed to follow its policies for preventing and investigating abuse and neglect, resulting in an Immediate Jeopardy situation.
A resident with multiple medical conditions and requiring substantial assistance was left unsupervised by a CNA, resulting in a fall and wrist fracture. The facility failed to investigate or report the incident, leading to an Immediate Jeopardy situation.
A resident with multiple medical conditions fell out of bed and sustained injuries due to inadequate supervision and failure to follow the care plan. The CNA repositioned the resident too close to the edge of the bed and left the room, leading to the fall. The facility did not report the incident immediately and failed to conduct a thorough investigation initially.
A resident with multiple medical conditions fell out of bed and sustained a wrist fracture after being repositioned to the edge of the bed and left unsupervised by a CNA. The facility did not report the incident to HHSC or conduct a thorough investigation, despite the resident's significant pain and injuries.
Failure to Provide Privacy During Perineal Care
Penalty
Summary
The facility failed to ensure personal privacy for one resident during perineal care when staff did not close the door or pull the privacy curtain. The resident was an elderly female with paranoid schizophrenia, severe cognitive impairment (BIMS score of 06), reduced mobility, gait abnormalities, muscle weakness, major depressive disorder with psychotic symptoms, edema, and total dependence on staff for toileting hygiene. Her MDS reflected she was always incontinent of bowel and bladder, and her care plan directed staff to check her frequently for incontinence and provide perineal care, including washing, rinsing, and drying the perineum and changing clothing as needed. During an observation, the resident’s room door was fully open, and from the hallway the surveyor could see the resident’s lower body fully exposed while a CNA provided perineal care without the privacy curtain drawn. When the surveyor knocked on the open door, the CNA responded “resident care” but did not stop or take any action to close the door or pull the curtain, and continued providing incontinent care with the resident exposed. After a second knock, the CNA again only stated “resident care” and completed the perineal care without providing privacy, then left the room to dispose of trash and soiled items. In an interview, the CNA acknowledged that facility expectations and procedures require closing the door or using the curtain during incontinent care and stated she believed the door had been closed but did not latch. The resident reported that the CNA had just changed her brief, that the door is typically closed for privacy during such care, and that the lack of privacy during this incident “did not make me feel good.” The DON and ADM both stated their expectations that staff close doors and/or pull curtains during incontinent care and characterized failure to provide privacy as a breach of dignity and a resident rights and privacy issue. Facility policies on Dignity, Resident Rights, and Perineal Care all require staff to promote and protect resident privacy, including bodily privacy, and to provide privacy by closing doors and curtains and draping the resident during personal care.
Meal Schedule Exceeded Allowed Overnight Interval
Penalty
Summary
The facility failed to ensure that no more than 14 hours elapsed between the substantial evening meal and breakfast the following day for 61 of 61 residents reviewed for meal frequency. The posted meal schedule outside the kitchen showed breakfast at 7:00 AM, lunch at 11:45 AM, and dinner at 4:45 PM, which created a 14.25-hour interval between dinner and breakfast. The facility’s only kitchen served meals for all 61 residents, and the report states this timing placed all 61 residents at risk of decreased intake and meal dissatisfaction. During a confidential resident group meeting, residents stated they did not help choose the mealtimes and that the ADM had given the RCP a piece of paper with new mealtimes to vote on. The residents said they wanted dinner later than the posted time, but were satisfied with the posted breakfast and lunch times. The ADM stated she would work with the RCP to have the council vote on new dinner and breakfast times and said the mealtimes had been set before she started a few months earlier. The DM stated she knew there should not be more than a 14-hour lapse between dinner and breakfast, and the RD stated the facility was at the 14-hour requirement when she last reviewed the mealtimes and that snacks should be offered to residents who had an order for them. The facility’s Open Style Dining policy also noted the federal requirement for no more than 14 hours between the substantial evening meal and breakfast unless a nourishing bedtime snack is provided and the resident group agrees to up to 16 hours.
Kitchen sanitation and alternate meal service concerns
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation. During an observation of the kitchen on 12/03/2025 at 9:58 a.m., surveyors found a freezer labeled veggie, dessert, and drinks with a yellow sticky residue spilled on the bottom shelf underneath an ice cream tub and around frozen packets of pancakes. In an interview shortly after, the DM stated she had worked at the facility for two weeks and said they were about to clean up the spill in the dessert freezer, adding that it must have happened overnight because it was not there the day before. She also stated her main goal since starting was to get the kitchen cleaned up. Additional interviews and observations showed concerns with alternate food items and resident meal preferences. The DM stated frozen ham was used to slice and make ham and cheese sandwiches, that residents could choose from an alternate menu if they did not like the posted menu, and that some residents had PB&J orders for lunch, dinner, or snacks. She confirmed that Resident #39 wanted meat with every meal to gain weight, but also made requests for different menu items and was served them upon request, to her knowledge. CNA C stated nursing staff were responsible for picking up alternate food items from the kitchen, but not preparing them or ensuring they were what the resident wanted, and said PB&J and ham and cheese sandwiches were common alternates. On 12/05/2025, an observation of the kitchen showed frozen ham in the freezer, canned soup in the pantry, and no alternate menu items such as burgers or baked potatoes prepared on the steam table. The ADM stated that when she started a few months earlier, the facility began ordering bacon and salads because residents had not been getting those items regularly, and the DON stated she had to explain to staff that some residents needed menus available in their rooms so they could submit substitutions before meals were served.
