Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Kaufman during CMS and state inspections, most recent first.
A resident with a stage IV pressure ulcer and multiple comorbidities was care planned for Enhanced Barrier Precautions (EBP), requiring staff to use a gown and gloves during high-contact care. During an observed wound care procedure, a Treatment Nurse performed dressing removal, wound cleansing, and redressing while wearing gloves but did not don a gown, even though EBP PPE was available outside the room. In interviews, the nurse acknowledged that residents with wounds required EBP, including gowns and gloves, and stated she forgot to wear the gown, while the DON confirmed that EBP for chronic wounds always required a gown and gloves per facility policy.
Food safety and sanitation deficiencies were identified in the kitchen when multiple food items were found unlabeled and undated, dry goods lacked required dates, unpasteurized eggs were present, and several surfaces and equipment items were dirty, including the microwave, juice spigot, ice machine, and ice scoop holder. Staff also failed to verify food and beverage temperatures after heating, and the dishwasher chlorine was checked at the wrong cycle, with the DM acknowledging gaps in food handling and temperature monitoring practices.
Respiratory care was not consistently provided or maintained for several residents with oxygen or nebulizer orders. One resident with a continuous O2 order was found in bed without oxygen in the room or applied, another resident with COPD had O2 tubing not dated or bagged and no oxygen sign outside the door, and two residents with PRN nebulizer orders had tubing or a facemask left out on a nightstand or bedside table instead of being dated and stored in a bag. Staff acknowledged the missing sign and improper storage of respiratory equipment.
Medications and carts were not properly secured, and pharmacy labels did not match MAR orders for multiple residents. A resident with seizures had lorazepam stored in an unlocked refrigerator, one resident with a g-tube had amlodipine and potassium chloride labels that said PO instead of enteral, and another resident's amlodipine label did not match the ordered dose. Staff also left a treatment cart open, left hydrogel wound gel on a cart, and left a med cart unlocked and unattended while giving meds.
Food was not palatable or served at an appetizing temperature for multiple residents. Residents reported the food could be warmer and one resident said the food was not good. A sampled lunch tray had lukewarm beef stroganoff with a mushy texture and overpowering garlic flavor, cold and bland green beans, and a soggy, greasy appearance. A CNA stated she reheated cold food in the employee breakroom without checking the temp or reporting the complaint, while other staff said residents sometimes complained about cold or bland food.
The facility failed to maintain infection control practices during resident care and equipment use. Staff were observed providing incontinent care without proper hand hygiene or glove changes, not wearing required PPE for a resident on EBP, failing to perform hand hygiene before medication administration, and using a blood pressure monitor between two residents without disinfecting it. Staff acknowledged the missed hand hygiene, PPE, and disinfection steps during the observations.
Open EMR Exposed Resident PHI During Medication Administration: An LVN left a resident’s EMR open on the medication cart while entering the resident’s room to give meds, and the screen was visible in the hallway to staff, residents, visitors, and surveyors until the ADON closed it. The resident had severe cognitive impairment, a BIMS score of 7, and a G-tube for nutrition related to CVA with dysphagia.
A resident’s room had damaged lower wall trim that was lifting, jagged, and later removed, leaving the wall exposed without a finished covering. The resident said she was scared she could be injured when propelling her wheelchair, and a CNA reported the wheelchair would catch on the hanging trim. The MDS/maintenance director acknowledged the damage had been known for weeks, and the ADON identified the loose trim as a tripping hazard.
A resident admitted with bipolar disorder and anxiety had an inaccurate PASRR Level 1 screening marked negative, with no PASRR evaluation completed. The MDS Coordinator entered the hospital-supplied information, but the screening did not reflect the resident’s mental health diagnosis. Interviews with the Local Authority, ADON, DON, and Administrator confirmed the screening should have identified the mental illness diagnosis and been completed accurately.
A newly admitted resident with pneumonia did not have a baseline care plan initiated or completed within 48 hours of admission. The resident said he had not yet had a care plan meeting or received an explanation of his plan of care, and staff confirmed the baseline care plan was past due and the admission MDS/comprehensive care plan had not been completed.
