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 Jefferson during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dysphagia, and multiple comorbidities had a care plan and MD orders requiring monitoring and intervention for poor intake, including use of health shakes when less than half of a meal was consumed. Over an extended period, documentation showed repeated meal refusals and 0–25% intake, yet there was no record that health shakes were provided or that the MD or resident representative were notified. On one occasion, the resident became combative, refused medications, would not allow vital signs to be taken, and would not swallow, but this was not documented as having been reported to the nurse or MD. The MD and resident representatives reported they were not informed of the poor intake or refusals, while facility staff and leadership acknowledged that such changes should have been reported per the facility’s change-in-condition policy, resulting in a deficiency for failure to promptly notify the physician and representative of significant changes in condition.
Surveyors found that the facility did not complete or update comprehensive care plans for two residents and failed to implement a prescribed nutrition order. One resident with multiple CVA-related deficits, pain, incontinence, fall and pressure-ulcer risk, and several high-risk medications had a care plan that only addressed skin integrity and a prior fall, omitting allergies, code status, cognition, incontinence, ADLs, pain, diet, disease processes, and medication-related risks. Another resident with severe cognitive impairment and extensive neuro and medical conditions had an ADL care plan that still stated he could feed himself, despite MDS documentation that he was totally dependent for eating, and staff did not document providing ordered health shakes when he consumed less than 50% of meals, even though intake records repeatedly showed poor or refused intake.
Food safety standards were not followed in the kitchen. Surveyors observed open and improperly stored food items, an unlabeled and undated container of pink liquid, freezer staining, juice tubing on the floor, and ground hamburger meat thawing in the sink without continuous cool running water. The cook/dietary aide, Dietary Manager, and Interim Administrator all acknowledged proper sealing, labeling, dating, storage, and thawing procedures were expected.
Failure to Provide Dignified Assisted Dining: A resident with severe cognitive impairment, dementia, depression, and malnutrition required extensive ADL assistance, including feeding. During lunch, a CNA stood over the resident, used a personal cell phone, and did not speak to the resident while assisting with the meal. The CNA acknowledged she knew assisted dining should be done at eye level with conversation and that personal phone use was not allowed in resident care areas.
Unrepaired wall damage and a leaking skylight left resident rooms and the dining room in disrepair. A resident with COPD, depression, SOB, and legal blindness, another resident with anxiety, depression, and chronic pain, and a third resident with heart disease, fatigue, and back pain all had exposed sheetrock, missing paint, or peeling wallpaper near their beds. In the dining room, water dripped from a skylight into a bucket, with puddling, discoloration, and dirty vents with missing ceiling texture. Staff said the leak had been present for months to years and that the wall damage had been present for an extended period.
Failure to Provide Scheduled Bathing Assistance: A resident with DM2, A-fib, and insomnia required substantial assistance with personal hygiene and bathing, with scheduled showers three times weekly. Records showed only one documented bath in the month reviewed, and the resident stated staff repeatedly gave excuses when he asked for help. He was observed unshaven with mild body odor, while staff said showers were expected as scheduled and could be challenging when staffing was limited.
Palatable and Attractive Food Not Provided: Three residents reported meals that were bland, tasteless, or served too cool, and one lunch tray was observed by the Dietary Mgr and surveyors to have lukewarm, bland broccoli and flavorless mashed potatoes. A resident with DM, a resident with MS and seizures, and a resident with AFib, chronic pain, and CAD all described poor taste and temperature, while staff acknowledged seasoning was limited and that food quality and temperature were not consistently meeting expectations.
A resident with DM, cellulitis, and a moderate cognitive impairment had incomplete skin and wound documentation, including a newly identified stage II pressure injury without a full assessment recorded and a postoperative stitch not reflected in the chart. The MAR showed multiple severe hyperglycemic readings, but progress notes did not document interventions, and staff used a shared EHR login for charting, preventing identification of the individual entering the records.
A facility failed to follow EBP for two residents with indwelling Foley catheters. An LVN assessed one resident’s catheter without PPE, the ADON checked the catheter bag without gloves or a gown, and a CNA provided catheter care to another resident without donning PPE. Staff interviews confirmed they knew residents with catheters required gowns and gloves during direct care, and the ADON and DON were responsible for ensuring PPE use.
Missing Consent for Antipsychotic Medications: A cognitively intact resident with psychotic diagnoses was receiving Haldol and Zyprexa, but the EMR contained no signed psychotropic consent forms and the HHSC consent form was not completed for the need for and benefits of treatment. The resident said he was unaware of the antipsychotic medications and their side effects, and a family member stated no permission had been given. The LVN said she forgot to obtain the signed consent, and the DON and Administrator stated consent was expected before psychotropic meds were administered.
Inaccurate MDS Coding for Restraint Use: A resident with Alzheimer's disease, anemia, and malnutrition had a quarterly MDS that coded restraint use less than daily despite no restraint order in the chart and staff stating there were no restraints in the facility. The MDS Nurse identified the entry as a miscoding, and the Regional Nurse, DON, and Administrator all acknowledged the responsibility for accurate MDS completion and transmission.
Baseline Care Plan Not Completed Timely: A resident admitted with extradural and subdural abscess, acute on chronic heart failure, and COPD did not have a baseline care plan completed within 48 hours of admission. The admission MDS showed unclear speech, moderate cognitive impairment, and no behaviors or refusal of care. Staff interviews showed the admitting nurse was responsible for the baseline care plan, the RN stated it should be completed within 48 hours, and the Interim Administrator said nursing management was responsible for monitoring timely completion.
Failure to Secure Foley Catheter: A resident with an indwelling Foley and multiple urinary diagnoses was observed with blood near the insertion site, a urine bag on the floor without a privacy bag, and no visible securement device anchoring the tubing. Staff interviews confirmed the resident pulled on the catheter and did not like the securement device or privacy bag, while facility policy required the catheter to remain secured with a leg strap to reduce friction and movement at the insertion site.
A resident with a PICC line and IV antibiotics had a dressing change order for weekly and PRN care, but the dressing remained dated from the day of re-admission and no dressing change was documented in the MAR/TAR or wound records. Staff said the order was entered in the wrong record, did not populate to wound care, and nurses administering meds should have checked the line and dressing.
Improper Storage of Oxygen Mask: A resident with acute respiratory failure, tracheostomy status, and ventilator use had a trach oxygen nebulizer mask observed laying directly on the nightstand without a storage bag. Staff stated oxygen equipment not in use should be bagged, and the facility policy did not address proper storage of the equipment while not in use.
A resident with schizophreniform disorder and psychotic disorder was receiving Haldol and Zyprexa, and the pharmacist’s DRR recommended that psychotropic consents be obtained and added to the chart, along with side effect and behavior monitoring. The DON stated the recommendation should have been reviewed and that the nurse receiving the order was responsible for getting the consent signed before the first dose, but the facility did not complete the consent process.