Insufficient Emergency Water Supply
Penalty
Summary
The facility failed to establish procedures to ensure that enough water was available in the event of a loss of normal water supply. During observation of the kitchen, surveyors found four packs of 35 bottled waters at 16.9 fl oz each and one 5-gallon jug stored in the kitchen pantry as the facility’s emergency water supply. The DM stated this was all of the emergency water available in the building and said she was not aware of any additional water stored elsewhere. She also stated she was unsure how much water was needed per resident and did not think the facility currently had enough to supply all residents during a water emergency. The ADM stated the facility received water from a supplier and that orders for the required water supply would be placed soon. She confirmed that the water in the kitchen pantry was the only emergency supply in the building and that it was not enough to continue daily operations if a water emergency occurred. She also stated that emergency supply water had previously been discarded because it expired and had not yet been restocked. Review of the facility’s emergency preparedness guidance stated that at least one gallon of bottled water per person per day for 3 days should be maintained on hand, including residents, staff, families of residents, and families of staff who would be at the facility.
Failure to Provide Anonymous Grievance Access
Penalty
Summary
The facility failed to notify residents of how to file a grievance in an anonymous manner for 6 confidential residents interviewed about grievances. During observations on 12/03/2025 and 12/04/2025, surveyors found no blank grievance forms anywhere in the facility where residents or their representatives could obtain a form or submit a grievance anonymously. No grievance official information was posted, and the only mention of filing complaints was on a posterboard at the beginning of a hall near the nurses. In a confidential resident group interview, six residents stated they did not know how to file grievances anonymously because they had to obtain forms from the activity director, who would fill out the grievance form for them. They reported there was no place to obtain blank grievance forms on their own or during weekends and holidays when department heads might not be available, and no place to turn in grievances. The residents also stated they did not know they had the right to file grievances or complaints anonymously and said that in the past they felt they could not file a grievance without fear of retaliation because word would get around. In interviews, the AD stated she handled resident grievances and wrote them up during resident council or morning room rounds, while the ADM and DON stated anonymous filing was an option but forms were not available unless requested from staff.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents were free from abuse, including resident-to-resident abuse, when Resident #73 physically struck Resident #22 and Resident #45 on 11/21/2025. Resident #22 was a female with diagnoses including acute and chronic respiratory failure with hypoxia, acute conjunctivitis, dementia without behavioral disturbance/vascular dementia, and abnormal posture, and her MDS reflected that she rarely or never made herself understood or understood others. Resident #45 was a male with Alzheimer’s disease, unspecified dementia, major depressive disorder, and primary insomnia, and his BIMS score was 0, indicating severe cognitive impairment. Resident #73 had diagnoses including traumatic subdural hemorrhage with loss of consciousness, major depressive disorder, type 2 diabetes, and injury from a motor vehicle collision, and his assessment reflected severe cognitive impairment, delusions, and physical behavioral symptoms. The investigation file stated that Resident #73 grabbed Resident #22 by the face and hair while trying to get her up and out of her wheelchair, and then struck Resident #45 in the back several times. The report stated that neither resident suffered an injury. The facility’s review also stated that it was unaware of any concerning behavior by Resident #73 before the incident. Resident #73 had a care plan for verbally aggressive and physically aggressive behaviors, including hitting, pinching, kicking, and throwing objects, with interventions to administer medications, monitor labs, and maintain a calm environment. The facility also failed to ensure Resident #25 and Resident #73 were free from abuse when they were found in Resident #25’s room without clothes on and attempting to engage in a sexual act on 12/4/2025. Resident #25 had diagnoses including unspecified dementia with behavioral disturbance, Alzheimer’s disease, and delusional disorders, and her BIMS score was 2, indicating severe cognitive impairment. The witness statements described Resident #73 on top of Resident #25, with both residents unclothed, and Resident #73 rubbing back and forth while being uncooperative and agitated when staff intervened. The facility’s notes documented a head-to-toe assessment of Resident #25 with slight redness to the outer perineal area and no bruising, scratches, discoloration, discharge, pain, or other skin issues noted. Resident #25’s care plan focused on wandering and risk for injury from others in the secure/memory care unit, but the interventions listed did not address monitoring or resident-to-resident altercations.