Failure to care plan oxygen and nebulizer treatments for two residents. One resident with COPD had a continuous oxygen order, but the care plan did not include oxygen and oxygen was not present in the room during observation. Another resident with dementia had an order for Ipratropium-Albuterol breathing treatments, the MAR showed treatment was given, and a nebulizer was observed on the nightstand, but the care plan did not address the therapy.
A resident with MS, anxiety, muscle weakness, and moderate cognitive impairment was identified as a supervised smoker, but he was observed smoking beside a gas grill with a propane tank attached. Staff also found trash in the cigarette butt canister and cigarette butts on the ground near the oxygen storage area, and facility leaders acknowledged these conditions were fire hazards.
Improper incontinent care and hand hygiene: Two CNAs provided perineal care for a dependent resident who was always incontinent of bowel and bladder and had a history of UTIs. They used the same visibly soiled gloves throughout care, failed to change gloves, and did not perform hand hygiene before, during, or after care; one CNA said it was her first day and she had not completed skills check-off.
Facility assessment was not reviewed and updated to reflect two residents’ care needs. One resident had a G-tube for nutrition with severe cognitive impairment and dependence with eating, while another resident had COPD, PRN O2, and hemodialysis. The Administrator stated these needs should have been included in the assessment, and the RNC stated there was no policy and procedure regarding facility assessment.
Smoking assessments were not completed quarterly for two residents who were identified as smokers. One resident had MS, anxiety, muscle weakness, and moderate cognitive impairment and was listed as a supervised smoker; another resident had COPD, ESRD, bipolar disorder, and moderately impaired cognition and was listed as a safe smoker who required a smoking apron. Both were observed smoking, and staff said nurses were responsible for the assessments but were unsure of the required timeframe.
The facility's kitchen was found to have significant sanitation deficiencies, including a can opener with a black substance and rust, carbon buildup on various cooking utensils, and a microwave with unclean surfaces. The Dietary Manager was aware of these issues but was unsuccessful in resolving them. Previous Quality Assurance Monitors indicated a lack of cleaning schedules and routine cleaning, contrary to the facility's policy and FDA guidelines.
The facility failed to maintain an effective infection prevention and control program, resulting in several deficiencies. An LVN did not perform proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer, increasing the risk of infection. In the laundry room, staff did not use appropriate PPE when sorting contaminated linens, potentially spreading germs. Additionally, enhanced barrier precautions were not implemented for a resident with a mid-line catheter and a urinary tract infection, as the DON mistakenly believed it was unnecessary.
A resident with severe cognitive impairment was at risk due to the facility's failure to maintain hot water temperatures within the safe range of 100°F to 110°F. Observations revealed temperatures as high as 125°F, contrary to facility policy, posing a scalding risk. The Maintenance Supervisor was responsible for monitoring these temperatures.
A medication aide left a resident's medications, including controlled substances, unattended on a medication cart due to a personal emergency. This failure to secure the medications as per facility policy was acknowledged by the ADON, DON, and Administrator, who recognized the risk of medication misuse or diversion.
A resident with severe cognitive impairment and a history of wandering eloped from the facility, crossing a highway before being found at a convenience store. Despite having a wander guard, the resident exited through a door with a delay in locking. Staff were unaware of the door issue until after the incident, highlighting a lapse in supervision and security measures.
Failure to Use Required Gown Under Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the use of Enhanced Barrier Precautions (EBP) during wound care. A male resident with multiple diagnoses, including a stage IV pressure ulcer to the left calf present on admission, diabetes, osteoarthritis, and coronary atherosclerosis, was care planned for EBP. The care plan specified that staff must use a gown and gloves during high-contact resident care activities that could result in transfer of multidrug-resistant organisms (MDROs) to staff hands and clothing. The resident’s MDS indicated he was usually able to understand and be understood by others and had a BIMS score of 11, indicating moderate cognitive impairment. During an observation, the Treatment Nurse performed wound care on this resident without donning a gown, despite EBP personal protective equipment (PPE) being available outside the room. The nurse knocked, explained the procedure, performed hand hygiene, opened supplies, and wore gloves, but did not put on a gown while removing the old dressing, cleansing the wound, and applying new dressings. After completing the procedure, the nurse disposed of trash, removed gloves, and performed hand hygiene. In an interview, the Treatment Nurse acknowledged that residents with wounds required EBP, including gowns and gloves, and stated she did not wear the gown because it “slipped her mind.” The DON confirmed that EBP was required for residents with chronic wounds and that EBP for wound care always included a gown and gloves, with goggles or face shield if splashing was anticipated. The facility’s EBP policy stated that EBP is an infection control intervention using targeted gown and glove use during high-contact resident activities to reduce MDRO transmission.
