Below average — CMS composite of the measures below.
The next survey window likely opens around May 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 Johnson City during CMS and state inspections, most recent first.
The facility failed to complete annual performance reviews for 2 nurse aides and failed to provide completed competency checklists for a mechanical lift for 2 CNAs. A resident with severe cognitive impairment and a care plan requiring 2-person mechanical lift transfers fell during a lift when the sling was improperly placed, resulting in a head injury that required stitches and CT imaging. Interviews showed the CNAs were transferring the resident when the fall occurred, and facility leaders stated improper lift use and incomplete competency documentation could lead to serious injury.
A resident with severe cognitive impairment fell from a mechanical lift when the sling was not properly secured to the sling bar, causing a laceration and bruising. Two other residents were found with call lights out of reach while one was in a recliner and another had the light placed away from the bed. The facility also served a resident with dysphagia and a mechanical soft diet food from another resident’s plate, and staff allowed the resident to eat a whole meatball despite the ordered diet.
Food Storage, Labeling, and Kitchen Sanitation Failures: Surveyors found multiple unlabeled and undated food items in refrigerators and a freezer, a staff drink stored with resident food, and an ice scoop kept inside the ice machine and in an open bag on top of it. They also observed debris in a utensil drawer and on a coffee cup tray. Interviews with the DM, CK, DA, and ADM confirmed that personal items were not supposed to be in the kitchen, food items were to be labeled and dated, and kitchen sanitation was staff responsibility.
A resident with severe cognitive impairment and multiple diagnoses was transferred by CNAs using a mechanical lift for showering, but video showed the resident fully uncovered on the bed and during the transfer. The resident later had a laceration above the eyebrow and bruising, and a family member stated the resident had fallen from the lift and hit the floor. Staff interviews confirmed the transfer involved two CNAs, one of whom said she did not pause or ask for help when the resident moved too fast in the Hoyer, and the DON stated that exposing a resident during transfer was a dignity issue.
Incomplete Comprehensive Care Plan: A resident with Parkinson's disease, aphasia, pneumonia, UTI, severe cognitive impairment, total dependence for many ADLs, incontinence, mechanically altered diet, oxygen therapy, and hospice services had a care plan that listed only DNR status and related interventions. The ADON and DON both acknowledged the care plan was incomplete, and the DON stated triggered care from the MDS assessment should have been carried over into the care plan.
Expired medications and supplies were found in the 100 hall med cart, including an eyelid cleanser and nystatin topical powder. LVN B said she checked for expired meds every couple of weeks, while the ADON, DON, and ADM described staff responsibility for checking expiration dates and cart review intervals. The facility policy stated that outdated or deteriorated meds or biologicals are to be handled through the dispensing pharmacy.
A resident with serious medical conditions was admitted with an Out-of-Hospital DNR form that was signed by the responsible party and the BM/HR but lacked the required physician signature. The resident’s orders and record listed the code status as full code, and the care plan did not address code status. The BM/HR, who was responsible for admission paperwork and had been trained that a physician signature was required for a valid DNR, did not obtain the physician’s signature or communicate the family’s DNR wishes to clinical staff. When the resident was later found unresponsive, a CNA and an LVN checked the record, saw the resident listed as full code, and the LVN initiated CPR and used an automatic compression device while EMS was called, resulting in life-saving measures being performed contrary to the resident’s stated DNR wishes.
A resident admitted with a heel abrasion did not receive timely wound care orders or consistent weekly skin assessments. Staff observed changes in the wound but did not ensure physician notification or proper documentation, and the facility lacked clear leadership and communication regarding skin integrity issues, resulting in missed interventions and monitoring.
Three residents did not receive their scheduled medications on time due to significant delays in administration, with an LPN working an extended shift after coverage could not be found. The LPN reported exhaustion and feeling unsafe to continue medication passes, while staff interviews revealed confusion about medication administration timeframes. Facility policy required medications to be given within one hour of the scheduled time, but this was not followed.
The facility did not ensure RN coverage for at least 8 consecutive hours on two days, resulting in LVNs working extended shifts without RN support. Staffing records and interviews confirmed that no RN was present during these periods, and the facility's own policy requiring daily RN coverage was not met.
Surveyors found that the facility did not properly seal, label, or date food items in the kitchen and nourishment room, with expired and unsealed foods present and unsanitary conditions in storage areas. Staff interviews revealed confusion about responsibilities for food safety practices, and quality assurance records showed ongoing issues with food labeling and cleanliness.
Two residents with significant medical and cognitive needs were found with their call lights out of reach, contrary to their care plans and facility policy. One resident's call light was on the floor, inaccessible while in bed, and another's was wrapped around an overhead fixture, also out of reach. Staff interviews confirmed the expectation that call lights should always be accessible, and the facility's policy required this practice.