Failure to Provide Requested Meal Alternatives and Menu Variety
Penalty
Summary
The facility failed to ensure that Resident #39 received food that accommodated her preferences and nutritional needs. Resident #39 was an [AGE]-year-old female with diagnoses including atrial fibrillation, high blood pressure, arthritis, osteoporosis, and malnutrition, and her BIMS score was 15, indicating intact cognition. Her MDS showed she was admitted on [DATE], and the RD’s medical nutrition therapy assessment dated 10/07/2025 recommended snacks, supplements, and her food preferences because she was at risk for severe malnutrition. Her care plan dated 11/18/2025 did not address her dietary preferences or desire to gain weight. Resident #39 stated that when she complained about meals and took them to the dining room, kitchen staff would offer her a PB&J sandwich, though she wanted a meat sandwich and sometimes was offered a hamburger if available. She said she was usually given only a PB&J when she asked for something different and was not aware of the always available menu items. The facility’s winter breakfast menus showed the same limited breakfast choices repeated across weeks, and in a confidential resident group meeting, residents reported that room trays were sometimes cold, cafe menu items were not always served when requested, and PB&J sandwiches were commonly given instead of other requested foods. Residents also stated they wanted a change in the breakfast menus because of the repetitiveness, and some said they skipped breakfast because they could not stand to look at the same plate over and over again.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide advance notice of a change in Medicare-covered services and charges for one resident who was discharged from Medicare Part A skilled services with benefit days remaining. Resident #77 was admitted with a principal diagnosis of heart failure and had a BIMS score of 15, indicating normal cognitive function and intact cognitive response. The resident’s record showed a discharge home with home health, and the discharge summary and nursing note documented that the resident left the facility with personal items and medications and was stable at departure. Record review showed Resident #77’s Medicare Part A skilled services episode began on 6/2/2025 and the last covered day of Part A services was 6/17/2025. The SNF Beneficiary Protection Notification Review form indicated the facility/provider initiated the resident’s discharge from Medicare Part A services when benefit days were not exhausted because the resident decided to go home per family. The form also showed that a Notice of Medicare Non-coverage was not provided, and facility staff did not select a listed reason for why the notice was not given; instead, staff wrote that the resident was discharged to another facility. The resident’s progress notes included a physician follow-up visit stating the patient expressed a desire to return home, and therapy staff estimated the patient would be ready to return home in 7-10 days. The physician’s orders did not include a discharge order at the time of departure, although a verbal order for discharge home with home health was obtained the following day. During interview, the administrator stated she could not say for certain the circumstances of the discharge or locate notices or forms issued to the resident, and explained that information was missing and incomplete due to employee and record transitions.
Employment of Individual With Disqualifying Criminal History
Penalty
Summary
The facility failed to ensure it did not employ an individual who had a criminal conviction barring employment by law. Record review of the Maintenance Director’s personnel file showed a hire date of 09/19/2025 and a national background check completed on the same date. The background check reflected an offense date of 09/04/2018 and a disposition date of 07/29/2022 for credit or debit card abuse elderly: 32:31 (D), a 3rd degree felony, with a final plea of guilty and a sentence of 10 years’ confinement and 5 years’ probation dated 09/12/2025. During interview, the Maintenance Director stated he had worked at the facility since October 2025 and served as Maintenance Director for the duration of his employment. HR stated that the Maintenance Director had been approved by the previous Administrator and that the facility did not want to go back and terminate him. The Administrator stated the criminal history report had been run prior to employment and later stated she would get with HR and Corporate for a full audit of employee files to ensure criminal history checks were reviewed. The facility’s Employee Handbook stated unsatisfactory background reports would result in rescinding the employment offer or termination of employment, and the Abuse Prevention Program stated the facility would not knowingly employ any individual convicted of abusing, neglecting, or mistreating individuals.
MDS assessments inaccurately coded aspirin as anticoagulant use
Penalty
Summary
The facility failed to ensure resident assessments accurately reflected resident status for 2 of 10 residents reviewed. For Resident #52, the Quarterly MDS assessment was coded to show anticoagulant use and indication, while antiplatelet use and indication was not marked. Resident #52’s record showed diagnoses including repeated falls, weakness, traumatic subdural hemorrhage without loss of consciousness, hypertension, and GERD. The resident’s BIMS score was 4, indicating severe cognitive impairment. Resident #52’s order summary did not show any anticoagulant medications ordered during the assessment period or currently, but it did show an active order for Aspirin 81 mg, which is an antiplatelet medication. The care plan did not reflect the use or indication of anticoagulants or antiplatelets, or monitoring for either medication class. The facility’s order summary also included a monitoring order listing anticoagulant and antiplatelet medications and signs of adverse drug events. For Resident #61, the Quarterly MDS assessment was also coded to show anticoagulant use and indication, while antiplatelet use and indication was not marked. Resident #61’s record showed diagnoses including Alzheimer’s disease, urinary tract infection, fall, unsteadiness on feet, and megaloblastic anemia, and the BIMS score was 00, indicating severe cognitive impairment. The order summary did not show any anticoagulant medication, but it did show an active order for Aspirin 81 mg chewable tablet and an antiplatelet monitoring order. The care plan did not reflect anticoagulant or antiplatelet use or monitoring. During interview, the MDS Nurse stated she had been told and trained to code aspirin as an anticoagulant and that she referred to the RAI manual for coding.
Failure to Provide Scheduled Bathing and Hygiene Care
Penalty
Summary
The facility failed to ensure Resident #15, a male resident with diagnoses including HTN, kidney failure, HLD, stroke, hemiplegia, seizure disorder, depression, unspecified pain, generalized edema, constipation, and gout, received necessary bathing and hygiene services. His quarterly MDS indicated he was dependent on staff for showering/bathing and had a BIMS score of 13, indicating intact cognition. His care plan documented that he would refuse showers, bed baths, ADLs, incontinent care, and linen changes, and that he could curse at staff. The care plan goal was for him to remain free from skin breakdown, with the intervention to encourage him to take a bed bath or shower. During interview, Resident #15 stated he was supposed to receive showers on Tuesdays, Thursdays, and Saturdays, but staff had not been following that schedule recently. He said it had been a few months since he had a bed bath or shower, although he acknowledged that he would occasionally refuse care, mostly when agency staff were involved. Observation of the resident showed dead skin flakes on his face and feet, with large chunks of dead skin on the bed near his feet. A CNA stated the resident only got bed baths and that if he refused, she would offer again later and report it to the charge nurse. An LVN stated the resident would not allow staff to touch his feet and legs because of pain, that he mostly received bed baths, and that he was given a bed bath on 12/4/25. The LVN also observed that the resident’s feet were still peeling and stated she would request an order for sodium lactate. She said the buildup of dead skin or potential skin breakdown could occur if he did not receive adequate baths. The DON stated the intervention on the care plan was not adequate and that she would update it, and she confirmed the expectation was to bathe or shower residents 3 times weekly, with residents who refused being offered again. The facility policy stated residents unable to perform ADLs independently would receive services necessary to maintain grooming and personal and oral hygiene, and that staff should identify underlying causes when residents resist care and monitor and revise responses to interventions.