The facility failed to maintain kitchen sanitation and food safety standards, with the Dietary Manager not wearing proper facial coverings and the kitchen having cleanliness issues like food particles on the dishwasher and grease buildup on the stove. Despite policies requiring a cleaning schedule and hair restraints, these were not followed or documented, posing a risk of food contamination.
The facility failed to provide adequate respiratory care for three residents, leading to potential risks of respiratory infections. A resident's oxygen tubing was not changed as ordered, another resident's humidification bottle was found dry, and tracheostomy care for a third resident was not performed using aseptic techniques. These deficiencies were confirmed through observations and staff interviews.
The facility failed to ensure call buttons were within reach for three residents, compromising their ability to request assistance. A resident with pneumonia, dementia, and hypertension had her call button on the floor, out of reach. Another resident with heart conditions had her call button far under her bed, and a third resident with muscular degeneration had her call button behind a dresser. Staff interviews confirmed the responsibility to ensure call buttons are accessible, as per facility policy.
The facility failed to complete and provide baseline care plans within 48 hours of admission for three residents, including an 85-year-old male with multiple health issues, a male with sepsis and heart disease, and a male with heart disease and COPD. The care plans were either outdated, undated, or lacked necessary signatures, and responsible parties were not provided with copies. Staff interviews revealed confusion about responsibilities, contributing to these deficiencies.
The facility failed to update care plans for two residents, one with a reopened Stage IV pressure ulcer and another with a history of falls. The MDS Coordinator and nursing staff did not ensure care plans reflected current conditions, leading to deficiencies in addressing medical and safety needs. Interviews revealed a lack of communication and responsibility among staff, contributing to the oversight.
Two residents at high risk for pressure ulcers were found to have incorrect settings on their pressure-relieving mattresses, with one set at 350 pounds and the other at 50 pounds, despite their actual weights being 203 and 230 pounds. Nursing staff, including RNs and LVNs, were unclear about who was responsible for monitoring these settings, leading to a failure in adhering to the facility's policy on pressure injury prevention. This oversight placed the residents at risk for developing or worsening pressure ulcers.
A resident with an indwelling catheter and a history of urinary tract infections exhibited symptoms such as red-tinged urine and increased confusion. Despite these signs, the nursing staff failed to document or report the red-tinged urine to the physician, delaying necessary medical intervention. This oversight led to the resident being sent to the emergency room with symptoms of septic shock.
A resident with moderately impaired cognition was left with a dose of Gabapentin at their bedside, contrary to the facility's policy that requires medications to be administered safely and timely. Interviews with staff confirmed that medications should not be left unattended, as it poses a risk of drug diversion and incorrect dosages.
A resident with dementia was administered Quetiapine, an antipsychotic, without an appropriate diagnosis or indication of use. Facility staff expressed confusion over the proper use of antipsychotics, with some stating that dementia is not a suitable diagnosis for such medication. The facility's medication reconciliation process failed to ensure a justified use of Quetiapine, despite pharmacy recommendations for alternative therapy.
A resident in the facility experienced significant medication errors due to improper scheduling of Levothyroxine and Pantoprazole. Despite the need for specific timing to ensure therapeutic effects, these medications were administered at suboptimal times, as confirmed by staff interviews and record reviews. The facility lacked a process to review medication administration times, leading to ineffective treatment and potential adverse reactions.
A facility failed to report a drug diversion incident involving a resident's hydromorphone medication to the State Survey Agency. The medication was tampered with, and the ADM did not report it, believing the hospice company would handle it. The resident, who had Parkinson's, COPD, and diabetes, was not harmed as he had additional medication available. The facility's policy required reporting such incidents within 24 hours, which was not followed.
A resident with Alzheimer's and osteoporosis was improperly handled by staff, who failed to follow facility policy for safe repositioning. Video evidence showed staff pulling the resident by the wrist and arms, contrary to the policy requiring two staff members and a draw sheet. Staff cited the resident's combative behavior and personal limitations as reasons for not following proper procedures.
A resident with a history of diabetes and muscle wasting experienced pain during wound care treatment, but the facility failed to provide appropriate pain management. Despite the resident's complaints and visible signs of pain, the treatment nurse did not offer pain medication or hold the procedure, and the resident's physician orders did not include PRN pain medications.
The facility failed to maintain an infection prevention program, leading to potential infection risks for four residents. The Treatment Nurse did not wash her hands or change gloves appropriately during wound care procedures, as observed and confirmed through interviews and record reviews. The DON and ADON acknowledged the nurse's incomplete training and misunderstanding of hand hygiene protocols.
Failure to Notify Physician and Representative of Resident’s Poor Intake and Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and resident representative (RP) of significant changes in the resident’s condition, including poor oral intake, refusal of meals, and refusal of medications, as required by facility policy. The resident was an older adult with multiple serious diagnoses, including cerebral infarction, dysphagia, cerebrovascular disease, chronic kidney disease, right eye blindness, vascular dementia, malignant brain neoplasm, repeated falls, depression, and hypertension. A quarterly MDS showed severe cognitive impairment (BIMS score of 7), total dependence for all ADLs including eating, wheelchair use, and complete bowel and bladder incontinence. The care plan identified a nutritional problem or risk and directed staff to monitor, document, and report to the MD as needed for signs and symptoms of dysphagia, including refusing to eat. Record review showed an order for a health shake to be given if the resident consumed less than 50% of a meal, with instructions to encourage intake and notify the nurse. The MAR and order summary contained this order, but there was no documentation that the resident ever received a health shake during the review period. Nutrition intake records documented repeated days where the resident ate 0–25% of meals, refused entire meals, or had missing documentation for some meals over multiple days. Despite this pattern of poor intake and refusals, nurses’ notes from the beginning to the middle of the month did not show that the physician or the resident’s RP were notified about the resident’s refusal of meals or poor eating. On one date, a medication aide documented that the resident was resistant to medication administration, swinging and swatting, not allowing blood pressure to be taken, and not swallowing anything, but there was no documentation that the nurse was notified of this behavior. In interviews, the resident’s RPs stated they had not been informed of the resident’s refusal to eat or take anything by mouth and indicated they would have intervened had they known. The physician reported he did not recall being notified that the resident was not eating well or that the resident was combative and refusing medications, and stated he would have expected notification so he could implement interventions. Facility staff, including an LVN, the DON, and the ADM, acknowledged in interviews that such changes in condition, including meal refusals, medication refusals, and abnormal behaviors, should have been reported to the nurse, the physician, and the RP, in accordance with the facility’s written policy on change in condition, which requires prompt notification of the physician and representative for significant changes and for refusal of treatment or medications three or more consecutive times. The facility’s policy titled "Change in a Resident's Condition or Status" required the nurse to notify the attending or on-call physician when there was a significant change in the resident’s physical, emotional, or mental condition, and when there was refusal of treatment or medications three or more consecutive times. It also required notification of the resident’s representative when there was a significant change in the resident’s physical, mental, or psychosocial status, with notifications to be made within 24 hours of the change, except in emergencies. Despite these requirements, the record and interview evidence showed that the physician and RPs were not notified of the resident’s ongoing poor oral intake, repeated meal refusals, and the episode of combative behavior and medication refusal, leading to the cited deficiency for failure to promptly notify the physician and resident representative of changes in condition.