Food Safety and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards in the kitchen. During the initial tour, multiple food items were observed unlabeled and undated, including containers of cherries and fruit loops and pitchers of orange juice, cranberry juice, and tea. Additional dry goods were also found without required dates, including loaves of wheat bread, packages of hamburger buns, a package of tortillas, and a box of tea filter pouches. A box of 108 eggs was observed to be unpasteurized. Kitchen sanitation concerns were also observed. The inside of the microwave had a yellow buildup, the juice machine spigot had a thick gooey red substance, and cups, bowls, and plate domes were stacked while still wet with water pooled between them. The outside of the ice machine had a white substance, and the bottom of the ice scoop holder had a wet brownish gooey substance. Staff interviews indicated that labeling and dating, cleaning the microwave and juice nozzle, air drying items before stacking, and cleaning the ice scoop holder were expected responsibilities, but these conditions were present during the survey observation. Food preparation and temperature monitoring practices were also deficient. The Dietary Manager ran the dishwasher to heat the water and tested chlorine at less than 10 ppm before placing dirty dishes in the machine, while the sales representative later stated the chlorine should be checked during the second cycle and read between 50-100 ppm. The Dietary Manager prepared pureed beef stroganoff, noodles, green beans, and a roll, microwaved the plate, and checked only the stroganoff temperature, which was 125 before reheating and 140 after reheating; the temperatures of the noodles, green beans, and roll were not checked. A Dietary Aide heated a resident’s glass of sweet tea in the microwave and served it without checking the temperature. Interviews also confirmed the Dietary Manager was unaware the eggs were unpasteurized until surveyor intervention and stated she did not know the proper reheating method to reach 165 degrees before serving.
Respiratory Equipment and Oxygen Not Properly Managed
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for multiple residents who had orders or care plan interventions related to oxygen or nebulizer use. For Resident #11, the physician ordered oxygen at 2 to 4 liters per minute via nasal cannula continuously on 12/18/25, but during observations on 01/05/26 and 01/06/26 the resident was in bed without oxygen in the room and without oxygen applied. The resident’s care plan revised on 10/20/25 did not indicate she required oxygen, and the MDS dated 12/04/25 did not show oxygen use during the look-back period. On 01/07/26, an LVN stated the resident had an oxygen order but no oxygen was in the room, and said the resident often refused oxygen, but it should still have been in the room and applied as ordered. For Resident #36, the care plan dated 09/24/25 identified oxygen related to COPD and directed staff to provide oxygen as needed and change oxygen tubing and cannula or mask weekly on Sunday. The physician order dated 11/21/25 directed oxygen at 2 to 4 liters via nasal cannula as needed for shortness of breath. During observations on 01/05/26 and 01/06/26, the resident had oxygen on at 2 liters per nasal cannula, but the tubing was not dated and not bagged, and the tubing was observed lying on the floor and later on the bed. No oxygen sign was posted outside the resident’s door during either observation. A CNA later verified the missing sign and the tubing not being dated or stored in a bag, and stated the tubing should have been bagged for infection reasons. For Resident #27, the physician order dated 12/18/25 directed Ipratropium-Albuterol solution by inhalation every 8 hours as needed for shortness of breath or wheezing, and the MAR showed a breathing treatment was given on 01/03/26. During observations on 01/05/26 and 01/06/26, the resident’s hand-held nebulizer tubing was on the nightstand, not bagged and not dated. A CNA confirmed the tubing was not dated or in a bag and stated it should be bagged for infection reasons. For Resident #15, an order summary dated 01/08/26 showed Ipratropium-Albuterol nebulization every 8 hours as needed for shortness of breath or wheezing. During observation on 01/08/26, the resident’s facemask was on the bedside table without being bagged or dated. An LVN stated the resident had recently received a nebulizer treatment and she failed to return the facemask to the storage bag because she had been busy, and acknowledged that bagging the facemask is intended to prevent contamination and bacteria spread.
