Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Jeffrey Place during CMS and state inspections, most recent first.
Food Storage, Hair Restraints, and Thermometer Sanitation Failures The kitchen had multiple food items in the refrigerator, freezer, and pantry that were not properly labeled or dated, including cheese, lunch meat, butter, soup, raw chicken, cooked chicken, waffles, okra, dinner rolls, breadcrumbs, tortillas, and cereal. In the kitchen, the ice scoop holder contained dirty water and a black piece of plastic. During food temp checks, a CK wore a hairnet that did not fully cover the hair and used a paper towel instead of sanitizing the thermometer between items, while also missing some food temps.
Missing controlled substance count documentation was identified on the 300 Hall, with multiple shift change narcotic count sheets lacking start/end counts and off-going or oncoming nurse signatures. MA C stated staff were required to count narcotics and sign the sheet, though signatures were sometimes omitted if the same person worked the next shift. The DON stated the off-going and on-coming nurses were expected to count narcotics together at shift change, and the facility policy required joint counts and reporting discrepancies to the DON.
A facility failed to ensure timely administration of scheduled pain medications for two residents. One cognitively intact resident with a left foot amputation and chronic pain received scheduled oxycodone more than an hour late, and another cognitively intact resident with fibromyalgia and other diagnoses received scheduled lidocaine patch and acetaminophen-codeine late during the morning med pass. Staff acknowledged the delays, and the MARs did not document reasons for the late administrations.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain the services of a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. Surveyors observed environmental hazards and insufficient staff monitoring, resulting in a deficiency related to resident safety.
A resident was not protected from a significant medication error, as required, due to a failure in the medication administration process.
The facility failed to maintain sanitary conditions in the kitchen, risking cross-contamination and food-borne illness for residents. Staff used gloved hands to touch surfaces and food without changing gloves or washing hands. Additionally, food items were not properly labeled, dated, or stored, with some items being past their use-by date. These actions violated the facility's policies on food storage, preparation, and employee sanitation.
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by sticky floors, a roach in the hallway, and gnats in a resident's room and the conference room. A resident's room was cluttered with personal items, causing discomfort. Staff acknowledged the responsibility for maintaining a homelike environment, but issues persisted despite a pest control contract. Grievances included a report of a roach on a bedside table, highlighting lapses in maintaining cleanliness and order.
The facility failed to maintain an effective infection prevention and control program, with staff not adhering to proper infection control practices. An LVN was observed contaminating a medication cart and not performing hand hygiene during glucose checks and insulin administration. CNAs did not change gloves or perform hand hygiene during incontinent and catheter care. Another LVN administered medication without PPE. Staff interviews revealed lapses in following infection control protocols.
A resident with limited mobility and a history of stroke had her call light placed out of reach, contrary to her care plan. Despite staff awareness, the issue persisted, with the resident relying on yelling for help. The facility's policy on accommodating individual needs was not followed.
A resident was moved to a different room without receiving written notice, violating their rights. The resident, with intact cognition and multiple health conditions, was verbally informed of the move due to payment reasons, but later told it was for remodeling. Facility staff acknowledged the lack of written notice, and the Social Worker did not assess the resident's wellbeing before the move.
A facility failed to implement a comprehensive care plan for a resident with moderate cognitive impairment and expressive aphasia, whose primary language was Mandarin. The care plan did not adequately address communication needs, leading to ineffective communication. Staff relied on non-verbal cues and an ineffective translation app, without using a communication board or proper translation services, contrary to the facility's policy on person-centered care plans.
A facility failed to support a resident with communication deficits, who primarily spoke Mandarin, by not providing effective communication tools or support. The resident, with a history of cerebral infarction and aphasia, was not using a communication board, and staff relied on inadequate methods like a Google Translate app. Observations showed ineffective communication, and staff interviews revealed a lack of training and resources. This deficiency highlights a failure to maintain the resident's well-being as per facility policies.
A resident with moderate intellectual disabilities did not receive her hearing aid as ordered by a physician, despite multiple observations over three days. Staff interviews revealed awareness of the order, but the hearing aid was not applied due to time constraints. The DON confirmed the expectation to follow orders, but the ADM could not find relevant policies.