Failure to Provide In-Room Activities Based on Resident Preferences
Penalty
Summary
The facility failed to provide an ongoing program of activities based on the comprehensive assessment, care plan, and resident preferences for Resident #4, who spent most or all of her time in her room. Resident #4 was a [AGE] year-old female with diagnoses including heart failure, high blood pressure, diabetes mellitus, high cholesterol, anxiety, depression, schizophrenia, morbid obesity, urinary tract infection, and constipation. Her quarterly MDS reflected a BIMS score of 07, indicating severe cognitive impairment. Her care plan dated 11/06/2025 stated that she did not like to attend activities and enjoyed the snack cart, reading books, watching television, and one-on-one visits, with an intervention to encourage and assist her in attending and participating in activities. During an interview and observation on 12/04/2025, Resident #4 was lying in bed in a nightgown and stated she often became irritated living in the nursing home, but watching television and talking to people at the facility helped her mood. She stated she did not get out of her room because of her medical condition and required a mechanical lift and approximately 5 staff to help her out of bed and into her wheelchair. She also stated that the Activity Director did not bring her books, cards, or puzzles, and that she would enjoy doing puzzles. No puzzles, books, or other activities were observed in her room aside from her television. Review of the EHR showed no recent Resident Preference Assessment to determine what activities she preferred, and the AD confirmed she had not completed one for Resident #4.
Failure to Maintain Clean and Properly Stored Oxygen Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for Resident #17, a cognitively impaired female with diagnoses including unspecified dementia, heart failure, hyperlipidemia, and hypertension. Her care plan stated that she required supplemental oxygen to maintain adequate oxygen saturation levels, and her physician ordered oxygen at 2 liters per minute via nasal cannula every shift, with oxygen tubing and water to be changed weekly and as needed. During observation, she was found in bed with oxygen in place, but the nasal cannula was not dated, and the oxygen concentrator filter was packed with white lint-like substance, dust, and debris. A later observation showed the resident was not in the room, and the oxygen tubing was still undated and wound around the dirty concentrator. The portable oxygen tank on a wheelchair had tubing rolled up on the armrest and left open rather than bagged. During interview, the DON stated the concentrator and filter were dirty, the tubing should have been dated and bagged when not in use, and nurses were responsible for ensuring concentrators, filters, and tubing were changed, dated, and cleaned. The DON also stated there were no set dates or days for filters to be checked and cleaned.
Missing Stop Date for Antibiotic Order
Penalty
Summary
The facility failed to ensure that Resident #10’s drug regimen was adequately monitored and free from unnecessary drugs when it did not obtain a stop date for Amoxicillin-Pot Clavulanate started for cellulitis. Resident #10 had diagnoses including diverticulosis of the small intestine, diabetes type 2, chronic kidney disease, and cellulitis, and the annual MDS reflected a BIMS score of 10 with moderate cognitive impairment, lower body impairment, and dependence on staff for upper and lower body dressing. Record review showed a hospital discharge medication list dated 11/26/2025 with an order for Amoxicillin-Pot Clavulanate 500 mg-125 mg orally twice daily for cellulitis. The physician order summary dated 12/05/2025 reflected the same medication order as started on 11/27/2025, and the MAR showed the resident received the antibiotic for nine days from 11/27/2025 through 12/05/2025. A progress note dated 12/05/2025 stated the resident was on day 9 of 10 of Augmentin for cellulitis. During interview, the DON stated all antibiotics should have a stop date, that charge nurses were responsible for obtaining it by contacting the ordering physician, and that she was responsible for monitoring nursing orders for accuracy. The facility policy on antibiotic stewardship reflected that all resident antibiotic regimens would be documented, including the stop date and total days of therapy.
Infection Control Lapses During Medication Pass and Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for three residents reviewed for infection control. During an observation of medication pass at 8:45 a.m. on 12/4/25, a medication assistant checked Resident #57’s blood pressure and then used the same electronic blood pressure cuff on Resident #39 without cleaning it between residents. Resident #39’s record reflected admission on 10/01/2025 with diagnoses including atrial fibrillation, hypothyroidism, heart disease, and hypertension, and the care plan noted she received antihypertensive medication and required blood pressure checks before administration. Resident #57’s record reflected admission on 08/25/2025 with diagnoses including Alzheimer’s disease, anemia, hypertensive chronic kidney disease, and age-related physical debility. During the observation, the medication assistant stated she knew the cuff was supposed to be cleaned between residents but forgot because she was nervous. She also stated she had been educated by the DON and pharmacist on medication pass policy, including cleaning the blood pressure cuff between residents, and acknowledged that failing to do so could spread germs and cause infections. The facility also failed during wound care for Resident #42. Resident #42’s record reflected diagnoses including atherosclerosis of native arteries of the extremities, type 2 diabetes mellitus, unstable angina, weakness, and a diabetic foot ulcer, and the care plan and physician order summary reflected enhanced barrier precautions for wound care. During an observation at 10:17 a.m. on 12/04/2025, LVN A washed her hands, gloved, removed the soiled dressing, disposed of the dressing and gloves, then applied clean gloves and continued wound care without washing or sanitizing her hands after glove removal and without donning the gown for enhanced barrier precautions. LVN A stated she forgot to wash or clean her hands between glove changes and forgot to put on the gown, and said the risk was infection due to bacteria spreading from open wound beds from resident to resident.