A resident with multiple mental health diagnoses, including bipolar disorder, major depressive disorder, and personality disorders, was admitted with a PASRR Level 1 Screening that failed to indicate the presence of mental illness. Despite clear documentation of these conditions in the resident's records, the screening was not corrected, and staff interviews confirmed that the process for ensuring PASRR accuracy was not followed.
Two residents did not have comprehensive care plans reflecting all their needs, including one with a history of smoking and acute gastritis with bleeding, and another whose care plan was not updated to reflect current ADL status and incontinence. Staff interviews confirmed that care plans were incomplete or outdated, and that these documents are essential for guiding care provided by CNAs and nurses.
A resident with a history of vascular dementia and impaired mobility fell from bed due to inadequate supervision and assistance in a LTC facility. The resident required two-person assistance for bed mobility, but a nurse aide attempted to provide care alone, resulting in the resident sustaining serious injuries, including a laceration, subdural hematoma, subarachnoid hemorrhage, and possible vertebrae fractures. The incident was reported, and the resident was hospitalized for treatment.
A resident with a history of UTIs and sepsis experienced severe pain in the lower abdomen and groin area, which was not effectively managed by the facility. Despite repeated complaints and visible distress, the nursing staff did not adequately address the pain or investigate its cause. The resident was eventually diagnosed with a UTI, sepsis, and a blood clot in the bladder after being sent to the ER. The facility failed to follow its pain management policy, resulting in prolonged suffering for the resident.
A resident with Alzheimer's and a history of falls was improperly transferred by a single CNA, resulting in fractures to her tibia and fibula. The resident's care plan required 2+ person assistance or a mechanical lift, but inconsistent documentation and lack of adherence to transfer requirements led to the injury. Staff interviews revealed a lack of consistent understanding of the resident's transfer needs.
Two residents were unable to receive visitors of their choosing due to facility-imposed restrictions requiring advance notification and scheduling. Despite expressing a desire to see the family of a former resident, the facility's actions were not documented in care plans or progress notes, and residents felt isolated. Staff cited the need to protect other residents' rights, but there was no documentation to support this, conflicting with the facility's visitation policy.
The facility failed to check and log food temperatures before serving breakfast, as required by professional standards for food service safety. A staff member admitted to forgetting to document the temperatures due to being behind schedule. The Dietary Manager acknowledged the potential health risks of not checking food temperatures, and the Director of Nursing noted possible adverse effects on residents. The facility's policy mandates that food temperatures be recorded before service to ensure resident health.
Two residents expressed frustration with the food and the Dietary Manager's (DM) lack of attendance at Resident Council meetings, despite multiple invitations. The DM stated he was too busy and unaware of the expectation to attend. This led to feelings of neglect among residents, as their concerns were not being addressed, contrary to the facility's policies on grievances and resident rights.
The facility failed to provide fresh fruit to residents, despite their repeated requests and dissatisfaction with canned fruit. Observations showed no fresh fruit in the kitchen, and staff interviews revealed that the DM was aware but did not consistently order fresh fruit. The AD personally purchased fresh fruit to meet residents' desires, while the DON acknowledged the importance of serving requested food but noted the lack of a policy on food preferences.
Incomplete CNA Competency Review and Mechanical Lift Transfer Injury
Penalty
Summary
The facility failed to complete annual performance reviews for 2 of 4 nurse aides reviewed, and it also failed to provide completed competency checklists for use of the mechanical lifting device for CNA A and CNA C. The report states that the competency assessment for the mechanical lift was done by the ADON in March 2026, but the records did not include employee names, titles, signatures, IDs, initials, or completed dates, and the facility did not provide properly completed documents showing that any employee had taken the competency assessment and in-service before the resident injury. Resident #27 was admitted with multiple diagnoses including atherosclerotic heart disease, violent behavior, dementia, depression, gait and mobility abnormalities, lack of coordination, and cognitive communication deficit, and had a BIMS score of 00 indicating severe cognitive impairment. The care plan required assistance by 2 staff with mechanical lift transfers and staff assistance with bathing/showering. On 06/01/2026, video evidence showed Resident #27 falling from the mechanical lift due to improper placement of the sling strap, and the resident sustained a head injury that required stitches and CT imaging of the brain and neck. During interviews, CNA C stated that he and CNA A were transferring Resident #27 with a mechanical lift when the resident fell, and that the sling was improperly placed. CNA C stated the resident was not centered in the lift and that both staff were responsible for ensuring proper positioning. CNA A stated the resident was moving during the transfer and that she did not pause or ask for help. The ADON, DON, LVN A, and ADM each stated that improper use of the mechanical lift and incomplete competency documentation could lead to serious injury, and the facility policy on mechanical lifting devices described safe lifting principles using the device.