A resident with chronic respiratory conditions did not receive oxygen at the prescribed rate of 4 lpm, as required by their care plan and physician's orders. Observations showed the oxygen was often set incorrectly, both higher and lower than ordered. Staff interviews confirmed that nurses were responsible for setting the flow rates, but the facility's policies were not consistently followed, resulting in a deficiency in care.
The facility failed to store and label medications properly, as observed in two medication carts. On one cart, nine medication cups with multiple medications for unidentified residents were found, and on another, insulin pens for two residents lacked open dates. Staff acknowledged the potential for medication errors and expired medication administration, contrary to facility policies.
A resident with dementia and major depressive disorder was inadequately prepared for discharge from an LTC facility. The facility failed to document necessary discharge planning, leading to the resident being taken to the ER for psychiatric evaluation. The discharge was handled by the interim DON without the administrator's presence, and the family was not given post-discharge care information.
The facility failed to provide adequate ADL care and hygiene for several residents, resulting in untrimmed nails and delayed incontinence care. Residents with severe cognitive impairments and various medical conditions did not receive necessary nail care, and one resident was left soiled for over three hours. Staff interviews revealed non-compliance with facility policies on nail care and incontinence checks.
Two medication carts were found unattended and unlocked, making prescription and over-the-counter medications accessible to unauthorized individuals. Med Cart #1 was left near the dining room entrance, and Med Cart #2 was across from the nurses' station. Staff interviews revealed inconsistent adherence to the facility's medication policy, with the ADON and ADM emphasizing the responsibility of CMAs and nurses to secure the carts.
A facility failed to notify a resident's representative about an incident where a female resident with Alzheimer's wandered into a male resident's room during a private act. The LVN involved did not document the event or notify the representative, contrary to facility policy. The DON and AD confirmed the lack of documentation, citing potential computer issues.
A facility failed to update a resident's care plan to address inappropriate sexual behaviors, despite documented incidents and awareness by the DON and AD. The resident, with moderate cognitive impairment and multiple health issues, exhibited behaviors such as masturbating in front of others and inappropriate touching of staff. The facility's policy required ongoing assessments and care plan revisions, which were not followed.
A verbal abuse incident occurred when a CNA repeated an insult back to a resident during a smoke break. The resident, with a history of mood disorder and cognitive impairment, had initially insulted the CNA. The CNA self-reported the incident, acknowledging her actions. The resident did not recall the incident when interviewed later.
A medication cart was found unattended and unlocked in a hallway, with its top drawer slightly open, containing medical supplies and medications. Two residents were present in the hallway at the time. The LVN responsible was unaware of the oversight, and both the DON and ADM confirmed that facility policy requires carts to be locked when out of sight or positioned in a resident's doorway with drawers facing inward.
A resident with severe cognitive impairment eloped from the facility due to inadequate supervision and a disabled front door alarm. The resident was found disoriented two blocks away. The facility's elopement policy was not effectively implemented, and the resident's care plan lacked specific elopement interventions.
The facility failed to protect two residents from abuse by an LVN. One resident reported verbal abuse, while another reported inappropriate physical contact. Witnesses corroborated the residents' accounts, noting the LVN's erratic behavior. The administration was informed, and an investigation confirmed the abuse, leading to the LVN's termination.
A resident with progressive dementia and other medical conditions was not allowed to return to the facility after hospitalization, despite being cleared for discharge and not requiring psychiatric services. The facility staff insisted on psychiatric treatment before accepting the resident back, violating the facility's bed-hold policy.