Medications and carts left unsecured; pharmacy labels did not match orders
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in locked compartments and that medication labels matched the orders in the electronic charting system. During observation and record review, Resident #16, who had seizures and anxiety and a BIMS score of 10, had lorazepam 2 mg/ml stored in a black lock box inside an unlocked refrigerator in the Hall 100/200 medication storage room. Staff stated the medication should have been secured behind two locks, but the refrigerator was unlocked and the lock box was accessible. Resident #15, who had a gastrostomy tube, essential hypertension, hypokalemia, and severe cognitive impairment with a BIMS score of 7, had amlodipine and potassium chloride labels from the pharmacy that stated the medications were to be given by mouth, while the physician orders in the electronic record directed enteral administration through the g-tube. During observation, the medications were being prepared for g-tube administration despite the pharmacy labels not matching the orders. The report also documented an unlabeled cup containing a cloudy, slightly transparent cream on Resident #15's bedside table with opened oral swabs, and staff stated the substance was believed to be petroleum jelly but could not verify when or by whom it was placed there. Resident #41, who had essential hypertension and a BIMS score of 9, had an amlodipine pharmacy label that stated 5 mg once daily by mouth, while the physician order directed 10 mg once daily. During observation, staff prepared two 5 mg tablets for administration. In addition, the Hall 100/200 treatment cart was observed open, a tube of hydrogel wound gel was left on top of the Hall 200 nurses' cart without staff present, and the Hall 200 medication cart was left unlocked and out of sight while medication was being administered. Staff interviews confirmed the carts and medications were not secured as required.
Food Served Cold, Bland, and Poorly Prepared
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 10 of 10 residents reviewed for food and nutrition services, including Resident #32 and 9 confidential residents. During a confidential resident group meeting, 9 residents stated the food could be warmer. Resident #32 stated during an interview that the food was not too good, but did not provide further detail. During an observation and interview, a lunch tray sampled by the Dietary Manager and surveyors contained beef stroganoff that was lukewarm, had a mushy texture, and an overpowering garlic flavor; green beans that were cold and bland; and an overall appearance that was soggy and greasy. The Dietary Manager stated the beef stroganoff could have been warmer and the noodles were overdone, and the green beans were bland, below room temperature, and could have been separated more. CNA D stated residents had complained about cold food and that she reheated food in the employee breakroom without taking the temperature afterward or reporting the complaints. CNA E and RN B also stated residents complained about food being cold or bland, and that alternatives would be offered and complaints reported to dietary staff. The Dietary Manager and Administrator stated they expected food to be at the appropriate temperature and seasoned for palatability, and the facility policy stated residents are to be provided a nourishing, palatable, well-balanced diet.
Infection Control Failures During Resident Care and Equipment Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 6 of 6 residents reviewed for infection control. During observation of incontinent care for a resident with dementia, diabetes, severe cognitive impairment, and dependence for toileting and personal care, CNA K wiped the resident’s peri area, turned the resident, and continued care without hand hygiene or changing gloves. CNA K then used the same gloves to wipe the buttocks, applied a clean brief, changed gloves without hand hygiene, and continued touching the resident’s stuffed animal and linen. CNA K later stated she did not perform hand hygiene or change gloves after touching the resident, clean brief, stuffed animal, and linen with dirty gloves. For another resident with COPD, ESRD with a dialysis catheter, bipolar disorder, and incontinence of bowel and bladder, the facility had an enhanced barrier precautions sign on the door, but no PPE was noted in the bins outside the room during observation. CNA N stated she wore gloves and a mask but no gown when providing care and was not aware a gown was required. CNA L also stated she was not aware the resident required PPE until she read the sign at the door, which indicated a gown and gloves were to be worn. The resident stated staff did not wear gowns when providing incontinent care. For a third resident who was always incontinent of bowel and bladder and required dependent assistance with toileting hygiene, CNA G and CNA H provided incontinent care without proper hand hygiene and glove changes. CNA G did not perform hand hygiene or change gloves when her hands were visibly soiled, and CNA H used the same gloves to clean both the front and back perineal areas after a bowel movement. In addition, RN B did not perform hand hygiene before administering IV medication to one resident, and MA C used the same automatic wrist blood pressure monitor for two residents without disinfecting it between uses. Facility staff, including the ADON, RNC, and Administrator, acknowledged that hand hygiene, PPE use, and disinfection of reusable equipment were expected and that the actions observed could lead to cross-contamination or infection.