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. The resident, an elderly female with diagnoses including COPD, dementia, diabetes type 2, HTN, and hypothyroidism, was admitted and only received a baseline care plan at admission. The comprehensive care plan, which was due within 21 days of admission and 7 days after the comprehensive assessment, was not completed. Review of care plan records confirmed that only the baseline care plan was present, and no updates or comprehensive plan had been made by the due date. Interviews with facility staff, including the MDS coordinator, LVN, CNA, DON, and ADM, revealed a lack of awareness regarding the requirement to complete a comprehensive care plan within the specified timeframe. Staff acknowledged the importance of care plans in guiding resident care and preventing negative outcomes, but the responsible staff member was unaware of the 21-day requirement. Facility policy also confirmed the expectation for timely development of comprehensive, person-centered care plans based on thorough assessment.
Failure to Document and Order Oxygen Therapy for Resident with COPD
Penalty
Summary
The facility failed to ensure that a resident's medical record included an ongoing assessment of respiratory status, a practitioner's order, and clear indications for the use of oxygen therapy. The resident, who had a diagnosis of COPD, dementia, diabetes type 2, HTN, and hypothyroidism, was observed to have an oxygen concentrator in her room and had documented use of oxygen via nasal cannula on several occasions. However, there was no physician's order for oxygen therapy in the resident's chart, and the care plan did not address oxygen therapy. Oxygen saturation levels were recorded on multiple dates, indicating use of oxygen, but without corresponding orders or documentation of assessment specific to oxygen therapy. Interviews with facility staff, including the MDS-LVN, LVN, CNA, DON, and ADM, confirmed that oxygen therapy requires a physician's order and should be reflected in the care plan. Staff acknowledged awareness of the resident's use of oxygen upon admission but confirmed the absence of a current order and care plan documentation. The facility's policy also requires a physician's order and ongoing assessment for oxygen administration, which was not followed in this case.
Failure to Administer Prescribed Medication for Itching
Penalty
Summary
The facility failed to administer triamcinolone acetonide cream to a resident experiencing increased itching from December 16, 2024, through March 17, 2025. The resident, an elderly female with a history of rash, pruritus, acute kidney failure, and major depressive disorder, was admitted to the facility with these conditions. Despite having a physician's order for the medication to be applied every 12 hours as needed for itching, the medication was not administered consistently, and there was no documentation of its administration. The resident's care plan did not address her skin conditions or pruritus, and progress notes indicated that the resident continued to experience severe itching and discomfort. The resident frequently reported itching and pain, and despite attempts to manage the symptoms with other medications like hydroxyzine and tramadol, the itching persisted. The facility staff, including LVNs and CNAs, were aware of the resident's ongoing discomfort and the presence of sores from scratching, yet the prescribed triamcinolone was not utilized. Interviews with facility staff, including the ADON, DON, and the resident's MD, revealed a lack of awareness and action regarding the administration of the prescribed medication. The medication was not available when checked, and the staff did not document its use. The facility's failure to administer the medication as ordered and to document its administration resulted in the resident not receiving potential relief from her symptoms, which was acknowledged as a deficiency in the quality of care provided.
Resident Injury During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure a safe environment for a resident during a transfer from a shower chair to a bed using a mechanical lift, resulting in a cut and bruise on the resident's right toe. The resident, an elderly female with dementia and lower extremity impairments, required substantial assistance with transfers. During the transfer, the shower chair did not remain on the ground and was lifted along with the resident, causing the resident to grab the chair. The chair subsequently fell, and a wheel hit the resident's toe, causing injury. The incident was documented in the facility's event report, and interviews with staff confirmed the sequence of events. The resident expressed distress during the incident, and the staff attempted to manage the bleeding. The facility's policy on safety and supervision emphasizes maintaining an environment free from accident hazards, yet this incident highlights a lapse in ensuring safe lifting and movement of residents. The administrator acknowledged the incident and indicated a need to investigate further.
Failure to Report and Assess Resident's Bruise
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This deficiency was identified during the review of a case involving a resident who had a purple bruise on her forearm that went unreported and unassessed. The resident, who had moderate cognitive impairment and several medical conditions including type 2 diabetes mellitus and muscle weakness, was observed with a bruise on her forearm, but there were no records or treatment orders addressing this bruise in her care plan or medical records. Interviews with the facility staff revealed a lack of awareness and communication regarding the resident's bruise. The Director of Nursing (DON) and Licensed Vocational Nurse (LVN) A were unaware of the bruise until it was pointed out during the survey. The Certified Nursing Assistant (CNA) B, who was responsible for the resident's care, did not observe or report the bruise, and there was no documentation of any skin assessments or events related to the bruise. The staff, including the DON, LVN, and CNA, acknowledged the importance of reporting injuries of unknown origin but failed to do so in this instance. The facility's documentation and training records showed no in-services related to quality of care, change in condition, or injury of unknown origin during the relevant period. The DON admitted to not recalling when the last review of injury of unknown origin was conducted with the staff. The Medical Doctor (MD) was notified of the bruise but did not find it unusual, assuming it was an injury of unknown origin. The Administrator (ADM) was also not informed of the bruise and emphasized the importance of reporting such injuries to ensure a full investigation and resident safety.