Food Storage, Hair Restraints, and Thermometer Sanitation Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed. During observation of the standalone refrigerator, freezer, and walk-in pantry, multiple food items were found without required labeling or dating, including cheese in a Ziplock bag with no open date or use-by date, lunch meat in a sealed container dated 4-3 with no use-by date, butter packages with no date, uncovered soup not dated, raw chicken with no open date or use-by date, cooked diced chicken dated 4-6 with no use-by date, packaged waffles with no dates, breaded okra with no open date or use-by date, dinner rolls dated 4-3-2026 with no use-by date, breadcrumbs dated 2-10 with no use-by date, tortillas with no open date or use-by date, and cereal in clear containers dated 3-12 with no use-by date. In the kitchen, the ice scoop holder contained dirty water in the bottom of the container along with a black piece of plastic. During observation of food temperature checks, CK A wore a hairnet that covered only the bun on top while hair below the cheek was uncovered. CK A wiped the thermometer with a paper towel between food items and did not take the temperature of the beans on the warming table or the chicken tenders in the basket over the fryer. CK B later stated that the thermometer should be sanitized between each food item and that she had used a paper towel because she was nervous. Interviews with the DA, DM, CK A, and CK B confirmed that labeling and dating food items was everyone’s responsibility, that food in refrigerators should be checked daily, and that food in the freezer and pantry should be checked at least weekly. The DA stated all food should be covered or wrapped in plastic, hair restraints should always cover the hair, and residents could get sick if served food that was out of date or if hair fell into the food. The DA also stated there had been no in-service training on labeling, hair nets, and sanitation. The facility’s Food Preparation and Service Policy stated that thermometers must be clean, sanitized, and calibrated, hair restraints must prevent hair from contacting food, all food service equipment and utensils will be sanitized, and opened food must have use-by dates.
Missing Controlled Substance Count Documentation
Penalty
Summary
The facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of drugs and biologicals to meet each resident’s needs. Record review of the Change of Shift Narcotic Count Sheets for the 300 Hall showed multiple instances of missing documentation, including missing start and end counts and missing off-going and oncoming nurse signatures across several shifts between 04/01/2026 and 04/07/2026. During interviews, MA C stated that the off-going and oncoming staff were required to count narcotic medications and sign the Narcotic Count Sheet, but sometimes did not sign if the same person worked the next shift. She stated staff received training at new hire, annually, and through in-services, with the last one about two weeks earlier. The DON stated it was her expectation that the off-going nurse and on-coming nurse counted the narcotics together at shift change, and that failure to consistently follow the narcotic count expectations could allow drug diversion. Record review of the Controlled Substances Policy, dated November 2022, stated that nursing staff count controlled medication inventory at the end of each shift, the nurse coming on duty and the nurse going off duty make the count together, and discrepancies are reported to the DON.
Late Administration of Scheduled Pain Medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for 2 of 6 residents reviewed. Resident #4, a cognitively intact male with a diagnosis of partial traumatic amputation of the left midfoot and a care plan addressing pain related to an infected vascular wound of the left foot, had an order for oxycodone HCl 15 mg every 8 hours for severe pain. The MAR reflected the medication was scheduled for 8:00 AM and 4:00 PM, but on 04/09/26 the 8:00 AM dose was not administered until 9:20 AM. The MAR did not include a reason for the late administration, and the resident stated at 9:20 AM that he had still not received his pain medication at the scheduled time. Resident #46, a cognitively intact female with diagnoses including fibromyalgia, bipolar disorder with psychotic features, delusional disorder, acute respiratory failure with hypoxia, and edema, had orders for a lidocaine 4% patch daily and acetaminophen-codeine 300-3 mg twice daily for pain. The MAR reflected these medications were to be given during the morning medication pass, but on 04/07/26 they were not administered until 11:36 AM. The MAR did not include a reason for the late administration. During observation and interview, the resident stated her pain medication and lidocaine patch should have been given earlier that morning and that her pain level was about seven. Staff interviews confirmed the late medication administration. MA A stated she was late passing medications and that Resident #46’s patch and Tylenol 3 were supposed to be given between 6:00 AM and 10:00 AM. MA B stated she knew med passes were to occur within an hour before or after the scheduled time and that Resident #4’s oxycodone was scheduled for 8:00 AM. The DON stated scheduled medications were to be administered within an hour before or after the scheduled time unless otherwise specified, and that Resident #4 had no special instructions. The facility policy stated scheduled medications are to be administered within one hour of the prescribed time, and time-critical medications, including scheduled opioids used for chronic pain or palliative care, are to be administered at the scheduled time or within 30 minutes.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. This deficiency was identified based on direct observations and findings during the survey, which indicated lapses in maintaining a safe environment and in providing necessary supervision to prevent accidents.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident experienced a significant medication error, indicating a failure in the medication administration process. Specific details regarding the actions or omissions that led to the error, as well as the resident's medical history or condition at the time, are not provided in the report.