Unsafe Lift Transfer, Call Light, and Diet Service Failures
Penalty
Summary
The facility failed to keep the environment free from accident hazards and to provide adequate supervision and assistance devices to prevent accidents for four residents. One resident with severe cognitive impairment, dementia, abnormal gait and mobility, lack of coordination, and need for personal care assistance fell from a mechanical lift during a bed-to-shower-chair transfer. Video evidence showed the resident fell because the sling strap was not properly placed on the lift bar. Staff interviews stated that two people were involved in the transfer, but the sling was in the wrong position and the resident was not centered in the lift when the fall occurred. The resident sustained a left eyebrow laceration and bruising, and the wound required stitches and hospital evaluation. The facility also failed to keep call lights within reach for two residents who required assistance with ADLs. One resident with intact cognition was observed in a room with the call light placed in a drawer and not within reach. Another resident with diagnoses including metabolic encephalopathy, behavioral disturbance, psychotic disturbance, anxiety, dysphagia, and muscle wasting was observed sitting in a recliner with the call light hanging on the wall behind the bed and out of reach. Both residents stated they could not reach the call light from where they were positioned. Staff interviews confirmed that call lights should be kept within reach and moved with the resident when the resident changes position. The facility also failed to serve a mechanically altered diet to a resident with dysphagia and severe cognitive impairment. During lunch service, the resident was served mechanically softened meatballs while another resident at the same table received full-size meatballs. The resident complained that she had not received meatballs, accepted meatballs from the other resident’s plate, and the CNA stood by watching. Another CNA intervened and the DON later monitored the resident while she ate the whole meatball. The resident’s care plan and order summary reflected a mechanical soft diet, and staff interviews confirmed that the resident should not have been allowed to eat food from another resident’s plate.
Food Storage, Labeling, and Kitchen Sanitation Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen reviewed for food and nutrition services. During observations, surveyors found multiple food items in Refrigerator #1 that were not labeled or dated, including individual butter and jelly containers, a staff member’s cup, herbs in a zip-top bag, cut bell pepper in a sealed bag, and blueberries in the original container with no date on the package. In Refrigerator #2, surveyors observed frosting in a sealed bag with only a date of 5-27-2026, a tray with juice that was not labeled with a date, a plastic bag of lettuce that was neither labeled nor dated, jello in a clear container labeled with only a date of 6-1-2026, a bowl of an unknown food item labeled with only the date 5-25-2026, a sandwich bag with cut red onion that was not labeled, dated, or sealed, a sealed bag with cut tomatoes that had no open date and no use-by date, and lettuce in its original packaging with no date on the package. In Freezer #1, surveyors found plastic bags containing frozen egg rolls, frozen chicken nuggets, and frozen garlic that were not labeled with what was in the bag or with an open or use-by date. Surveyors also observed the ice scoop stored inside Ice Machine #1 on a hook and another ice scoop stored in an open Ziplock bag on top of the ice machine. In the kitchen, the drawer containing serving utensils had food debris at the bottom and the tray holding coffee cups had debris. Interviews with the DM, CK, DA, and ADM confirmed that personal food items should not have been in the refrigerator or kitchen area, that food items were supposed to be labeled and dated, that kitchen staff were responsible for cleaning, and that the ice machine scoop should not have been stored in the ice machine. Record review showed a Labeling and Dating Policy requiring resident foods to be labeled with the resident's name, item, and use-by date, and a Sanitation Policy requiring staff to maintain kitchen sanitation through a written cleaning schedule.
Failure to Maintain Resident Dignity During Mechanical Lift Transfer
Penalty
Summary
The facility failed to treat Resident #27 with dignity and respect during a mechanical lift transfer from the bed to a chair. Resident #27 had diagnoses including atherosclerotic heart disease, violent behavior, dementia, depression, gait and mobility abnormalities, lack of coordination, cognitive communication deficit, and required assistance with personal care. The quarterly MDS reflected a BIMS score of 00, indicating severe cognitive impairment, and the care plan identified the resident as needing assistance by 2 staff with mechanical lift transfers and assistance with bathing/showering. During observation and interview, Resident #27 was seen in a wheelchair with an above-the-left-eyebrow laceration and bruises on the left arm. The resident's family member stated the resident had fallen from the mechanical lift and hit the floor, and also stated the resident could not express pain but showed pain by becoming angry. Video evidence reviewed by surveyors showed Resident #27's body fully uncovered on the bed and during the transfer from the bed to the mechanical lift. Interviews with CNA C and CNA A showed both staff were involved in the shower transfer and both had received training on abuse, neglect, exploitation, and mechanical lift use. CNA A stated the resident was moving too fast in the Hoyer, that she did not ask for help or pause during the transfer, and that the resident fell from the lift. The DON stated that failing to cover a resident's private area during a transfer was a dignity issue and that residents should be covered, while the facility's dignity policy stated that resident safety, dignity, comfort, and medical condition must be incorporated into lifting and moving decisions and that practices compromising dignity are prohibited.