Storage Room Door Left Open, Creating Hazard
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards, specifically in the 100-hallway where a storage room door was observed open. On 9/24/2024, the door with a punch number keypad was found open approximately six inches, with no staff present for over five minutes. The storage room contained various items such as mouthwash, razors, and other potentially hazardous materials. This situation posed a risk to residents, particularly those with cognitive impairments, who might access and misuse these items. Interviews with multiple staff members, including medical assistants, certified nursing assistants, and a licensed vocational nurse, revealed a consensus that storage room doors should remain closed and locked unless a staff member is present. Staff members acknowledged the potential hazards these rooms could pose to residents, including exposure to sharp objects, chemicals, and other dangerous items. Despite the facility's policy requiring equipment and hazardous items to be stored securely, the open door indicated a lapse in adherence to these safety procedures.
Medication Administration Delays
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the timely administration of medications to meet the needs of 18 residents. On a specific date, medications that were scheduled to be administered at 9:00 AM were given after 11:00 AM. This delay in medication administration was observed for residents with various medical conditions, including cerebral palsy, epilepsy, diabetes, heart failure, Parkinson's disease, Alzheimer's disease, and other chronic conditions. The late administration of medications could potentially lead to medication errors and jeopardize the health and safety of the residents. The report details specific instances of late medication administration for each resident, including the types of medications involved and their intended administration times. For example, one resident with a history of cerebral palsy and epilepsy received medications such as Cephalexin, Clonidine, and Valproic acid late. Another resident with Parkinson's disease and heart failure received medications like Allopurinol and Carbidopa-Levodopa late. These delays were documented in the residents' Medication Administration Records (MARs) and noted by the Director of Nursing (DON) in progress notes. In some cases, the DON notified the residents' physicians about the late medication administration, and the physicians reportedly stated it was acceptable. However, the report indicates that not all residents or their responsible parties were informed about the delays. Additionally, there were instances where progress notes did not reflect any notification to the residents, their responsible parties, or the physicians about the late administration of medications.
High Medication Error Rate Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that the medication error rate was below 5%, resulting in a 15% error rate during a medication pass observation. This deficiency affected 16 out of 24 residents, with 27 errors out of 177 opportunities. The errors primarily involved the late administration of medications, which were supposed to be given by 9:00 AM but were administered after 11:00 AM. This delay in medication administration was observed for multiple residents, including those with serious medical conditions such as epilepsy, Parkinson's disease, Alzheimer's disease, and other chronic illnesses. The report highlights specific instances where residents did not receive their medications on time, leading to potential health risks. For example, a resident with epilepsy did not receive their anti-seizure medications, Keppra and Phenobarbital, on time. Another resident with Parkinson's disease did not receive their Gabapentin and Ropinirole as scheduled. These delays were documented in the residents' Medication Administration Records (MARs) and progress notes, with notifications made to physicians, although the medications were still administered late. The deficiency was exacerbated by staffing issues, as the scheduled medication aide did not report for duty, leaving only one medication aide to cover multiple hallways. This situation led to significant delays in medication administration, as observed and reported by residents and staff. The Assistant Director of Nursing (ADON) and other staff members attempted to manage the situation by taking on additional responsibilities, such as passing medications and checking vital signs, but these efforts were insufficient to prevent the high medication error rate.
Undercooked Rice Leads to Resident Dissatisfaction
Penalty
Summary
The facility failed to provide palatable food for residents, as evidenced by the undercooked rice served during a meal. During an anonymous group interview, residents expressed dissatisfaction with the quality of food, noting that it was not cooked properly and often overcooked, such as vegetables turning to mush. On the day of the survey, a test tray sampled by surveyors contained rice that was not fully cooked, with hard bits throughout. The Dietary Manager confirmed the rice was undercooked and acknowledged that the cook had not tasted it before serving. A staff member involved in the preparation admitted to not checking the middle layer of the rice, which contributed to the issue. Interviews with residents revealed that they did not consume much of the rice due to its hardness, indicating a lack of palatability. The Director of Nursing (DON) emphasized the importance of palatable food to prevent weight loss among residents. The Dietary Manager expressed his expectations for properly cooked meals and acknowledged ongoing efforts to improve food quality and staff training. The facility's policy on Food and Nutrition Services mandates that meals be nourishing, palatable, and well-balanced, with staff responsible for inspecting trays to ensure food is attractive and palatable.