Open EMR Exposed Resident PHI During Medication Administration
Penalty
Summary
The facility failed to ensure a resident’s right to personal privacy and confidentiality of medical records when LVN A left the resident’s EMR open while entering the resident’s room to administer medications. During observation, the Hall-400 medication cart laptop was seen with the screen open to the resident’s information and facing into the hall while staff, residents, visitors, and surveyors were walking nearby. The screen remained open until the ADON closed it after the surveyor pointed out that the resident’s PHI was visible. The resident involved was a [AGE] year-old female admitted with a diagnosis that included gastrostomy. Her quarterly MDS reflected severe cognitive impairment with a BIMS score of 7, rare or no ability to make herself understood, and dependence with eating and use of a feeding tube. Her care plan noted she required a gastrostomy tube for nutrition after CVA with dysphagia, with interventions including observation of the PEG/G-tube site, NPO status, and oral hygiene every shift. LVN A stated she should have locked the screen when she walked away from the cart and acknowledged the importance of keeping resident information confidential.
Damaged Wall Trim Left Resident Room Unfinished
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for Resident #15 when the wall trim in the resident’s room was found lifting and jagged along the lower portion of the wall. During observation, the trim was uneven with sharp edges exposed, and later the damaged trim had been removed, leaving the interior wall exposed without replacement trim or a protective covering installed. The facility’s homelike environment policy stated that residents are to be provided with a safe, clean, comfortable, and homelike environment and encouraged to use personal belongings to the extent possible. Resident #15 stated she was scared she would get injured by the missing trim that had been jagged when she propelled her wheelchair. A CNA reported that the trim had been coming off the wall and that the resident’s wheelchair would catch the hanging trim when moving past it. The CNA said she had verbally reported the broken trim to the maintenance director several weeks earlier, and the maintenance director acknowledged awareness of the damaged trim and stated it had been removed, but the area had not been restored to a finished residential condition at the time of observation. The ADON stated all staff are responsible for ensuring rooms are safe and have a homelike appearance, and identified the loose trim as a tripping hazard.
Incorrect PASRR Screening for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to ensure that a resident with a mental health diagnosis received an accurate PASRR Level 1 screening and referral process. Resident #36 was admitted with diagnoses including bipolar disorder and anxiety, and the record showed a PASRR Level 1 screening that indicated no evidence or indicator of dementia or mental illness, with no PASRR evaluation completed. The resident’s record also showed a comprehensive care plan addressing altered affect/mood related to bipolar disorder and anxiety, quarterly MDS documentation noting an active diagnosis of bipolar disorder, and physician orders for Divalproex Sodium and Buspirone HCl related to bipolar disorder and anxiety disorder. During interview, the MDS Coordinator stated she was responsible for entering the PASRR Level 1 information before admission and said she input the information sent by the hospital. She and the surveyor reviewed the screening and diagnosis list and saw that bipolar disorder was listed as an admitting diagnosis, but the screening had been marked negative. The Local Authority stated the resident’s PL1 was negative because Section C was marked No for indicators of mental illness, and that bipolar disorder should have constituted a positive PL1 screening if the primary diagnosis was not dementia. The ADON said she was not aware of the PASRR process, and the Director of MDS said an incorrect PASRR Level 1 should prompt a Form 1012 so the resident could be reevaluated for services. The Administrator stated the MDS was responsible for the PASRR Level 1 screening and expected it to be completed accurately.