Sanitation Deficiencies in Kitchen Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which placed all residents at risk of cross-contamination and food-borne illness. Observations revealed that staff used gloved hands to touch various kitchen surfaces and then handled food without changing gloves or washing hands. Specifically, a dietary aide was seen touching kitchen surfaces, handling silverware, and placing rolls on food trays without changing gloves or using tongs, which could lead to cross-contamination. The dietary aide acknowledged forgetting to use tongs and recognized the risk of illness to residents. Additionally, the facility did not properly label, date, and store food items in the kitchen. Observations of the facility's freezer and cooler showed open boxes of cookie dough and chopped pecans exposed to air, and an opened package of turkey lunchmeat that was past its use-by date. The dietary manager confirmed that all food items should be labeled and dated when removed from their packaging and discarded by their expiration date. The facility's policies on food storage, preparation, and employee sanitation were not adhered to, contributing to the unsanitary conditions.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several observations and interviews. Hallways 2 and 4 had sticky residue on the floors, making it uncomfortable to walk, and a roach was seen crawling across Hall 2. Additionally, gnats were observed flying around in both the conference room and Resident #19's room, where personal items were cluttered and stacked against the wall. Resident #19 expressed discomfort with the clutter, stating she was unable to organize her belongings herself since moving into the room. The facility's Director of Nursing (DON) and other staff acknowledged the responsibility of maintaining a homelike environment, yet the issues persisted. Interviews with staff, including the DON, Certified Medication Aides (CMA), and Maintenance Supervisor (MS), revealed that the facility had a contract with a pest control company, with the last treatment conducted in January. However, the presence of pests and clutter indicated a lapse in maintaining the environment. The facility's policy emphasized providing a clean, sanitary, and orderly environment, yet grievances from the past three months included a report of a roach on a bedside table. Staff interviews highlighted the potential negative impact of a cluttered and unsanitary environment on residents' well-being, yet the issues remained unaddressed at the time of the survey.
Infection Control Deficiencies in Staff Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to proper infection control practices. LVN F was observed exiting a resident's room, which was under droplet precautions, without properly doffing PPE and subsequently contaminating the medication cart. Additionally, LVN F did not perform hand hygiene or clean the glucometer before and after checking glucose levels for residents, nor did they perform hand hygiene before and after administering insulin. CNA I and CNA J were observed performing incontinent care for a resident without changing gloves or performing hand hygiene between the dirty and clean aspects of care. CNA K failed to don PPE and did not retract the foreskin during catheter care for another resident, which is a necessary step in the cleaning procedure. Furthermore, CNA I did not perform hand hygiene during wound care assistance, and LVN G administered medication via PEG tube without donning PPE, despite the resident being on precautions. Interviews with the staff involved revealed a lack of adherence to infection control protocols, with some staff members admitting to forgetting to perform hand hygiene or don PPE. The facility's policies on perineal care, glucose monitoring, and hand hygiene were not followed, which could lead to infection control issues. The Director of Nursing acknowledged that these failures could result in infection control problems.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's needs and preferences were reasonably accommodated, specifically regarding the accessibility of the call light. Resident #14, a cognitively intact individual with a history of cerebral infarction and requiring maximal assistance for mobility and daily activities, had her call light placed out of reach at the foot of her bed. This was observed multiple times over several days, despite the care plan indicating the need for the call light to be within reach due to her risk for seizures. Interviews with staff, including the DON and CMA, revealed an awareness of the issue, with some staff indicating that the resident would yell for help instead of using the call light. However, it was acknowledged that this could lead to potential harm if the resident attempted to get up without assistance. The ADM and DON discussed the possibility of using a pad-style call light, which the resident could use, but this had not been implemented at the time of the observations. The facility's policy emphasized the importance of accommodating individual needs and preferences, which was not adhered to in this case.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide written notice to a resident before a room change, violating the resident's rights. The resident, a female with intact cognition and a history of acute kidney failure, heart failure, major depressive disorder, and weakness, was moved to a different room without receiving any written notification. The resident was informed verbally by staff that the move was due to the room being a Medicare room, and she needed to be in a Medicaid room. However, the resident expressed confusion about the reason for the move and was unaware that she could refuse the relocation. She also expressed dissatisfaction with the new room, as it lacked a window view, unlike her previous room. Interviews with facility staff, including the Director of Nursing (DON), Administrator (ADM), and Social Worker (SW), revealed inconsistencies in the reasons provided for the room change. The DON mentioned the move was due to payment reasons, while the ADM cited remodeling as the cause. Both acknowledged that the resident should have received written notice. The SW admitted not assessing the resident's wellbeing before the move and was unsure if it was protocol to do so. The facility's policy requires written explanations for room changes initiated by staff, which was not followed in this case.