Infection Control Lapses in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff neglecting proper hand hygiene practices. On the memory care unit, staff members, including an LVN and CNAs, were observed not performing hand hygiene while serving meals and assisting residents with eating. Specifically, one CNA was seen adjusting her clothing without washing her hands before handling food trays, and another CNA did not sanitize her hands after picking up trash from the floor. These actions were confirmed through interviews with the staff, who acknowledged their lapses in following hand hygiene protocols. In another instance, a CNA was observed taking blood pressure readings from multiple residents without sanitizing the equipment or performing hand hygiene between uses. This occurred in the main dining room, where the CNA used a wrist blood pressure cuff on several residents consecutively without cleaning it. The CNA admitted to not having recent training on obtaining blood pressure and cited difficulty in performing hand hygiene due to a cast on her hand. The ADON confirmed that the CNA had completed skills check-offs for obtaining vitals and hand hygiene, but the CNA's actions did not reflect this training. Interviews with the ADON, DON, and Administrator revealed that the facility had policies in place for infection control, including hand hygiene and equipment sanitation. However, the staff's failure to adhere to these policies posed a risk of spreading infection among residents. The facility's in-service training materials emphasized the importance of standard precautions, yet the observed deficiencies indicated a gap between policy and practice. The staff's acknowledgment of their mistakes and the potential for contamination highlighted the need for improved adherence to infection control protocols.
Pest Control Deficiency Due to Ineffective Measures
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in two of the four halls and the kitchen area. Observations and interviews revealed that residents on Hall 200 and Hall 300 were experiencing issues with flies in their rooms. Resident #10 and her roommate, Resident #2, both reported being bothered by flies, with Resident #10 noting that flies were landing on her hydration cup. Resident #6 also reported flies in her room, stating that they were a nuisance and that she frequently asked staff to cover her legs to avoid them. Other residents on Hall 200, such as Resident #24 and Resident #50, expressed similar frustrations, although no flies were observed at the time of the interview. In the kitchen, an observation revealed seven flies on a table near the stove, meal prep, and tray service areas. The kitchen door was found open with a large fan blowing into the kitchen, which could have facilitated the entry of flies. The Dietary Manager, who was also acting as the Maintenance Director, was unaware of the fly issue in the rooms and acknowledged that the open door could be contributing to the problem in the kitchen. The facility's pest control policy, revised in May 2008, mandates an ongoing pest control program to keep the building free of insects and rodents, but it appears that these measures were not effectively implemented. Interviews with staff indicated a lack of awareness and communication regarding the pest issue. The Housekeeping Supervisor, who had been employed for only a week, was not aware of the fly problem in the rooms and planned to have housekeeping deep clean the affected areas. The Dietary Manager stated that the nursing staff were responsible for reporting pest issues, and there was a maintenance logbook for such notifications. However, it seems that these procedures were not followed, leading to the persistence of the fly problem in the facility.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to maintain the dignity and respect of a resident in the memory care unit dining room. On two separate occasions during a lunch meal, both an LVN and a CNA were observed standing while feeding a resident, which is against the facility's policy and training. The resident, who has severe memory loss, depression, and anorexia, requires assistance with eating. The staff members acknowledged their mistake, with the CNA stating she forgot to sit down, which is part of her training to ensure effective communication and safe feeding practices. The LVN also admitted to not being at eye level with the resident due to space constraints. Interviews with the staff, including the DON and the Administrator, confirmed that the facility's policy requires staff to sit at eye level with residents during feeding to promote a dignified dining experience. The DON emphasized that standing over residents while assisting them with meals is not acceptable and that staff are trained to respect residents' rights to dignity. The facility's Resident Rights policy, revised in February 2021, mandates that all employees treat residents with kindness, respect, and dignity.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess and document the use of bed rails and enabler/grab bars for Resident #224. Observations and record reviews revealed that the facility did not review the risks and benefits of these devices with the resident or their representative, nor did they obtain informed consent prior to installation. Additionally, there was no evidence of a physician's order or a safety assessment conducted for the use of these devices. This oversight was noted during observations on multiple occasions, where the resident's bed had quarter bed rails/enabler bars installed and raised on both sides. Resident #224, a male with multiple medical conditions including transient cerebral ischemic attack, hypertension, epilepsy, muscle wasting, and reduced mobility, was admitted to the facility with a care plan that identified a risk for falls and pain. However, the care plan did not include the use of bed rails or grab bars for repositioning or pain reduction. The absence of a documented physician's order and safety assessment for the use of these devices indicates a lack of compliance with the facility's policy and procedures. Interviews with facility staff, including medical assistants, certified nursing assistants, and a licensed vocational nurse, highlighted a lack of clarity and consistency in understanding the potential risks and benefits of bed rails and enabler bars. Staff acknowledged the potential negative outcomes, such as entrapment or injury, and emphasized the importance of educating residents and their representatives about these risks. Despite this, the facility's records did not reflect the necessary informed consent or safety assessments, as required by their policy.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident's preferences, specifically for Resident #40, who did not receive his preferred breakfast of toast and was instead given pancakes. This issue was identified through observation, interview, and record review. Resident #40, who has multiple medical conditions including quadriplegia, dysphagia, and moderate cognitive impairment, expressed dissatisfaction with the meals provided, stating that the kitchen staff did not adhere to meal tickets and often served him food he disliked, such as pancakes. The resident's care plan indicated a history of significant weight loss and emphasized the importance of honoring his nutritional needs and preferences. Despite this, the facility's dietary staff failed to consistently provide meals that matched the resident's documented preferences. During an interview, the Dietary Manager acknowledged the oversight and stated it was the first time he was made aware of the resident's dislike for pancakes, despite the resident's claims of having communicated this preference multiple times. Additionally, a group interview with other residents revealed similar issues with meal tickets not matching the meals served, with some residents receiving foods they were intolerant to or disliked. The facility's policy for Food and Nutrition Services requires that each resident's dietary preferences be considered and that food trays be inspected to ensure the correct meal is provided. However, the failure to adhere to these policies resulted in dissatisfaction among residents and the potential risk of weight loss due to unappealing meals.