Failure to Develop and Implement Comprehensive Care Plans and Nutrition Orders for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans addressing all identified needs for two residents, as required by facility policy and the MDS assessments. For one resident with cerebrovascular disease, hemiplegia/hemiparesis following cerebral infarction, adult failure to thrive, polyneuropathy, hypertension, atherosclerotic heart disease, and nutritional deficiency, the admission MDS showed moderate cognitive impairment (BIMS 12), functional limitations in range of motion, wheelchair use, partial to substantial assistance with most ADLs, frequent urinary incontinence and occasional bowel incontinence, frequent pain requiring scheduled pain medication, a history of falls, risk for pressure ulcers, and use of antidepressant, diuretic, opioid, antiplatelet, and anticonvulsant medications. Despite this, the resident’s care plan, with an admission date of 1/18/26, contained only two problem areas: risk for impaired skin integrity/wound and an actual fall, and did not include problem areas or interventions for allergies, discharge plans, code status, cognitive status, incontinence status, activities, pain management, diet, ADL assistance, fall risk, pressure ulcer risk, bleeding risk, preferences, disease processes, or the listed medications. Observation and interview with this resident showed he was sitting in a wheelchair and reported he could not use his right arm or leg and had previously been very independent and active before his stroke. He stated he was continent of urine but needed assistance to use a urinal because he could not manage his clothing and hold the urinal with one hand, and he expressed reluctance to ask for help while also not wanting to soil himself. He also stated he was angry about his current health situation, that his whole life had changed, and that he did not feel the facility realized that. The MDS Coordinator acknowledged that the comprehensive care plan was her responsibility along with another MDS Coordinator, that it should include areas such as code status, diet, allergies, assistance needed, skin, bowel and bladder, medications, fall and pressure ulcer risk, and health conditions, and that the comprehensive care plan for this resident was not completed within the required 21 days from admission. For the second resident, who had diagnoses including cerebral infarction, dysphagia, cerebrovascular disease, chronic kidney disease, right eye blindness, vascular dementia, malignant neoplasm of the brain, cognitive symptoms following cerebral infarction, repeated falls, depression, and hypertension, the quarterly MDS indicated severe cognitive impairment (BIMS 7), wheelchair use, dependence on staff for all ADLs including eating, and continuous bowel and bladder incontinence. However, the resident’s ADL care plan, with an admission date of 12/27/25, still described an ADL self-care performance deficit related to confusion and impaired balance and stated that the resident was able to feed himself with meal and tray set-up, last revised on 8/20/25, and was not updated to reflect dependence on staff for eating. Additionally, there was a physician order, present on the order summary and MAR, for the resident to receive a health shake if less than 50% of a meal was consumed, with encouragement of intake and notification of the nurse, but there was no documentation that the resident ever received a health shake during the review period, despite multiple documented meals where intake was 0–25%, 26–50%, or refused. Nursing notes did not indicate that health shakes were offered or refused. Facility staff, including LVNs, the MDS Coordinator, the DON, the physician, and the administrator, stated that the comprehensive care plan is intended to direct resident care, should be complete and accurate, and that physician orders, including the health shake order, should have been followed.
Food Storage and Thawing Deficiencies Observed in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in its only kitchen reviewed for sanitation. During the initial kitchen tour, surveyors observed an open box of frozen biscuits and frozen corn in the vegetable freezer, an unlabeled and undated container holding a thick pink substance in the milk refrigerator, an open plastic bag of yellow shredded cheese in the salad bar cooler, and an open resealable bag of frozen chicken nuggets in the potato freezer. The bottom of the potato freezer had large brownish-yellow stains and a small layer of ice. The orange juice tubing was on the ground in front of the juice boxes and was not connected to the box of juice. Surveyors also observed two long packages of ground hamburger meat sitting at the bottom of the third sink of the three-compartment sink with no water running, and later observed the meat submerged by hot steaming water in the sink, not in a container and without continuous running water. During interview, the cook/dietary aide stated food was supposed to be sealed, labeled, and dated, meat should have been thawed in a pan with cool water running constantly, and the conditions observed were unsanitary. The Dietary Manager stated staff knew how to label, date, and package food, that the juice tubing should not have been on the ground, and that meat should have been thawed in a pan with cool water running continuously. The Interim Administrator stated dietary staff were responsible for following proper food preparation protocols and the Dietary Manager was responsible for monitoring them.
Failure to Provide Dignified Assisted Dining
Penalty
Summary
The facility failed to treat Resident #60 with respect and dignity and to provide care in a manner that promoted maintenance or enhancement of quality of life. Resident #60 was an elderly female admitted with major depressive disorder, protein calorie malnutrition, and dementia. Her significant change MDS dated 11/10/2025 showed a BIMS of 00, indicating severe cognitive impairment, and she required substantial assistance with ADLs including eating, toileting, transfer, and bathing. Her care plan dated 07/24/2025 identified an ADL deficit related to dementia and stated she required one staff assist with ADL care. During an observation on 12/01/2025, a CNA stood over Resident #60 while feeding her lunch, looked at and typed on a cellular device throughout the observation, and did not speak to the resident during the meal. In interview, the CNA stated she was on a personal cellular device for a short time while assisting the resident, said she stood because there was no chair in the room, and could not recall whether she interacted with the resident. She acknowledged she knew she was supposed to sit at eye level and talk with the resident while feeding her and that personal cell phone use should not occur in resident care areas. Other staff and the Regional Nurse stated assisted dining should be done while sitting and engaging the resident, and that cell phone use in resident care areas was prohibited. Review of the facility’s inservice binder showed no in-service on assisting dependent residents with meals, and the facility policy on dignity stated residents should be cared for in a manner that promotes well-being, self-worth, self-esteem, and a dignified dining experience.