Incomplete Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for one resident, identified in the report as Resident #14, that reflected the resident's diagnoses and preferences. The resident's face sheet showed diagnoses including Parkinson's Disease with dyskinesia with fluctuations, muscle weakness, lack of coordination, aphasia, pneumonia, and a UTI. The resident's quarterly MDS assessment showed a BIMS score of 3, indicating severe cognitive impairment, and documented that the resident needed substantial to maximal assistance with eating, oral hygiene, upper body dressing, personal hygiene, rolling, bed mobility, transfers, and other activities of daily living. The assessment also reflected that the resident was always incontinent of bowel and bladder, was on a mechanically altered diet, was at risk for pressure ulcers/injuries, was taking an antidepressant, a diuretic, oxygen therapy, and was receiving hospice care. Record review of the comprehensive care plan showed only one focus: DNR Resident Choice, with a goal that the resident's wishes would be honored. The interventions addressed code status education, ensuring the code status was in the medical record, not performing CPR if arrest occurred, notifying a receiving facility of the code status, placing DNR in the resident's record, and reviewing quarterly. No other focus, goal, or intervention was listed to address the resident's diagnoses, hospice services, pneumonia, UTI, functional dependence, incontinence, diet needs, oxygen therapy, or other identified needs. During interviews, the ADON stated that care plans were used so staff would know how to properly care for residents and confirmed that hospice services should have been included in the care plan. The DON stated that care plan accuracy and completion were left to the MDS nurse and agreed the resident's care plan was incomplete, noting that triggered care from the MDS assessment should have been carried over. CNA D and LVN A both stated that care plans needed to be complete to guide resident care, and the ADM deferred to the MDS nurse regarding the care plan contents. The facility policy stated that a comprehensive, person-centered care plan with measurable objectives and timetables should be developed and implemented for each resident and should reflect the comprehensive assessment, resident goals, services to be furnished, and recognized standards of practice.
Expired medications found in medication cart
Penalty
Summary
The facility failed to ensure safe storage of medications and medical supplies in the medication cart on the 100 hall. During observation, surveyors found expired items in the cart, including OCuSoft Lid Scrub Plus, an eyelid cleanser for moderate-severe conditions, which had expired in 12/2025, and Nystop Nystatin Topical Powder, USP 100,000 USP Units per gram, which had expired on 05/31/2026. The expired products were located in the medication cart reviewed for pharmacy services, and the deficiency involved 1 of 2 medication carts reviewed. During interviews, LVN B stated she had been checking expired medications every couple of weeks and acknowledged that expired medication can affect potency. She stated she would check more promptly, at least once a week, and said she had been trained to check for expired medication and remove it immediately when found. The ADON stated that expired medication could not get the full chemicals of the medication and might not be fully absorbed, which could cause a negative reaction, and said nursing staff and anyone assigned to the medication cart were responsible for checking expiration dates. The DON stated expired medication could result in a medication error or the medication may not be therapeutic, and the ADM stated that expired medication should be checked monthly by nursing staff and the ADON. The facility policy titled Medication Labeling and Storage stated that discontinued, outdated, or deteriorated medications or biologicals are to be handled by contacting the dispensing pharmacy for instructions regarding resuming or destroying the items.
Failure to Obtain Valid Physician-Signed DNR Resulting in CPR Against Stated Wishes
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to formulate and have a valid advance directive honored. A male resident with diagnoses including sepsis, pneumonia, and a prosthetic heart valve was admitted with an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that had been signed and dated by his responsible party (RP) and the Business Manager/Human Resources (BM/HR), but the form lacked the required physician signature. Record review showed the resident’s orders listed his code status as “FULL CODE,” and his comprehensive care plan did not mention any code status. The facility’s policy stated that advance directives, including DNR orders, are to be honored in accordance with state law and facility policy. During admission, the BM/HR obtained the RP’s signature on the OOH-DNR form and also signed it herself, based on instructions she reported receiving from a regional trainer to have families complete the OOH form at admission. She acknowledged responsibility for obtaining paperwork for new admissions and for uploading the OOH-DNR to the resident’s file, and she had received training that the form was not valid without a physician’s signature. The BM/HR did not obtain the physician’s signature and did not communicate the family’s DNR wishes to clinical staff. The DON later confirmed that the BM/HR was responsible for obtaining all required signatures on admission paperwork and that the OOH-DNR without a physician’s signature was not valid. On the morning the resident was found unresponsive in bed, a CNA notified LVN A, who assessed the resident and found no pulse or vital sign readings. Both the CNA and LVN A checked the electronic record and the resident’s file for an advance directive and found the resident listed as “full code.” Based on this information, LVN A contacted the NP and initiated CPR using an automatic compression device while the CNA called EMS. The resident was pronounced dead later that morning. Subsequent review by the DON and corporate office confirmed that the OOH-DNR form signed by the RP was invalid without a physician’s signature, and the resident’s RP reported that he believed signing the OOH-DNR document at admission was sufficient to establish the resident’s DNR wishes.