Failure to Implement Effective Communication Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, identified as Resident #43, which included measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs. Resident #43, a male with moderate cognitive impairment, had a primary language of Mandarin and required a translator to communicate effectively with healthcare staff. Despite this need, the care plan did not adequately address the communication barriers, leading to ineffective communication with the resident. Observations and interviews revealed that the staff did not utilize appropriate translation services or tools, such as a communication board, to facilitate communication with Resident #43. The social worker attempted to use a Google Translate app, but the process was cumbersome and ineffective, taking approximately 25 minutes without successful communication. Additionally, the resident's care staff, including an LVN and CNAs, did not use a translator and relied on non-verbal cues like head shaking and thumbs up, which were insufficient for understanding the resident's needs. The facility's policy on comprehensive, person-centered care plans emphasized the importance of culturally competent services and resident involvement in care planning. However, the lack of a proper communication strategy for Resident #43, who had expressive aphasia and spoke Mandarin, demonstrated a failure to adhere to this policy. This deficiency in communication could potentially prevent the resident from receiving the necessary care to maintain their highest practicable level of health and well-being.
Failure to Support Resident Communication Needs
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish without a medical reason. Specifically, the facility did not adequately support a resident with communication deficits, who had a history of cerebral infarction, aphasia, and other medical conditions. The resident, who primarily spoke Mandarin, was not provided with effective communication tools or support, which could lead to a decrease in quality of life. Observations and interviews revealed that the resident was not using a communication board, and staff relied on inadequate methods such as a Google Translate app, which was not effectively utilized. The process of communication was cumbersome and ineffective, as demonstrated during an observation where the resident did not speak to the phone and only used head shaking and thumbs up as forms of communication. Staff interviews indicated a lack of training and resources to communicate effectively with the resident, and there was no evidence of a communication board being used. The facility's policies on care planning and resident rights emphasize the importance of person-centered care and accommodating individual needs, including communication. However, the facility did not adhere to these policies, as evidenced by the lack of effective communication strategies for the resident. This deficiency highlights a failure to maintain the resident's highest practicable physical, mental, and psychosocial well-being, as required by the facility's policies.
Failure to Apply Hearing Aid as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the application of a hearing aid as per physician orders. Over a period of three days, the resident was observed multiple times without the hearing aid in her right ear, despite having a physician's order for it to be applied every morning and removed at bedtime. The resident, who has moderate intellectual disabilities and other health conditions, expressed that the staff did not consistently apply the hearing aid, and a family member confirmed never seeing the resident with the hearing aid during visits. Interviews with facility staff, including an LVN and the DON, revealed that the staff were aware of the physician's order for the hearing aid but failed to implement it. The LVN admitted to not having time to apply the hearing aid, and the DON confirmed that the order should have been followed as it was documented in the Treatment Administration Record. The ADM was unable to locate any policies regarding the quality of care or documentation of treatment administration, indicating a lack of adherence to established procedures for following physician orders.