Unrepaired wall damage and leaking skylight left resident areas in disrepair
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by leaving multiple areas of disrepair in resident rooms and the dining room. During observations, Resident #18, Resident #40, and Resident #57 each had damaged walls with exposed sheetrock and missing or peeling paint or wallpaper near their beds. Resident #18 was observed sleeping in bed with an approximately 12-inch vertical area of exposed sheetrock and peeling paint beside the head of the bed. Resident #40 was observed in bed with peeling wallpaper above the bed, missing paint beside the bed, and exposed sheetrock. Resident #57 was observed in bed with a large area of exposed sheetrock and several smaller areas of missing paint on the wall beside the bed. Resident interviews reflected that the wall damage had been present for an extended period. Resident #18 said the wall had been that way since he moved into the room and said he had heard the Maintenance Supervisor tell his roommate he would repair the damage about 3 to 4 weeks earlier. Resident #40 said the wall damage and peeling wallpaper had been present since she was placed in the room and stated the condition made her feel like rats could come into her room. Resident #57 said he did not know how long the wall had been damaged and did not remember the maintenance man speaking to him about it. The dining room also had visible environmental disrepair. During observations, water was dripping from a skylight into a bucket placed on a table, with a puddle on the floor beneath it and black and yellow discoloration around the drip area. The dining room ceiling had missing texture with exposed sheetrock around one vent, and two other vents were observed with black or gray substances on them. Staff interviews stated the skylight had been leaking for months to years, with buckets used to catch the water when it rained heavily. The Maintenance Supervisor stated he had been working on vents over the last couple of months, but said vent #2 and vent #3 had been missed and that he was not aware of the missing texture around vent #1. The Administrator and other staff stated that damage in resident rooms and the dining room should have been reported and repaired, and the facility policy stated maintenance was responsible for keeping the building in good repair and free from hazards.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide the necessary services to maintain personal hygiene for 1 of 18 residents reviewed for ADL care, Resident #3. Resident #3 was a 77-year-old male with diagnoses including diabetes type II, atrial fibrillation, and insomnia. His admission MDS dated 09/24/2025 showed a BIMS of 13, indicating no memory impairment, and he required substantial assistance with personal hygiene and bathing. A shower schedule identified his bath days as Monday, Wednesday, and Friday on the 2-10 shift. Record review of the bathing ADL sheet for November 2025 showed only one documented bath for Resident #3, on November 19, with no other baths documented that month. During interview, Resident #3 stated he only had one bath in November and that staff repeatedly had excuses when he asked for assistance. He stated he was normally a clean person, became angry about being dependent on staff who would not help with a basic human need, and did not want to name the CNAs he asked. An observation noted he appeared unshaven and had mild body odor. Staff interviews confirmed he was expected to receive showers on the scheduled days, that showers could be challenging when staffing was limited, and that all baths should be given according to the schedule and when requested.
Palatable and Attractive Food Not Provided
Penalty
Summary
The facility failed to provide food that was palatable and attractive for 3 of 5 residents reviewed for palatable food. Resident #3, a 77-year-old male with diabetes type II, atrial fibrillation, and insomnia, had a BIMS of 13 and required set-up only assistance with eating. He was ordered a regular consistency cardiac diet. During interview and observation, he stated the food was tasteless, like air or plain water, and that it was unappetizing enough that he often left half of his food uneaten. At lunch, he consumed less than 50% of the meal and again stated the food was bland and not something he wanted to finish. Resident #16, a 74-year-old female with multiple sclerosis, seizures, and morbid obesity, had a BIMS of 15 and required set-up only assistance with eating. Her care plan reflected a regular diet with no restrictions. She stated the food tasted bland and not seasoned at all, and that she ate in her room most days because the dining room environment was not appetizing. She described cereal as the most flavorful meal served. During lunch observation, she said the mashed potatoes tasted exactly like air and appeared to have no salt, pepper, butter, garlic powder, or spice. She consumed less than 50% of the meal. The Regional Nurse stated she was unaware of the complaints and acknowledged there was no reason salt or pepper could not be used if restrictions or allergies were not the issue. Resident #75, a male with atrial fibrillation, urinary tract infection, chronic pain, and atherosclerotic heart disease, had a BIMS of 11 and was independent with eating and oral hygiene. His care plan addressed nutritional concerns and monitoring for signs of malnutrition and poor intake. He stated the food was awful and refrigerator cold. During lunch observation, the Dietary Manager and surveyors tasted the tray and described the broccoli as lukewarm and bland and the mashed potatoes as having no flavor and being cooler than they should have been. Staff stated pepper was not used because one resident was allergic to pepper, and the Dietary Manager said she had received complaints about seasoning and that some meals were less seasoned depending on the cook. The Interim Administrator and Dietary Manager both stated it was important for food to look good, taste good, and be served at the appropriate temperature, and the facility policy required food to maximize flavor, appearance, and nutritional value and to be attractively served at the proper temperature.
Incomplete Skin, Wound, and Diabetes Documentation with Shared EHR Logins
Penalty
Summary
The facility failed to ensure complete and accurate medical record documentation for Resident #52, a female admitted with acute embolism and thrombosis of the popliteal vein and with a history that included type 2 diabetes mellitus, TIA, hypertension, and COPD. Her quarterly MDS reflected a BIMS of 11, indicating moderate cognitive impairment, and she required standby and set-up assistance for several ADLs. During the survey, the resident stated that the surgeon had left stitches on the posterior calf and that she had reported the stitches, pain, redness, and swelling in her lower legs to nursing staff, but she could not recall who she told or when. Record review showed that physician orders addressed bilateral lower extremity cellulitis, but the condition was not addressed in the skin assessments or skin checks. A progress note documented that she was taking an antibiotic for redness and warmth of the left leg. A skin assessment completed by an LVN documented a boil on the sacrum and right buttock, but it did not reflect a stage II pressure injury or residual postoperative stitch. Later, the EHR identified a new stage II pressure injury to the sacrum when a physician order was entered by the wound care nurse, but the EHR did not contain a pressure injury or skin assessment with measurements, drainage, or surrounding tissue condition at the time it was identified. The wound care nurse stated she identified the pressure injury during a skin check, wrote the information by hand in a notebook, and did not enter the skin assessment into the computer before leaving the shift. The record also showed incomplete documentation related to diabetes management. Resident #52 had orders for Humulin R sliding scale insulin and finger stick blood sugar checks three times daily, and the MAR showed multiple elevated blood glucose readings, including 569, 470, 307, 388, and 331. For those elevated readings, the MAR directed staff to see progress notes, but the progress notes for that period did not list any interventions. Interviews revealed that LVN L contacted the nurse practitioner about the blood sugar of 569 and received an order for Lantus, but she had not yet documented the communication in a note. The facility also allowed multiple staff members, including agency staff, to use the shared EHR login "Nurse2025," and several progress notes for the month were entered under that generic login, preventing identification of the staff member responsible for the entries. The DON and Administrator stated they expected documentation to be completed by the staff providing the care and acknowledged that shared logins and incomplete documentation were against facility policy.