Failure to Provide Timely Wound Care and Skin Assessments
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the resident was admitted with a superficial abrasion on the right heel, but there were no physician orders in place to treat or monitor the heel abrasion from the time of admission through several weeks. Despite an order for a wound consult and a pressure-relieving mattress, there was no documentation of wound care being performed, and no wound consult notes were found in the resident's chart. The care plan identified a risk for impaired skin integrity, but interventions were not implemented or documented as required. Weekly skin assessments were not completed as scheduled, with missed assessments on two specific dates. Nursing staff interviews revealed confusion and lack of clarity regarding responsibility for skin assessments and reporting of skin changes. One RN was unable to access the electronic charting system and did not complete or document all required skin assessments, nor did she escalate the issue to facility management or corporate staff. Other staff members observed changes in the resident's heel, such as blistering and discoloration, and reported these to nurses, but there was no evidence that these reports led to timely physician notification or initiation of treatment orders. Multiple staff interviews confirmed that changes in the resident's skin condition were not consistently reported to the appropriate clinical leadership, such as the DON, ADM, or physician. The facility lacked a DON at the time, and staff were unclear about the reporting chain. Observations of the resident's heel showed progression from an abrasion to areas suggestive of pressure injury and possible necrosis, yet no wound care or monitoring was documented. Facility policy required full assessment and documentation of pressure ulcers and prompt physician notification, but these standards were not met in this case.
Failure to Administer Medications on Time Due to Staffing and Policy Lapses
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate and timely administration of medications for three residents. Review of medical records and medication administration records (MARs) showed that multiple medications, including Divalproex Sodium, Sacubitril-Valsartan, Aspirin, Baclofen, Buspirone, Potassium Chloride, Donepezil, and Pantoprazole, were administered significantly later than the scheduled times as indicated by physician orders. For example, medications scheduled for 7:00 AM were administered between two to over four hours late. The facility's policy required medications to be administered within one hour of their prescribed time, but this was not followed. The delays in medication administration were linked to staffing issues. One LVN reported working a 25-hour shift due to the oncoming nurse calling out for a family emergency, and the facility's administrative and staffing personnel were unable to find coverage. The LVN described feeling overwhelmed, exhausted, and not competent to safely administer medications after working such an extended period without rest. She communicated her concerns to the administrator but continued to work and administer medications despite her fatigue. Interviews with other nursing staff revealed inconsistent understanding of the facility's medication administration timeframes, with some stating a one-hour window and others referencing a more liberalized timeframe. The administrator was unaware of the specific timeframes for medication administration. The facility's policy emphasized safe and timely medication administration, but the observed practices did not align with these requirements, resulting in late medication administration for multiple residents with complex medical needs.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, there was no RN coverage on two reviewed days, with the nurse schedule and time sheets confirming that only licensed vocational nurses (LVNs) were present during those periods. On these days, LVN staff worked extended shifts, including one LVN who worked 25 hours straight due to a lack of relief, and no RN was available to fulfill the required coverage. Interviews with staff revealed that the staffing coordinator, a CNA, was responsible for managing call-ins and attempting to find replacements when nurses called out. On the days in question, an LVN called in with a family emergency, and the scheduled RN subsequently decided not to come in, citing discomfort with being the only nurse on duty and unfamiliarity with passing medications to the residents. Despite efforts to contact other staff and corporate, no RN was secured to cover the required shift, resulting in LVNs covering the floor for extended hours. The facility's own policy required an RN to provide services at least eight hours every 24 hours, seven days a week. Both the administrator and the staffing coordinator acknowledged the absence of RN coverage and the risks associated with staff working beyond their scheduled hours, including exhaustion and potential medication errors. The deficiency was confirmed through review of schedules, time sheets, and staff interviews, all indicating that the facility did not meet the RN coverage requirement on the specified days.
Failure to Properly Store, Label, and Discard Food Items
Penalty
Summary
The facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in both the kitchen and nourishment room. Observations revealed multiple instances of food not being properly sealed, labeled, or dated, including an open box of thawed bacon, open bags of potato chips, and several loaves of bread left out or past their use-by dates. Expired food items such as yogurt and thickened sweetened tea were found in the refrigerator, and some items were not discarded as required by facility policy. Additionally, the dry storage area contained an open bag of chips, and the nourishment room refrigerator and freezer contained unlabeled and undated food items, as well as expired products like yogurt and popsicles. The nourishment room's refrigerator and freezer were observed to be unsanitary, with dirty shelves, food crumbs, hair, sticky residue, and red stains. Food items in these areas were not labeled with residents' names or dates, despite posted signs instructing staff to do so. Interviews with staff revealed inconsistent understanding and implementation of food labeling, dating, and discarding procedures. Some staff were unclear about their responsibilities for cleaning and monitoring the nourishment room, and there was confusion about who was responsible for discarding expired or improperly labeled food. Review of facility policies and quality assurance documentation showed that the expectations for food storage, labeling, and cleanliness were not being met. The registered dietitian's monthly checklists and comments repeatedly noted issues with labeling, dating, and cleanliness in the nourishment room. Despite staff training and posted policies, the facility did not ensure that all food was properly stored, labeled, and discarded according to professional standards and its own procedures.