Inconsistent Oxygen Administration for Resident with Respiratory Conditions
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards and the resident's care plan for a resident with chronic respiratory conditions. The resident, who was admitted with acute and chronic respiratory failure, COPD, and heart failure, had a physician's order for continuous oxygen at 4 liters per minute (lpm). However, observations and record reviews revealed that the resident's oxygen was frequently set at incorrect flow rates, both higher and lower than the prescribed 4 lpm. This inconsistency in oxygen administration was noted in 17 out of 83 recorded entries, with the resident receiving oxygen at 5 lpm during multiple observations. Interviews with staff, including CNAs and LVNs, confirmed that nurses were responsible for setting the oxygen flow rates according to physician's orders. Despite this, the resident's oxygen was not consistently set at the correct rate, as evidenced by the observations and staff interviews. The facility's policies on medication administration and oxygen administration emphasized adherence to physician's orders, yet these were not followed, leading to the deficiency in care for the resident.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and labeled according to professional principles, as observed in two of the three medication carts reviewed. On the 200 Hall medication cart, nine medication cups containing multiple medications for unidentified residents were found in the top drawer. CMA B, who was present during the observation, acknowledged the error and admitted that pre-prepping medications was not a good practice. On the 300 Hall medication cart, Lantus Solo-star for a resident and Insulin Aspart for another resident were found without open dates, which is against the facility's policy. The Director of Nursing (DON) and LVN F both acknowledged the potential negative outcomes of these practices, including medication errors and the risk of administering expired medications. The facility's policies require that medications be stored in locked compartments and labeled correctly, with open dates for medications like insulin. The failure to adhere to these policies could lead to drug diversion, lack of drug efficacy, and adverse reactions among residents.
Inadequate Discharge Planning for Resident with Dementia
Penalty
Summary
The facility failed to provide and document adequate preparation and orientation for a safe and orderly discharge of a resident diagnosed with unspecified dementia, major depressive disorder with psychotic symptoms, and hypertension. The resident was admitted to the facility and placed on a secure unit due to elopement risk. However, the facility did not complete necessary documentation such as the Minimum Data Set (MDS), Care Plan, Interdisciplinary Discharge Summary, or a 30-Day Discharge Letter. The resident was discharged the day after admission without a proper discharge plan, leading to the resident being taken to the emergency room for a psychiatric evaluation by a family member. Interviews revealed that the facility's staff struggled to manage the resident's behavior, and the decision to discharge was made without the administrator's presence, as she was on vacation. The facility's interim Director of Nursing handled the discharge, which was initiated by the facility. The family was not provided with information on how to care for the resident post-discharge, and the resident was eventually placed in another facility. The Corporate Director of Nursing acknowledged that the discharge was not conducted according to the organization's policy, and the medical record lacked essential discharge documentation.
Deficiency in ADL Care and Hygiene
Penalty
Summary
The facility failed to provide necessary services for residents unable to perform activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene. This deficiency was observed in five residents who did not receive adequate nail care or timely incontinence care. Residents with severe cognitive impairments and various medical conditions, such as traumatic brain injury, cerebral infarction, and dementia, were dependent on staff for ADL tasks, including nail care, which was not consistently provided as per their care plans. Resident #1, a male with severe cognitive impairment, was observed with untrimmed nails and a blackish/brownish substance underneath them, indicating a lack of daily nail care as required by his care plan. Similarly, Resident #2, a female with severe cognitive impairment and multiple health issues, also had untrimmed nails with a similar substance, and her care plan did not address nail care. Resident #3, another female with dementia, had excessively long fingernails and an ingrown toenail, with nail care not addressed in her care plan. Resident #4, a female with a history of stroke and diabetes, also had long nails with a blackish/brownish substance, and her care plan lacked nail care instructions. Additionally, Resident #5, a female with multiple health conditions, experienced a significant delay in receiving incontinence care. She was left in a soiled state for over three hours despite having activated her call light, leading to emotional distress. Interviews with facility staff, including LVNs and CNAs, revealed a lack of adherence to the facility's policy on nail care and incontinence checks, which mandates regular nail trimming and cleaning, as well as checking residents for incontinence every two hours. The staff acknowledged the adverse outcomes of these deficiencies, such as the risk of infections and skin breakdown.