Failure to Use EBP PPE During Catheter Care and Assessment
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents with indwelling urinary catheters who were on Enhanced Barrier Precautions (EBP). Resident #81 was a male readmitted with diagnoses including cerebral infarction, atherosclerotic heart disease, hypertension, benign prostatic hyperplasia with urinary symptoms, and chronic cystitis with hematuria. His care plan identified an indwelling Foley catheter related to atonic bladder, neurogenic bladder, obstructive uropathy, and urinary retention, and also noted behavioral issues involving his catheter tubing and privacy bag. The care plan required EBP, including a posted sign and gown and gloves during high-contact care with the indwelling medical device. During an observation, LVN L entered Resident #81’s room to assess the catheter and did not don PPE while performing the assessment, despite the EBP sign and supplies being present. During another observation, the ADON assessed Resident #81’s catheter bag in the hallway without gloves or a gown. The ADON stated she should have been wearing PPE but wanted to take a brief look at the catheter bag. Facility staff interviewed after the observations stated that residents with catheters were on EBP and that gowns and gloves were required during direct care or catheter care. Resident #83 was a male readmitted with diagnoses including sepsis due to Escherichia coli, candidal cystitis, urethritis, chronic obstructive pyelonephritis, neuromuscular dysfunction of the bladder, and hemiplegia/hemiparesis following cerebral infarction. His care plan identified an indwelling Foley catheter related to neurogenic bladder and required EBP with gowns and gloves during high-contact resident care activities. During an observation, CNA J provided catheter care after washing her hands but did not don PPE. CNA J stated she got nervous and forgot to put on a gown during care. Interviews with CNA J, CNA K, LVN G, the ADON, the DON, the Regional Nurse, and the ADM confirmed that staff were expected to wear gowns and gloves for residents on EBP and that the facility had posted signs and PPE available outside the rooms.
Missing Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure a cognitively intact resident with diagnoses of schizophreniform disorder, psychotic disorder, and chronic atrial fibrillation was informed in advance and had documented consent for antipsychotic medications. The resident had orders for Haldol 1 mg three times daily and Zyprexa 5 mg twice daily, and the MAR showed both medications were administered as ordered. However, review of the electronic medical record found no consent forms for either medication, and the HHSC Form 1012 Consent for Antipsychotic or Neuroleptic Medication did not have the section completed for the need for, and benefits of, the proposed treatment. During interview, the resident stated he was unaware he was on antipsychotic medications and did not know the side effects. A family member stated they had not signed consent or given permission for the medication. The LVN responsible for the forms stated she received the order changes but got busy and forgot to have the consent signed, and acknowledged that informed consent should have been obtained before the medications were administered. The DON and Administrator both stated psychotropic consent forms were expected before administration of psychotropic medications, and the policy reviewed did not address psychotropic consent forms.
Inaccurate MDS Coding for Restraint Use
Penalty
Summary
The facility failed to ensure an accurate MDS was completed for 1 of 18 residents reviewed for assessment accuracy. Resident #8 was a 100-year-old female admitted with diagnoses of Alzheimer's disease, anemia, and malnutrition. A quarterly MDS dated [DATE] documented a BIMS score of 05, indicating severe cognitive impairment, and showed that she required substantial assistance with bed mobility, eating, transferring, and toileting. The same MDS also coded the resident as requiring a restraint less than daily. Record review of December 2025 consolidated physician orders showed no order for a restraint for Resident #8. During interview, the MDS Nurse stated the resident should not have been coded as having a restraint less than daily on the MDS and said there were no restraints in the facility, identifying the entry as a miscoding. The Regional Nurse stated it was the MDS nurse's responsibility to ensure accurate MDSs were produced and transmitted to CMS, and the DON stated there was no system check in place to audit MDS accuracy. The Administrator stated it was the MDS Nurse's responsibility to produce accurate MDSs and care plans.
Baseline Care Plan Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to develop Resident #55’s baseline care plan within 48 hours of admission. Resident #55 was a [AGE] year-old male admitted with diagnoses of extradural and subdural abscess, acute on chronic heart failure, and COPD. The admission MDS reflected unclear speech, that he was sometimes understood by others, that he was able to understand others, and a BIMS score of 9, indicating moderately impaired cognition. The record showed the baseline care plan was completed on 11/17/25, one day later than the required timeframe, and the facility policy stated that a baseline plan of care to meet the resident’s immediate health and safety needs is developed within 48 hours of admission. During interview, the LVN stated admitting nurses were responsible for completing the baseline care plan and said she was unsure of the timeframe for completion. She also stated Resident #55 was admitted on her shift but she did not know why the baseline care plan was not completed until 11/17/25. The Regional Nurse stated baseline care plans should have been completed within 48 hours of admission and that the DON was responsible for ensuring they were completed. The Interim Administrator stated he expected baseline care plans to be completed within 48 hours of admission or as quickly as possible after 48 hours, and that nursing management was responsible for monitoring timely completion.
Failure to Secure Foley Catheter
Penalty
Summary
The facility failed to ensure appropriate catheter care and services to prevent urinary tract infections for a resident with an indwelling Foley catheter. The resident was a male with diagnoses including cerebral infarction, atherosclerotic heart disease, hypertension, benign prostatic hyperplasia with lower urinary tract symptoms, chronic cystitis with hematuria, atonic bladder, neurogenic bladder, obstructive uropathy, and urinary retention. His care plan identified that he had an indwelling catheter and included interventions to keep the drainage bag below bladder level, check tubing for kinks, maintain the bag off the floor, monitor for pain and signs and symptoms of UTI, and use enhanced barrier precautions. The resident’s care plan also documented behavioral issues related to fascination with the Foley tubing and privacy bag, including sitting on the tubing, removing the privacy bag, wrapping the tubing around his body, lifting the bag above bladder level, and emptying the catheter bag. During observation, he was seen lying in bed with blood near the insertion site, a urine bag on the floor without a privacy bag, and no securement device anchoring the catheter tubing. Later observations showed blood-tinged urine in the catheter bag attached to his wheelchair, and it was unable to be determined whether a securement device was in place. Staff interviews confirmed that the resident pulled on his catheter and that he did not like the securement device or privacy bag. Interviews with nursing and administrative staff showed that residents with catheters were expected to have a securement device and privacy bag in place, and that the securement device was intended to prevent pulling, pain, and infection. The facility policy titled Catheter Care, Urinary stated that the catheter should remain secured with a leg strap to reduce friction and movement at the insertion site and that catheter tubing should be strapped to the resident’s inner thigh. The report documented that the securement device was not in place during the observation on the resident reviewed for catheter care.