Baseline Care Plan Not Completed Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #53, a newly admitted male resident with pneumonia. Record review showed the baseline care plan was not opened or initiated and remained past due, and the admission MDS or comprehensive care plan had not been completed. The resident reported that he had not yet had a care plan meeting with the facility and had not received an explanation of his plan of care for pneumonia. Resident #53 was admitted on 01/02/2026, and the record also reflected that he had a fall during his stay on 01/03/2026 before the 48-hour timeframe for the completed care plan. Staff interviews confirmed the baseline care plan had not been completed within the required timeframe. The ADON stated an RN is responsible for initiating the baseline care plan assessment and that the DON oversees completion of assessments, while RN B reported she initiated the baseline care plan on 01/08/2026 but had not completed it.
Failure to Care Plan Oxygen and Nebulizer Treatments
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 2 residents. Resident #11 had diagnoses including COPD, anxiety, and stroke, and her physician orders indicated oxygen at 2-4 liters per minute via nasal cannula continuously. However, her care plan revised on 10/20/25 did not indicate that she required oxygen, and the MDS did not show she was receiving oxygen during the look-back period. During observation, she was found in bed without oxygen on, and a nurse later stated that Resident #11 had an oxygen order but no oxygen in her room, adding that she often refused oxygen but it should still be in her room and applied as ordered. Resident #27 had diagnoses including rhabdomyolysis, dementia, and diabetes. Her care plan revised on 10/06/25 did not include nebulizer treatments, even though a physician order dated 12/18/25 directed Ipratropium-Albuterol Solution every 8 hours as needed for shortness of breath or wheezing, and the MAR showed she received a breathing treatment. During observation, a hand-held nebulizer with tubing was found on her nightstand, not bagged or dated, and the resident stated she had a breathing treatment the other night. The ADON later confirmed that the nebulizer treatments should have been care planned and stated the care plan is meant to guide staff in the resident's care.
Smoking Area Fire Hazards and Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for Resident #17, a male resident with multiple sclerosis, anxiety, muscle weakness, and moderate cognitive impairment with a BIMS score of 7. The resident was identified in the care plan and smoking risk assessment as a supervised smoker, with staff responsible for providing supervision during smoking times. During observation, Resident #17 was seen smoking on the smoking patio next to a gas grill with a propane bottle attached, while several other residents were also smoking in the area. The same observation found trash in the red cigarette butt canister and cigarette butts on the ground near the oxygen storage area. The maintenance supervisor stated he had placed the propane tank outside next to the grill and acknowledged it was a smoking hazard when questioned. The DA M confirmed that trash did not belong in the cigarette butt bins and that cigarette butts should not be on the ground or near the oxygen storage area. The ADON and Administrator also acknowledged that the propane tank, trash in the cigarette bin, and cigarette butts on the ground could create fire hazards.
Improper Incontinent Care and Hand Hygiene
Penalty
Summary
The facility failed to ensure appropriate incontinent care was provided for a resident who was dependent for toileting hygiene and always incontinent of bowel and bladder. The resident had a history of urinary tract infections and was care planned to keep skin clean and dry due to moisture-associated skin damage to the buttocks and skin folds. During observation, two CNAs provided incontinent care after a bowel movement and used the same visibly soiled gloves throughout the entire care, failed to change gloves, and failed to perform hand hygiene before, during, and after the care. During interviews, one CNA acknowledged the failure to change gloves and perform hand hygiene during the resident’s perineal care and stated the resident was on enhanced barrier precautions. The second CNA stated it was her first day on the job and she had not completed incontinent care skills check-off. Nursing administration stated they were responsible for conducting check-offs before staff worked independently, and the Administrator stated staff were responsible for performing incontinent care. The facility policy for perineal care required hand washing, glove use, discarding soiled gloves, sanitizing hands, and re-gloving before touching clean linens or an adult brief.