Unattended and Unlocked Medication Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, making them inaccessible to unauthorized staff, visitors, and residents. On 07/17/2024, two medication carts, Med Cart #1 and Med Cart #2, were found unattended and unlocked. Med Cart #1 was left near the entrance to the dining room, unsupervised, with prescription and over-the-counter medications, glucometer supplies, insulin pens, and syringes accessible. The CMA responsible for the cart was approximately thirty yards away, with her back turned, and the cart's computer, containing resident information, was also unlocked. The ADON intervened to secure the cart. Similarly, Med Cart #2 was found across from the nurses' station, unsupervised and unlocked, with similar contents accessible. The nurse responsible for this cart was not present, and the ADON had to secure it as well. Interviews conducted with various staff members, including CMAs, LVNs, CNAs, and the ADON, revealed a lack of consistent adherence to the facility's medication policy. CMA - A admitted to leaving Med Cart #1 unlocked while passing medications, despite being trained on the policy. Other staff members, including LVN - B and CNA - D, acknowledged that it was the responsibility of CMAs and nurses to lock the medication carts. The ADON emphasized that it was everyone's responsibility to ensure the carts were locked and secured. The ADM stated her expectation that the nurses and CMAs would lock the carts, highlighting a gap between policy and practice within the facility.
Failure to Notify Resident's Representative of Incident
Penalty
Summary
The facility failed to notify the representative of a resident regarding a change in the resident's condition. This deficiency involved an incident where a female resident with Alzheimer's disease and severe cognitive impairment wandered into another male resident's room while he was engaged in a private act. The male resident, who had moderate cognitive impairment, did not alert staff and continued his activity. The incident was discovered by a Licensed Vocational Nurse (LVN), who redirected the female resident back to her room. The LVN involved in the incident stated that she believed she had documented the event in the female resident's electronic medical record (EMR) and informed the resident's representative in person. However, upon review, there was no documentation of the incident or notification in the EMR. The Director of Nursing (DON) and the Assistant Director (AD) confirmed the lack of documentation and stated that the expectation was for the incident to be recorded and the representative to be notified. The facility's policy requires prompt notification of changes in a resident's condition to the resident, their physician, and their representative. Despite this policy, the representative of the female resident was not informed about the incident, raising concerns about the facility's communication and documentation practices. The report highlights issues with the facility's computer systems, which may have contributed to the lack of documentation.
Failure to Update Care Plan for Inappropriate Sexual Behaviors
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. Specifically, the care plan was not updated to reflect the resident's inappropriate sexual behaviors towards staff, despite multiple documented incidents. The resident, a male with a history of mood disorder, diabetes, alcohol abuse, pulmonary hypertension, atrial fibrillation, and ventricular fibrillation, exhibited moderate cognitive impairment as indicated by a BIMS score of 10. Incidents included the resident masturbating in front of another resident and staff, and inappropriate touching of a nurse, which were documented in progress notes but not reflected in the care plan. Interviews with the Director of Nursing (DON) and Assistant Director (AD) revealed awareness of the incidents and acknowledgment that the care plan should have been updated. The DON stated it was the responsibility of the team, including the MDS Nurse and charge nurses, to update the care plan, but ultimately her responsibility to ensure it was done. The facility's policy on comprehensive person-centered care plans emphasized the need for ongoing assessments and revisions as residents' conditions change, which was not adhered to in this case.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to ensure residents were free from verbal abuse, as evidenced by an incident involving a certified nursing assistant (CNA) and a resident. The incident occurred when the resident, who has a history of unspecified mood disorder, Parkinson's Disease, and cognitive communication deficit, verbally insulted the CNA during a smoke break. In response, the CNA repeated the insult back to the resident. This exchange was self-reported by the CNA, who acknowledged her actions to the charge nurse immediately after the incident. The resident involved in the incident has a moderate cognitive impairment, as indicated by a BIMS score of 11, and is known to become verbally aggressive when redirected during smoke breaks if out of cigarettes. Despite the resident's cognitive challenges, she did not recall the incident or the name-calling when interviewed later. The facility's failure to prevent this verbal abuse incident could place residents at risk for psychosocial harm and further abuse.