PICC Line Dressing Not Changed as Ordered
Penalty
Summary
The facility failed to ensure a PICC line dressing was changed in accordance with the physician’s order for one resident who had been re-admitted with diagnoses including sepsis due to Escherichia coli, muscle wasting, and lack of coordination. The resident’s record showed a PICC line dressing change order entered on 11/23/25 for every 7 days and as needed, and the resident was observed on 12/02/25 with a transparent dressing to the left upper arm PICC line that was clean, dry, intact, and dated 11/21/25. Record review showed no documentation of a central venous line dressing change in the resident’s electronic medical record from 11/21/25 through 12/02/25. The MAR, TAR, Nurse Medication Record, and Wound Administration Record were reviewed, and the care plan did not indicate the resident had a PICC line or had received IV antibiotics beginning 11/21/25, despite the resident receiving IV antibiotics through the PICC line after return from the hospital. During interviews, the LVN stated she entered the PICC dressing change order but believed it may have been placed in the wrong category and did not populate for wound care documentation. The Wound Care Nurse stated the order never crossed over to her TAR and she was unaware the dressing change was needed, and the ADON and Regional Nurse stated the dressing should have been changed every 7 days and that nurses administering medications should have assessed the line and dressing. The PICC line was removed on 12/02/25, and staff stated the dressing had not been changed timely.
Improper Storage of Oxygen Mask
Penalty
Summary
The facility failed to ensure that respiratory care was provided consistent with professional standards of practice for a resident with acute respiratory failure, tracheostomy status, and a history of cardiac arrest. The resident’s MDS indicated no speech, that he was usually understood and understood others, and that he received tracheostomy care and used a ventilator while in the facility. His care plan identified altered respiratory status related to tracheostomy status and risk for secretions, congestion, respiratory infections, and infections to the tracheostomy site, with an intervention to administer nebulizer as ordered. During observations, the resident’s trach oxygen nebulizer mask was seen laying directly on the nightstand and was not stored in a bag, and no storage bag was present on the nightstand. Staff interviews confirmed that oxygen equipment not in use should be stored in a bag, that the resident did take the mask off and lay it around, and that the mask should have been bagged when not in use. The facility’s Oxygen Administration policy, last revised in 10/2010, did not indicate proper storage of equipment while not in use by a resident.
Failure to Complete Psychotropic Consent and Follow Pharmacist Review
Penalty
Summary
The facility failed to act on a licensed pharmacist’s medication regimen review recommendation for one resident who had schizophreniform disorder, psychotic disorder, and chronic atrial fibrillation. The resident’s record showed he was prescribed Haldol 1 mg three times daily and Zyprexa 5 mg twice daily, and the quarterly MDS indicated a BIMS score of 13 with minimal cognitive impairment and use of antipsychotic medications. The comprehensive care plan identified antipsychotic use for treatment of schizophreniform disorder. The pharmacist’s medication regimen review identified on the report that consents should be obtained and added to the chart for Haldol and Zyprexa, and also recommended side effect monitoring and behavior monitoring for the resident’s antipsychotic use. MAR review showed the resident received Haldol and Zyprexa from 11/21/2025 through 12/02/2025. During interview, the DON stated the pharmacy consultant recommendations should have been reviewed, that the nurse receiving the order was responsible for ensuring consents were signed and completed before the first dose, and that she could not explain why the recommendation was not completed. The Administrator stated he expected pharmacist recommendations to be reviewed with the physician and followed, and that psychotropic consent forms should be obtained prior to administering psychotropic medications.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. The Dietary Manager was repeatedly seen without proper facial hair covering, which is a requirement for maintaining hygiene in food preparation areas. Despite acknowledging the need for facial coverings, the Dietary Manager reported that the provided coverings did not fit properly and had informed the previous manager and the ADM about this issue. However, no corrective action was taken to address the ill-fitting facial coverings. Interviews with dietary staff confirmed that all kitchen staff, including those with facial hair, were expected to wear appropriate hair restraints to prevent contamination of food. Additionally, the facility's kitchen was found to have cleanliness issues, including food particles on top of the dishwasher and grease buildup on the gas stove. The Dietary Aide responsible for cleaning the dishwasher admitted to not having a checklist to mark completed tasks, leading to uncertainty about when the dishwasher was last cleaned. The Dietary Manager also acknowledged the presence of food particles and grease buildup, stating that there was no documentation or checklist for cleaning these areas. The lack of a structured cleaning schedule and verification process contributed to these sanitation lapses. The facility's policies, dated October 2018, outlined the need for a cleaning schedule and employee sanitation practices, including the use of hair restraints. However, the cleaning schedule was not being followed or documented as required. The ADM and DON both expressed expectations for a cleaning checklist to be in place and initialed upon task completion, but this was not being enforced. The absence of proper documentation and oversight in the kitchen cleaning process posed a risk of food contamination, potentially leading to foodborne illnesses among residents.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to potential risks of respiratory infections. For Resident #8, the facility did not change the oxygen tubing as per the physician's order, which required weekly changes every Friday. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that it was the responsibility of the nursing staff to ensure the oxygen tubing was changed and labeled with the new date, as failure to do so could place residents at risk for respiratory infections. Resident #48's care was compromised as the humidification bottle attached to her nasal cannula was found to be without water. The resident, who was on oxygen therapy due to congestive heart failure and ineffective gas exchange, was observed with a dry humidification bottle, which could lead to a dry nose and potential nosebleeds. The resident was unable to recall how long the bottle had been dry, and the nursing staff failed to ensure the bottle was filled, as confirmed by interviews with LVN Q and LVN R. For Resident #190, the facility did not adhere to aseptic techniques during tracheostomy care. LVN Q performed the procedure without using the prescribed sterile water and prepared solution, instead using normal saline. The trach care kit was contaminated when LVN Q used non-sterile gloves to handle items, and the tracheostomy cannula was not removed and cleaned as required. Additionally, the trach tube holder was changed without the assistance of a second staff member, contrary to the facility's policy. These actions placed the resident at risk for infection, as acknowledged by LVN Q and the DON during interviews.
Failure to Ensure Call Buttons Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call buttons for three residents were within reach while they were in bed, which is a violation of their right to reasonable accommodation of needs and preferences. Resident #7, a female with pneumonia, dementia, and hypertension, was found with her call button on the floor, out of reach, while her bed was in a high position. She reported that the call button had been on the floor all night and morning, leaving her unable to request assistance. Resident #17, a female with systolic heart failure, hypertensive heart disease, and a history of myocardial infarction, also had her call button out of reach, far under her bed. She expressed that she never used her call button because she could not reach it and needed someone to hand it to her. Her care plan indicated that staff should anticipate and meet her needs, ensuring the call light was within reach. Resident #50, a female with muscular degeneration, hyperlipidemia, and hypertension, had her call button several feet away behind a dresser, making it inaccessible. Interviews with staff, including a CNA, the DON, and the ADM, confirmed that it was the responsibility of all staff to ensure call buttons were within reach. The facility's policy on answering call lights emphasized the importance of making call lights accessible to residents.