Facility Assessment Not Updated for G-Tube, Oxygen, and Dialysis Needs
Penalty
Summary
The facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually, for 1 of 1 facility. The assessment did not include Resident #15’s gastrostomy tube and did not include Resident #36’s oxygen and dialysis needs. The Administrator stated he was responsible for completing and updating the facility assessment and stated those items should have been reflected in the assessment. He also stated it was important to update the facility assessment to prevent the proper focus on residents that need particular care, and that the risk associated with not updating the assessment was residents not receiving the proper care. Resident #15’s record reflected she was a [AGE]-year-old female admitted with a diagnosis including gastrostomy, and her quarterly MDS showed she was dependent with eating, had a feeding tube, rarely/never made herself understood, sometimes understood others, and had a BIMS score of 7 indicating severe cognitive impairment. Her care plan, edited on 10/06/25, reflected she required a gastrostomy tube for nutrition related to CVA with dysphagia, with interventions including monitoring the PEG/G-tube site, NPO status, and oral hygiene each shift. Resident #36’s record reflected she was a [AGE]-year-old female admitted with diagnoses including dependence on renal dialysis, COPD, and shortness of breath. Her quarterly MDS showed she received oxygen therapy and dialysis, made herself understood, usually understood others, and had a BIMS score of 9 indicating moderate cognitive impairment. Her care plan reflected PRN oxygen therapy for COPD and hemodialysis on Monday, Wednesday, and Friday.
Smoking assessments not completed quarterly for two residents
Penalty
Summary
The facility failed to establish and follow smoking policies for two residents who were identified as smokers. Resident #17, a male with multiple sclerosis, anxiety, muscle weakness, and a BIMS score of 7 indicating moderate cognitive impairment, had a comprehensive care plan identifying him as a smoker and directing staff to inform him and his representative of smoking risks and provide supervision while smoking. His Smoking Screen Assessment was last dated 09/27/24 and identified him as a supervised smoker, but the assessment was not completed quarterly as required. He was observed outside smoking with other residents and staff. Resident #36, a female with COPD, renal failure/ESRD, bipolar disorder, and a BIMS score of 9 indicating moderately impaired cognition, also had a care plan identifying her as a smoker and directing staff to complete a safe smoking screen upon admission and as needed and to inform her and her representative of smoking risks. Her Smoking Screen Assessment was last dated 09/06/25 and identified her as a safe smoker who required a smoking apron, but it was not completed quarterly as required. She was observed outside smoking while wearing a smoking apron. Staff interviews indicated nurses were responsible for completing smoking assessments, but they were not aware of the required timeframe and the assessments were only completed when they appeared on the user-defined assessment screen.
Sanitation Deficiencies in Kitchen Equipment
Penalty
Summary
The facility failed to maintain proper sanitation standards in its kitchen, as observed during a survey. The can opener blade was found to have a black substance and a rusty-like material, which could potentially contaminate food during preparation. Additionally, multiple cooking utensils, including skillets, sheet pans, and muffin pans, were observed to have significant carbon buildup, indicating a lack of proper cleaning. The microwave also had a thick, hard yellow substance and a brownish substance resembling rust on its inside top surface. Interviews with the Dietary Manager revealed an awareness of the issues with the pans and an unsuccessful attempt to clean them using a chemical for carbon removal. The Dietary Manager acknowledged the importance of kitchen sanitation to prevent foodborne illness and admitted that the microwave should be cleaned after each use. The Dietary Manager also recognized that the can opener should be clean and free of rust to prevent contamination of food items. The Director of Nursing (DON) and the Administrator both emphasized the responsibility of the Dietary Manager in ensuring the cleanliness of kitchen equipment and dishware. Record reviews of Quality Assurance Monitors from previous months indicated a consistent lack of cleaning schedules and routine cleaning of kitchen equipment. The facility's policy on kitchen sanitation and cleaning schedules was not being followed, as evidenced by the repeated findings of unclean equipment and surfaces. The FDA Food Code 2022 highlights the importance of maintaining clean and easily sanitized food-contact surfaces to prevent the buildup of pathogenic organisms, which the facility failed to adhere to.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved a Licensed Vocational Nurse (LVN) who did not perform proper hand hygiene during wound care for a resident with a stage 4 pressure ulcer on the sacrum/coccyx area. The LVN did not change gloves or use hand sanitizer after cleaning the wound and before applying medication and a clean dressing, which was acknowledged by the LVN, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON) as a risk for infection. Another deficiency was noted in the laundry room, where staff failed to use appropriate personal protective equipment (PPE) when sorting contaminated linens. The laundry aide and housekeeping supervisor admitted to not using aprons or goggles/shields, which could lead to the spread of germs if contaminated linens came into contact with their personal clothing. The ADON confirmed that staff should prevent their clothing from contacting contaminated linen, especially when residents are on transmission-based precautions. Additionally, the facility did not implement enhanced barrier precautions for a resident with a mid-line catheter and a urinary tract infection. The resident's room lacked signage indicating the need for such precautions, and a Certified Nursing Assistant (CNA) was unaware of the need for PPE or special precautions. The DON mistakenly believed that a mid-line catheter did not require enhanced barrier precautions, contrary to the facility's policy. This oversight was acknowledged by the ADON, who stated that proper precautions are necessary to prevent the spread of germs.