Failure to Ensure Call Lights Were Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, as required by their care plans and facility policy. For one resident with acute respiratory failure, diabetes, coronary artery disease, COPD, and moderate cognitive impairment, the call light was observed on the floor and out of reach while the resident was in bed. The resident stated he would have had to roll off the bed to access it and that it likely fell when staff were last present. His care plan specifically required the call light to be kept within reach at all times due to his fall risk and vision impairment. Another resident, diagnosed with dementia, diabetes, aphasia, and cerebral aneurysm, was observed lying in bed with the call light wrapped around an overhead light fixture and out of reach. This resident was dependent on staff for most activities of daily living and was not able to communicate effectively due to aphasia. The care plan for this resident also included interventions to keep the call light accessible and to provide verbal reminders to call for assistance with ADLs, as the resident did not typically call for help independently. Interviews with staff, including a CNA, LVN, DON, and the administrator, confirmed that it was the facility's expectation and policy for all residents to have their call lights within reach at all times. Staff acknowledged that failure to do so could prevent residents from obtaining needed assistance. The facility's policy, revised in March 2021, also required call lights to be within easy reach when residents are in bed or confined to a chair.
Failure to Ensure Accurate PASRR Level 1 Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident with multiple mental health diagnoses received an accurate Preadmission Screening and Resident Review (PASRR) Level 1 Screening. Record reviews showed that the resident, a female with diagnoses including bipolar disorder, major depressive disorder, dependent personality disorder, avoidant personality disorder, and anxiety disorder, was admitted with a PASRR Level 1 Screening that did not indicate the presence of a mental illness. Despite documentation in the resident's face-sheet, admission MDS, care plan, and history and physical all listing these mental health conditions, the PASRR Level 1 Screening completed prior to admission showed no evidence or indicators of mental illness. Interviews with facility staff, including the MDS coordinator, DON, and administrator, confirmed that the MDS coordinator was responsible for ensuring the accuracy of PASRR documentation and for contacting the acute care facility if corrections were needed. Staff acknowledged that a resident with the listed diagnoses should have had a positive PASRR Level 1 Screening and that an incorrect screening would prevent access to necessary care and services. The facility was unable to provide a policy related to PASRR Level 1 Screenings when requested.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy and regulation. For one resident with a history of acute gastritis with bleeding, Alzheimer's disease, dysphagia, and fibromyalgia, the care plan did not address the resident's status as a smoker or the diagnosis of acute gastritis with bleeding. This omission occurred despite documentation in the resident's assessments and a safe smoking evaluation indicating the resident's use of tobacco and the presence of the medical condition. Interviews with facility staff, including the DON, MDS nurse, and ADM, confirmed that these care needs should have been included in the care plan, and that the lack of inclusion meant the care plan did not fully reflect the resident's needs. For another resident with diagnoses including metabolic encephalopathy, bipolar disorder, major depressive disorder, type 2 diabetes mellitus, dependent and avoidant personality disorders, anxiety disorder, and muscle weakness, the care plan was not updated to reflect the resident's current ADL functional status. The resident required substantial assistance with toileting hygiene and was frequently incontinent, but the care plan continued to state that the resident toilets independently. Interviews with the resident and staff confirmed that the resident was unable to sit up independently and required assistance to use the bathroom, indicating a discrepancy between the care plan and the resident's actual needs. Staff interviews revealed that care plans are used by CNAs and nurses to determine and provide care, and that responsibility for updating care plans is shared among nursing administration, the MDS nurse, and other team members. The facility's policy requires that care plans include measurable objectives and timeframes to meet each resident's medical, nursing, mental, and psychosocial needs, and that all diagnoses and relevant care needs be addressed. The failure to update and accurately reflect residents' needs in their care plans was acknowledged by multiple staff members during interviews.
Resident Falls Due to Inadequate Supervision and Assistance
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. This deficiency was identified when a resident, who required two-person assistance for bed mobility due to hemiplegia and impaired mobility, was left unattended by a nurse aide who attempted to provide care alone. The resident rolled out of bed, resulting in a fall that caused significant injuries, including a laceration on the forehead, a subdural hematoma, a subarachnoid hemorrhage, and possible fractures of the C6 and T1 vertebrae. The resident involved in the incident was an elderly female with a history of vascular dementia, cognitive communication deficit, and sequelae of cerebral infarction. Her care plan clearly indicated the need for two-person assistance for bed mobility and transfers using a mechanical lift. Despite this, the nurse aide, who was not certified and was aware of the requirement for two-person assistance, proceeded to provide care without the necessary support, leading to the resident's fall and subsequent hospitalization. Interviews with staff revealed that the nurse aide was aware of the facility's policies and the resident's care requirements but chose to act independently. The incident was promptly reported, and the resident was transferred to the emergency room for treatment. The facility's failure to adhere to established care protocols and ensure adequate supervision and assistance for residents resulted in a serious accident, highlighting a significant lapse in the standard of care provided.