Failure to Complete and Distribute Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed and provided to residents and/or their representatives within 48 hours of admission for three residents. Resident #36, an 85-year-old male with multiple diagnoses including a fracture, vascular dementia, and diabetes, did not have a baseline care plan completed for his admission on 09/04/24. The facility provided a care plan dated from a previous admission, indicating a failure to update and complete a new plan for the current admission. Resident #2, a male with a history of sepsis, megaloureter, and atherosclerotic heart disease, had an undated baseline care plan that lacked signatures from the resident, representative, and staff. This indicates that the care plan was not properly completed or communicated to the responsible party. Attempts to contact the responsible party were unsuccessful, and no documentation was provided to show that the care plan was shared with them. Resident #190, a male with conditions such as atherosclerotic heart disease and COPD, also had an undated baseline care plan without necessary signatures. The responsible party for Resident #190 reported not receiving a copy of the care plan, which would have been helpful in understanding the resident's care needs. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion and distribution of baseline care plans, contributing to the deficiencies observed.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical and safety needs. For one resident, the care plan did not address a Stage IV sacral pressure ulcer that had reopened. Despite the ulcer being noted in the resident's medical records, the MDS Coordinator did not update the care plan to reflect the current condition, which was acknowledged as an oversight. Interviews with the MDS Coordinator, DON, and ADM confirmed that the responsibility for updating care plans was shared among nursing management, but the necessary updates were not made. Another resident's care plan failed to incorporate new interventions and updates for fall prevention, despite a history of multiple falls. The resident had been readmitted with several diagnoses, including protein-calorie malnutrition, dysphagia, COPD, Parkinson's disease, and epilepsy. The care plan had not been updated to reflect recent falls or to implement effective interventions. Interviews with various staff members, including CNAs, LVNs, and the DON, revealed a lack of awareness and communication regarding the resident's fall risk and the necessary interventions. The facility's policy on fall risk management was not effectively implemented, as evidenced by the absence of updated care plans and fall risk assessments. The facility's failure to update and implement care plans for these residents highlights a breakdown in communication and responsibility among the staff. The MDS nurse, DON, and other nursing staff were responsible for ensuring that care plans were current and reflective of each resident's needs. However, the lack of updated care plans and the failure to conduct timely fall risk assessments contributed to the deficiencies identified by the surveyors. The facility's policies on comprehensive care planning and fall risk management were not adequately followed, leading to potential risks for the residents involved.
Failure to Ensure Correct Pressure-Relieving Mattress Settings
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #36 and Resident #187, received appropriate care to prevent pressure ulcers. Both residents were at high risk for pressure ulcers, as indicated by their Braden scale scores and medical conditions. Resident #36 had a history of vascular dementia, Type 2 diabetes, and multiple wounds, while Resident #187 had a history of myocardial infarction and Type 2 diabetes. Despite these risks, the pressure-relieving mattresses for both residents were set incorrectly, with Resident #36's mattress set at 350 pounds and Resident #187's at 50 pounds, which did not correspond to their actual weights of 203 pounds and 230 pounds, respectively. Observations and interviews revealed a lack of clarity and responsibility among the nursing staff regarding the monitoring and adjustment of the pressure-relieving mattress settings. RN G, RN S, LVN Q, and LVN R all expressed uncertainty about who was responsible for ensuring the correct settings. RN S, the wound care nurse, acknowledged the importance of correct settings to prevent pressure ulcers and admitted that the settings for both residents were incorrect. The Director of Nursing (DON) and the Administrator (ADM) also confirmed that the nursing staff was responsible for checking and adjusting the mattress settings. The facility's failure to maintain the correct settings on pressure-relieving mattresses placed the residents at risk for developing or worsening pressure ulcers. The facility's policy on the prevention of pressure injuries emphasized the importance of selecting appropriate support surfaces based on residents' risk factors, but this was not adhered to in practice. The incorrect settings could lead to unnecessary pressure ulcers, skin breakdown, and discomfort for the residents.
Failure to Report Changes in Resident's Condition Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in preventing urinary tract infections. The resident, who had a history of urinary tract infections and other medical conditions, exhibited symptoms such as red-tinged urine, increased confusion, and an elevated white blood cell count. Despite these symptoms, the nursing staff did not document or report the red-tinged urine to the physician, which was a critical oversight given the resident's medical history and current symptoms. The report highlights that LVN Q observed the resident's pink-tinged urine but failed to document it or notify the physician, MD T, about this significant change. Although LVN Q communicated the elevated white blood cell count to the physician, the omission of the red-tinged urine was a crucial lapse. This lack of communication and documentation was compounded by the fact that the resident had been previously noted to have increased confusion, a symptom that could indicate a urinary tract infection. Further interviews revealed that the nursing staff, including LVN M and the DON, acknowledged the importance of notifying the physician about changes in the resident's condition. However, the failure to report the pink-tinged urine delayed the necessary medical intervention, ultimately leading to the resident being sent to the emergency room with symptoms of septic shock. The facility's policies on catheter care and acute condition changes were not adhered to, contributing to the deficiency in care provided to the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident. Specifically, staff left a dose of Gabapentin at the bedside of a resident who was not care planned to self-administer medications. The resident, who had a moderately impaired cognition as indicated by a BIMS score of 12, was unaware of the missed dose until informed by the surveyor. This oversight was observed during a survey, highlighting a lapse in the medication administration process. Interviews with facility staff, including a Certified Medication Aide (CMA), the Director of Nursing (DON), and the Administrator (ADM), confirmed that the medication aide is responsible for ensuring residents take or refuse their medications before leaving the room. The facility's policy on administering medications, dated April 2019, requires that medications be administered safely and timely, and any refused medication should be discarded. The failure to adhere to these procedures could lead to residents taking medications not prescribed to them, posing a risk of drug diversion and incorrect therapeutic dosages.