Failure to Prevent and Investigate Resident Abuse and Neglect
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse/neglect and investigate such allegations for one resident reviewed for accidents and supervision. The resident, a [AGE] year-old female with multiple medical conditions including multiple sclerosis and functional quadriplegia, required substantial assistance for all activities of daily living. On 4/14/2024, the resident sustained a wrist fracture and other injuries after being left unsupervised by a CNA, resulting in a fall from the bed. The incident was not reported to the appropriate authorities, and the facility did not conduct a thorough investigation. The resident's care plan indicated the need for total assistance and specific interventions to ensure safety, such as keeping the call light within reach and using side rails on the bed. Despite these measures, the CNA repositioned the resident to the edge of the bed and left the room, leading to the fall. The resident reported the incident to a family member, who then informed the facility. The Director of Nursing (DON) and the Administrator were aware of the incident but did not take immediate action to investigate or report it as required by the facility's abuse prevention program. Interviews with the resident and staff revealed that the incident was not handled according to the facility's policies. The Administrator admitted to not reporting the incident to the Health and Human Services Commission (HHSC) because she did not believe it was intentional. The facility's failure to follow its own policies and procedures for preventing and investigating abuse and neglect resulted in an Immediate Jeopardy (IJ) situation, which was identified on 4/18/2024. Although the IJ was removed the following day, the facility remained out of compliance due to incomplete staff training on abuse/neglect, incident/accidents, and reporting.
Failure to Investigate Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate an incident where a resident was left unsupervised and fell from the bed, resulting in a wrist fracture and other injuries. The resident, who required substantial assistance for all activities of daily living (ADLs) and had a history of multiple medical conditions, was repositioned by a CNA to the edge of the bed and left alone. The resident fell, hitting a bedside table and the floor, which caused significant pain and injuries. The incident was not reported to the appropriate authorities, and the facility did not conduct a thorough investigation as required by their abuse prevention program. Interviews with the resident and family members revealed that the resident was in considerable pain following the fall and had sustained a hairline fracture to her wrist and other injuries. The Director of Nursing (DON) and the Administrator were aware of the incident but did not take the necessary steps to investigate or report it. The Administrator believed the incident was not intentional and did not report it to the Health and Human Services Commission (HHSC). The facility's failure to investigate and report the incident promptly led to the identification of an Immediate Jeopardy (IJ) situation. The facility's records indicated that the resident required a two-person assist and a Hoyer lift for transfers and mobility. Despite these requirements, the CNA left the resident unsupervised, leading to the fall. The facility's abuse prevention program mandates timely and thorough investigations of all reports and allegations of abuse, which was not followed in this case. The lack of proper investigation and reporting placed the resident and potentially other residents at risk of harm and accidents.
Failure to Provide Adequate Supervision and Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for a resident. On a specific date, a CNA repositioned the resident too close to the edge of the bed, resulting in the resident falling out of bed and sustaining multiple injuries, including a fractured right wrist, a swollen right side of the face, and scratches on the legs. The resident required a brace for the wrist and was prescribed pain medication. The incident was not reported immediately, and the facility did not conduct a thorough investigation initially. The resident, who had multiple medical conditions including multiple sclerosis, functional quadriplegia, and chronic pain syndrome, required substantial assistance for all activities of daily living (ADLs). The care plan indicated that the resident needed a two-person assist and a Hoyer lift for transfers and mobility. However, the CNA did not follow these guidelines, leading to the resident's fall. Interviews with the resident and other staff members confirmed that the resident was left unsupervised after being repositioned, which directly contributed to the accident. The facility's failure to provide adequate supervision and follow the care plan resulted in immediate jeopardy for the resident. The incident highlighted lapses in staff training and adherence to protocols for repositioning and supervising residents. The facility's initial response was inadequate, as the incident was not reported to the appropriate authorities, and the investigation was not thorough. This deficiency placed the resident at significant risk of harm and indicated a need for immediate corrective actions to prevent future occurrences.
Failure to Report and Investigate Resident Injury
Penalty
Summary
The facility failed to report and investigate a serious injury sustained by a resident who fell out of bed. The resident, who had multiple medical conditions including functional quadriplegia and required substantial assistance for all activities of daily living, was repositioned by a CNA to the edge of the bed and left unsupervised. The resident fell, resulting in a wrist fracture and other injuries. Despite the severity of the incident, the facility did not report it to the Health and Human Services Commission (HHSC) and did not conduct a thorough investigation. Interviews revealed that the Director of Nursing (DON) and the Administrator were aware of the incident but did not believe it was intentional, and thus did not report it. The resident was in significant pain following the fall, and the facility's failure to ensure proper positioning and supervision directly contributed to the injury. The facility's abuse prevention program mandates timely and thorough investigation of all reports and allegations of abuse, which was not adhered to in this case.
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What surveyors actually found near you
We read the 30 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
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Illustrative
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Nursing homes near Hillsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Town Hall Estates | 0.5 mi | ★★★★★ | 13 | 2 |
| Avir At Itasca | 10.2 mi | ★★★★★ | 5 | 0 |
| Whitney Nursing And Rehabilitation Center | 13.6 mi | ★★★★★ | 2 | 0 |
| West Rest Haven | 13.7 mi | ★★★★★ | 5 | 1 |
| Renaissance Rehabilitation And Healthcare Center | 16.7 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.