Removal Plan
- Immediate Actions Taken for Those Residents Identified: [Resident #1] was assessed following fall, transferred to the ER, and subsequently admitted to the hospital for further evaluation and treatment.
- How the Facility Identified Other Possibly Affected Residents: All residents' orders, care plans, resident profile and MDSs reviewed to ensure the methods of transfer match. Any discrepancies will be discussed with the IDT to verify the proper method of transfer is occurring.
- Measures Put into Place/System Changes to remove the immediacy: Educate Director of Nursing and Assistant Director of Nursing on required new hire orientation with Certified Nurse Aides/Nurse Aides and licensed nurses to include return demonstration for where to find resident profile information in MatrixCare POC.
- Licensed Nurses and Certified Nursing Aides/Nurse Aides educated on Safe Lifting and Movement of Residents and checking resident profile to ensure appropriate number of staff used for all activities of daily living.
- Unlicensed Nurse Aides will be educated that they are not authorized to transfer any resident without a Certified Nurse Aide or licensed nurse present.
- Despite having documented education on Matrix POC and resident profiles, the NA was suspended immediately pending outcome of the investigation. The NA's employment will be terminated effective immediately.
- How the Corrective Actions Will be Monitored: Director of Nursing and/or Designee will observe 3 transfers/resident ADL activities to ensure staff check the resident profile and perform the appropriate transfer or ADL care based on the resident plan of care.
- Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy Template and the facility's plan to remove the immediacy.
Failure in Pain Management for Resident with Suprapubic Catheter
Penalty
Summary
The facility failed to provide effective pain management for a resident who complained of severe pain in the lower abdomen and groin area over several days. Despite the resident's repeated complaints and visible signs of distress, the nursing staff did not adequately address the pain or investigate its cause. The resident, who had a history of urinary tract infections and sepsis, was eventually diagnosed with a urinary tract infection, sepsis, and a blood clot in the bladder after being sent to the emergency room. The resident's medical history included acute kidney failure, diabetes, and a history of urinary tract infections and sepsis. He had a suprapubic catheter due to obstructive uropathy and was at risk for increased pain due to his medical conditions. Despite these risk factors, the facility's staff did not effectively manage his pain or communicate with the physician for alternative interventions when the prescribed pain medications, Tylenol and Tramadol, proved ineffective. Interviews with staff and the resident's family member revealed that the resident was in significant pain, which was not alleviated by the medications provided. The staff failed to notify the nurse practitioner or physician about the ineffectiveness of the pain management plan, resulting in prolonged suffering for the resident. The facility's pain assessment and management policy required timely reassessment and reporting of unrelieved pain, which was not adhered to in this case.
Removal Plan
- All residents' pain monitoring on the residents' Medication Administration Record MAR was reviewed by DCO. Director of Nursing and/or Designee will communicate with Medical Director all residents that triggered for pain and any new orders will be implemented by the Director of Nurses.
- Director of Nurses educated Assessing pain, treating pain (as ordered), monitoring for effectiveness, and notifying physician for any residents whose pain medication is not effective or new onset or increase/change in pain.
- Licensed Nurses and Certified Nursing Aides educated over pain & reporting pain. Licensed Nurses: Assessing pain, treating pain (as ordered), monitoring for effectiveness, and notifying physician for any residents whose pain medication is not effective or new onset or increase/change in pain. Licensed Nurses and Certified Nursing Aides will be educated prior to working their next shift. The Facility is not currently using agency personal, but PRN and new hires will be educated before working their first shift.
- Review pain assessments during clinical meeting and will be ongoing for any residents that have expressed or demonstrated pain to ensure effective intervention/investigation/notification for residents complaining of pain.
- Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy Template and the facility's plan to remove the immediacy.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and did not provide adequate supervision and assistance devices to prevent accidents for a resident. The resident, a female with Alzheimer's disease and a history of falls, was improperly transferred by a single CNA, resulting in her left leg getting caught on the wheelchair and causing multiple fractures to her tibia and fibula. The incident occurred despite the resident's care plan indicating she required extensive assistance with 2+ persons for transferring and bed mobility. The resident's care plan and documentation were inconsistent regarding her transfer status. While her care plan suggested a 1-2 person transfer or the use of a mechanical lift, the CNA attempted to transfer her alone, which was not aligned with the documented requirements. The CNA had previously transferred the resident alone without issues, but this time, the improper technique led to a severe injury. The facility's policy required ongoing assessment and documentation of residents' transfer needs, which was not adequately followed in this case. Interviews with staff revealed that there was a lack of consistent understanding and application of the resident's transfer requirements. The Physical Therapy Assistant noted that the resident's physical abilities fluctuated, and some aides were not comfortable transferring her alone. The Director of Nursing acknowledged that the care plans, MDS, and POC should match, but this was not the case for the resident involved in the incident. The failure to adhere to the documented transfer requirements and the lack of proper supervision and assistance devices directly contributed to the resident's injury.