Inappropriate Use of Antipsychotic Medication for Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident, who had not previously used psychotropic drugs, was not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for one resident who was administered Quetiapine, an antipsychotic medication, without an appropriate diagnosis or indication of use. The resident, an elderly female with a history of dementia, heart failure, atrial fibrillation, hypothyroidism, atherosclerotic heart disease, anxiety, and depressive episodes, was taking Quetiapine for unspecified dementia with psychotic disturbances, which was not adequately justified in her clinical records. Interviews with facility staff revealed inconsistencies and misunderstandings regarding the appropriate use of antipsychotic medications. LVN F stated that a resident with dementia should not be prescribed antipsychotic medication and emphasized the importance of clarifying diagnoses before administration. RN G and MDS Nurse H also expressed concerns about the appropriateness of using antipsychotics for dementia, indicating that diagnoses such as schizophrenia or bipolar disorder would be more suitable. The ADON and DON provided conflicting views, with the DON asserting that the medication was appropriate for unspecified dementia with psychotic disturbances, while the ADON acknowledged the need for proper diagnosis verification. The facility's medication reconciliation process was found to be lacking, as evidenced by the absence of a clear diagnosis supporting the use of Quetiapine for the resident. The pharmacy consultation had previously recommended considering alternative therapy due to the lack of an approved indication for the medication. Despite these recommendations, the facility did not provide a copy of their policy for psychotropic medication use, and there was no documentation of a comprehensive review or resolution of the medication discrepancy.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Levothyroxine and Pantoprazole. The resident, an 85-year-old male with diagnoses of hypothyroidism and gastro-esophageal reflux disease, was admitted to the facility with a medication regimen that required specific timing for optimal therapeutic effect. However, the medications were not scheduled appropriately, with Levothyroxine being administered at 8 a.m. and Pantoprazole at 9 a.m., contrary to the recommended times for these medications. Interviews with various staff members, including registered nurses and medication aides, revealed a lack of adherence to proper medication administration protocols. The staff acknowledged that thyroid medications like Levothyroxine should be given on an empty stomach and not with other medications, ideally before breakfast. Similarly, Pantoprazole should be administered at least 30 minutes before meals to be effective. The staff admitted that the medications were not scheduled at optimal times, which could render them ineffective and potentially lead to adverse reactions. The Director of Nursing confirmed that the medications were not scheduled therapeutically and that there was no process in place to review medication administration times. The facility's policy on administering medications emphasized the importance of timing for optimal therapeutic effect and preventing interactions, but this was not followed in practice. The deficiency was identified through a combination of record reviews and staff interviews, highlighting a systemic issue in medication scheduling and administration within the facility.
Failure to Report Drug Diversion Incident
Penalty
Summary
The facility failed to report an alleged drug diversion involving a resident's medication to the State Survey Agency and other officials as required by state law. The incident involved a bottle of hydromorphone that was tampered with, which was reported by a Licensed Vocational Nurse (LVN) to the Administrator (ADM) after receiving it from a hospice nurse. The ADM was informed of the tampering but did not report it as a drug diversion, believing it was the responsibility of the hospice company to do so. This oversight was identified during a complaint investigation by a Health and Human Services (HHS) nurse, who advised the ADM to report the incident. The resident involved was an elderly male with Parkinson's disease, COPD, and diabetes mellitus, who had cognitive impairment and required assistance with activities of daily living. Despite the tampering, the resident was not harmed as he had additional sealed bottles of hydromorphone available. The ADM acknowledged the failure to report the incident, stating he did not consider it a drug diversion since it was not his staff involved. The facility's policy required reporting all allegations of drug theft within 24 hours, which was not adhered to in this case.
Improper Resident Handling and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent avoidable accidents for a resident. The resident, who had Alzheimer's Disease, dementia, and osteoporosis, required assistance with activities of daily living (ADLs) and was sometimes understood and sometimes understood others. The resident's care plan noted a behavior problem where she would call out that she was being hurt when no one was touching her. Video evidence revealed improper handling of the resident by staff members. In one instance, a staff member pulled the resident by the wrist into a sitting position, causing the resident to express pain. In another instance, a staff member pulled the resident up in bed by her upper arms. Interviews with staff members indicated that the proper procedure was not followed, as the resident should have been repositioned using a draw sheet or pad with the assistance of two staff members. The facility's policy on repositioning, revised in May 2013, emphasized the use of two people and a draw sheet to avoid shearing while moving a resident. Despite this policy, staff members admitted to not following the correct procedures, citing reasons such as the resident's combative behavior and personal physical limitations. The Director of Nursing and the Administrator both acknowledged that the improper handling could lead to injuries, such as skin tears or fractures.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services. The resident, who was cognitively intact and had a history of diabetes, muscle wasting, and difficulty walking, complained of pain in her heel prior to and during wound care treatment. Despite her complaints and visible signs of pain, such as saying 'ouch' and grimacing, the treatment nurse did not offer any pain medication or hold the wound care procedure. The resident's physician orders did not include any PRN pain medications, and the treatment nurse did not take steps to address the resident's pain during the procedure. The resident's pain assessment indicated mild pain in the last five days, but there was no detailed documentation of the frequency or impact on activities. During an interview, the treatment nurse acknowledged hearing the resident's complaints of pain but did not think to ask if she wanted pain medication. The Director of Nursing (DON) was unaware of the resident's pain until the day of the observation. The facility's Pain Assessment and Management Policy emphasizes the importance of assessing and managing pain, but this was not followed in the case of this resident, leading to her experiencing pain during wound care.
Infection Control Deficiency Due to Improper Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment, leading to potential infection risks for four out of five residents reviewed. The Treatment Nurse did not wash her hands while providing wound treatments for Residents #1, #3, #4, and #5. Additionally, the nurse did not change her gloves between dirty and clean wounds for Resident #1 and did not change gloves from one wound to the next during Resident #5's wound treatments. These actions were observed during wound care procedures and were confirmed through interviews and record reviews. Resident #1, a [AGE]-year-old female with diagnoses including diabetes and muscle wasting, had a wound on her right heel. The Treatment Nurse did not wash her hands before or after the treatment and failed to change gloves after removing a soiled bandage. Resident #3, a [AGE]-year-old with Parkinson's disease and anxiety, received skin prep on her heels without the nurse washing her hands before or after the procedure. Resident #4, a [AGE]-year-old with heart failure and a pressure injury, had her wound treated without the nurse washing her hands, although gloves were changed appropriately. Resident #5, a [AGE]-year-old with dementia, had multiple wounds treated without the nurse changing gloves between different wound sites. During an interview, the DON and ADON acknowledged that the Treatment Nurse was new and had not completed her full training. They also mentioned that the nurse was in school to receive her RN license and would be sent to wound care classes upon completion. The ADON incorrectly stated that hand sanitizer was as effective as soap and water, contrary to the facility's policy. The facility's Wound Care Policy, dated October 2010, requires washing and drying hands thoroughly at multiple stages of the wound care process, which was not followed in these instances.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 32 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jefferson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marshall Manor Nursing & Rehabilitation Center | 16.4 mi | ★★★★★ | 0 | 0 |
| Marshall Manor West | 16.4 mi | ★★★★★ | 18 | 1 |
| Focused Care At Linden | 16.5 mi | ★★★★★ | 10 | 1 |
| Heritage House Of Marshall Health & Rehabilitation | 18.8 mi | ★★★★★ | 3 | 0 |
| Vivian Healthcare Center | 22.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Jefferson.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.