Unattended and Unlocked Medication Cart Found in Hallway
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required by state and federal laws. During an observation, a medication cart was found unattended and unlocked in the hallway, with the top drawer slightly open. The cart contained medical supplies, prescription, and over-the-counter medications. At the time of the observation, there were two residents present in the hallway, posing a risk of unsupervised access to the medications. An interview with the LVN responsible for the cart revealed that she was unaware that she had left the cart unlocked when she entered a resident's room. The Director of Nursing (DON) and the Administrator (ADM) both expressed that the facility's policy requires medication carts to be locked when out of sight or positioned in the open doorway of a resident's room with drawers facing inward. The failure to adhere to this policy was acknowledged as a potential risk to resident safety.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for a resident who eloped from the facility. The resident, who had severe cognitive impairment due to unspecified dementia, was found two blocks away at a convenience store on a busy road, disoriented and confused. The facility's front door alarm was turned off, allowing the resident to leave without detection, and there was no staff assigned to monitor the door at the time of the incident. Interviews with staff and record reviews revealed that the resident had a history of wandering behaviors but had not previously exhibited elopement or exit-seeking behaviors. On the day of the incident, the resident was seen displaying exit-seeking behaviors but was not adequately supervised. The facility's elopement policy was not effectively implemented, as the resident's care plan did not include specific elopement interventions prior to the incident. The facility's failure to monitor the front door and adequately supervise the resident placed the resident in immediate jeopardy. The incident highlighted deficiencies in the facility's supervision and elopement prevention measures, as well as a lack of timely updates to the resident's care plan to address the risk of elopement.
Failure to Protect Residents from Abuse by LVN
Penalty
Summary
The facility failed to protect two residents from abuse by a Licensed Vocational Nurse (LVN). Resident #3, a woman with a history of bipolar disorder, anxiety disorder, heart failure, cognitive communication deficit, and chronic kidney disease, reported that LVN E called her stupid and incompetent when she inquired about her nighttime medications. This incident occurred late at night, and Resident #3 stated that LVN E appeared fidgety and sweating, which made her question his competence. The verbal abuse upset Resident #3, and she reported the incident to the administration. Resident #4, a woman with acute kidney failure, hypertension, obesity, and major depressive disorder, reported inappropriate physical contact by LVN E. She stated that while she was in a shared area near the nurse's station, LVN E, who was acting strangely and talking loudly, began rubbing her neck, shoulder, and thigh. This made Resident #4 feel uncomfortable, and she reported the incident to other staff members. Witnesses, including CNA A and LVN A, corroborated the residents' accounts, noting that LVN E was acting erratically, talking loudly, and being argumentative with both staff and residents. The facility's administration was informed of the incidents on the night they occurred. An investigation was conducted, and LVN E was suspended pending the outcome. The investigation confirmed the residents' allegations of verbal and physical abuse, leading to LVN E's termination. The facility's abuse prevention program and resident rights policy emphasize the importance of treating residents with kindness, respect, and dignity, which was not upheld in these incidents.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization or therapeutic leave, violating their bed-hold policy. Resident #2, a male with progressive dementia, urinary tract infection, and heart failure, was not allowed to return to the facility after being cleared for discharge by the hospital. Despite the hospital's psychiatric evaluation indicating no need for psychiatric services, the facility staff, including the Marketing Liaison and the Director of Nursing (DON), insisted on psychiatric treatment before accepting the resident back. This refusal occurred even though the facility's bed-hold policy stated that residents should be allowed to return to their previous location in the center if an available bed exists. Interviews with the hospital RN case manager and facility staff revealed that the facility was informed of the resident's clearance for discharge but still refused to accept him back. The hospital provided the psychiatric assessment records to the facility, which confirmed no need for psychiatric services. However, the facility continued to deny the resident's return, citing behavioral issues and the need for psychiatric treatment. This action was contrary to the facility's documented bed-hold and return policy, which was last updated in August 2021.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 72 citations issued within 25 miles in the last 12 months — including the 4 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 Waco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Greenview Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 10 | 0 |
| Woodway Rehabilitation And Healthcare Center | 2 mi | ★★★★★ | 2 | 0 |
| The Chateau Waco | 2.4 mi | ★★★★★ | 7 | 2 |
| Ivy Creek Wellness & Rehabilitation | 2.4 mi | ★★★★★ | 1 | 0 |
| Ridgecrest Retirement And Healthcare Community | 2.5 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.