Failure to Maintain Safe Hot Water Temperature
Penalty
Summary
The facility failed to maintain a safe and comfortable hot water temperature for residents, specifically in the case of a resident with severe cognitive impairment. The resident, a female with a BIMS score of 7 indicating severe cognitive impairment, required partial assistance for daily activities such as bathing and dressing. During an observation, the water temperature in the resident's bathroom sink was found to be 125°F, which is significantly higher than the safe range of 100°F to 110°F as per facility policy. Interviews with the Maintenance Supervisor, Director of Nursing (DON), and the Administrator confirmed that it was the Maintenance Supervisor's responsibility to ensure the water temperature was within the safe range. The Maintenance Supervisor acknowledged the risk of scalding at the observed temperature of 122°F. The facility's policy mandates that hot water temperatures should not exceed 110°F to prevent scalding injuries, yet this standard was not met, posing a risk to residents.
Unattended Medications on Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored according to professional standards, specifically for one resident. During an observation, it was noted that a medication aide (MA A) left Resident #30's medications unattended on top of a medication cart. The medications included acetaminophen with codeine and aspirin, which were not secured as required. MA A admitted to leaving the medications unattended due to a personal emergency, mistakenly believing they were locked inside the cart. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator, confirmed that the incident should not have occurred. They acknowledged the risk posed by leaving medications unattended, especially with residents who might wander. The facility's policy on medication storage, which requires controlled substances to be handled with special care, was not followed in this instance, leading to the deficiency.
Resident Elopement Due to Inadequate Supervision and Door Security
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement incident involving a resident with severe cognitive impairment and a history of wandering. The resident, who had a diagnosis of unspecified dementia and a BIMS score indicating severe cognitive impairment, was identified as being at risk for elopement. Despite having a wander guard in place, the resident managed to leave the facility and cross a four-lane highway, eventually being found at a convenience store. This incident occurred on the morning of April 24, 2024, and was reported by the sheriff's department to the facility staff. Interviews with staff members revealed that the resident was last seen in his room before the shift change, and the wander guard was checked and found to be working. However, the facility's exit doors, particularly the one on Hall 300, had a delay in locking, which may have contributed to the resident's ability to leave the premises. The Maintenance Supervisor was unaware of the door delay until after the incident, and the door was repaired on the same day. Staff members acknowledged their responsibility to ensure residents' safety and prevent elopement, but the lapse in door security and supervision allowed the resident to exit the facility unsupervised. The facility's policy on wandering and elopement emphasized the need for adequate supervision and adherence to person-centered care plans to prevent such incidents. Despite these policies, the resident's care plan did not address the immediate transfer to a secure facility following the elopement event. The facility's failure to ensure the resident's safety and prevent elopement was identified as a deficiency, with the potential for serious harm to residents at risk for wandering.
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What surveyors actually found near you
We read the 254 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kaufman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunflower Park Health Care | 1.8 mi | ★★★★★ | 19 | 0 |
| Lakeside Health And Wellness | 11.2 mi | ★★★★★ | 25 | 0 |
| Terrell Healthcare Center | 11.5 mi | — | 43 | 0 |
| Kemp Care Center | 11.5 mi | ★★★★★ | 0 | 0 |
| Windsor Rehabilitation And Healthcare | 12 mi | ★★★★★ | 21 | 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.