Failure to Honor Residents' Visitation Rights
Penalty
Summary
The facility failed to honor the residents' rights to receive visitors of their choosing at their preferred times, affecting two residents. Both residents expressed a desire to visit with the family of a former resident, but the facility imposed restrictions that required these visitors to notify the facility in advance and schedule appointments. This was contrary to the residents' preferences and was not documented in the residents' progress notes or care plans. Interviews with the residents revealed that they were asked to sign documents regarding visitation, which they did not fully understand. One resident initially signed a document but later expressed a desire to revoke it, while the other resident was unsure why her visitors were restricted. Both residents expressed feelings of sadness and isolation due to these restrictions, indicating a negative impact on their emotional well-being. The facility's staff, including the ADM and SW, acknowledged the restrictions and stated that they were implemented to protect the rights of other residents who did not want visits from the specific family. However, there was no documentation in the resident council minutes to support these claims. The facility's policy on visitation emphasized supporting residents' rights to receive visitors, but the actions taken were not aligned with this policy, leading to the deficiency.
Failure to Check and Log Food Temperatures Before Meal Service
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that food temperatures were checked and logged before serving breakfast on a specific date. This lapse was identified in the kitchen, where it was found that there were no entries in the food temperature logbook for the breakfast meal service. Interviews with kitchen staff revealed that although complaints about cold food were received, they were not during the workdays of the staff member responsible for checking temperatures on the day in question. The staff member admitted to forgetting to take and document the food temperatures due to being behind schedule. The Dietary Manager (DM) acknowledged that not checking and documenting food temperatures could affect residents' health, potentially leading to foodborne illnesses. The DM confirmed that the staff member informed him about the oversight and noted that this was not a recurring issue. However, the DM had not recently retrained the cooks on the importance of checking and documenting food temperatures. The Director of Nursing (DON) also highlighted that failing to check and log food temperatures could lead to gastrointestinal and psychosocial adverse effects for residents. The facility's policy emphasized the importance of serving foods at the correct temperatures to ensure residents' health, requiring temperatures to be taken and recorded before service.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to honor the residents' right to organize and participate in resident/family groups by not ensuring that the views of the residents were considered and acted upon promptly. Specifically, two residents, who were cognitively intact, expressed frustration with the food served at the facility and the lack of response from the Dietary Manager (DM) to their requests for him to attend Resident Council meetings. Despite multiple invitations, the DM did not attend these meetings, stating he was too busy and unaware of the expectation to attend when invited. This lack of attendance led to feelings of neglect and frustration among the residents, who felt their concerns were not being heard or addressed. The facility's policies on grievances and resident rights emphasize the importance of considering and addressing resident concerns, yet these were not adhered to in this instance. The Assistant Director (AD) and Assistant Director of Nursing (ADM) both acknowledged the residents' repeated requests for the DM's attendance and the negative impact of his absence on the residents' morale. The Resident Council minutes further documented the residents' dissatisfaction with the DM's lack of engagement, highlighting a failure to treat residents with the respect and dignity outlined in the facility's policies.
Failure to Provide Fresh Fruit to Residents
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that met the daily nutritional and special dietary needs of residents, specifically in terms of providing fresh fruit. Three residents, all cognitively intact, expressed dissatisfaction with the lack of fresh fruit, stating that they only occasionally received bananas and were otherwise served canned fruit, which they did not prefer. These residents had been requesting fresh fruit for several months during Resident Council meetings, but their requests were not adequately addressed by the facility. Observations revealed that the facility's kitchen had no fresh fruit available, only canned fruit and brown bananas. Interviews with staff indicated that the Dietary Manager (DM) was aware of the residents' requests but had not consistently ordered fresh fruit, citing delivery issues. The Activity Director (AD) had been purchasing fresh fruit personally to meet residents' desires, and the Director of Nursing (DON) acknowledged the importance of serving requested food but noted the absence of a policy related to food preferences. A review of a recent food invoice confirmed that no fresh fruit had been purchased, despite ongoing resident complaints documented in Resident Council Minutes.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 11 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Johnson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Dripping Springs | 18.2 mi | ★★★★★ | 2 | 0 |
| The Brixton At Horseshoe Bay | 19.1 mi | ★★★★★ | 0 | 0 |
| Granite Mesa Health Center | 22.9 mi | ★★★★★ | 9 | 0 |
| Brookdale Lakeway Snf | 25.9 mi | ★★★★★ | 8 | 0 |
| Deer Creek Nursing And Rehabilitation | 26.5 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.