Below average — CMS composite of the measures below.
The next survey window likely opens around April 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 Kingsland during CMS and state inspections, most recent first.
Failure to Maintain Required RN Coverage: The facility failed to ensure an RN was on duty for at least 8 consecutive hours a day, 7 days a week on multiple reviewed days. Daily HR reports showed zero RN hours worked on several dates, and both the DON and ADM stated they could not explain why RN coverage was absent, while acknowledging the requirement for daily RN coverage and the administrator's responsibility for staffing.
Unappealing and Poor-Tasting Meals Served to Residents: Residents reported that facility meals were not good, repetitive, and often required backup salads instead of the main meal. An observed lunch tray included carnitas that looked unappealing, appeared boiled, and had little flavor. A cook and the ADM both stated the food did not look good, and the ADM said there was no policy for food palatability.
Food service staff failed to follow basic kitchen sanitation and food safety practices. An observation found multiple unlabeled or undated food items in a refrigerator, food debris on kitchen surfaces and utensils, staff passing breakfast trays without sanitizing hands between residents, and a CK rinsing a thermometer with water and using the same gloves and thermometer across multiple food temperature checks. The DM, DON, and ADM stated staff were responsible for labeling and dating food, cleaning the kitchen, and sanitizing hands between residents, and the facility policy required refrigerated foods to be labeled and dated, food prep items sanitized, and the kitchen cleaned regularly.
The facility failed to ensure two residents were informed and involved in psychotropic medication treatment. One resident received multiple psychoactive meds, including an antipsychotic, antianxiety, antidepressant, anticonvulsant, and dementia medication, but the chart lacked current active consents and did not show matching anxiety or depression diagnoses. Another resident had orders for Trazodone for insomnia and Quetiapine for depression without corresponding diagnoses, and the MD stated the Quetiapine order was entered incorrectly.
Failure to Knock Before Entering a Resident’s Room: A HK entered a resident’s room with laundry without knocking, despite the resident stating it bothered her when staff did not knock. The resident had moderate cognitive impairment and diagnoses including respiratory failure, DM2, psychotic disturbance, and mood disturbance. RN G, the DON, and the ADM stated staff were expected to knock or announce themselves, and the facility’s Resident Rights policy required residents be treated with respect, kindness, and dignity.
Two residents had psychotropic and related medications ordered and administered without the required documentation. One resident with severe dementia was receiving quetiapine, buspirone, paroxetine, Depakote ER, and donepezil, but the chart lacked current active consent for several of the drugs, had no consent for donepezil, and did not show active anxiety, depression, or psychotic disorder diagnoses to match the regimen. Another resident admitted after a hip fracture had trazodone for insomnia and quetiapine for depression despite no documented insomnia or depression diagnosis. The DON, ADM, NP, and MD all acknowledged gaps in consent and order accuracy.
The facility failed to prevent physical abuse when a resident with dementia and moderately impaired cognition, whose care plan did not address potential aggressive behavior despite increased confusion and paranoia, struck another resident with a cane multiple times to the head and arm. The assaulted resident, who had Alzheimer's disease and muscle wasting, sustained superficial scalp scratches, reported head and arm pain, and guarded the affected arm. Staff heard yelling, witnessed the assault, and intervened, but the incident demonstrated a failure to ensure residents were free from abuse as required by the facility's abuse prevention policy.
A resident with multiple complex conditions and moderate cognitive impairment, care planned as a moderate fall risk, experienced a fall near the nurses’ station during the night shift. An LVN completed an incident report documenting assessment and treatment, but the section for notifications showed none, and progress notes contained no evidence that the resident’s family or representative was informed. The family later reported they only learned of the fall during a subsequent visit, demonstrating a failure to notify the resident’s representative of a change in condition as required by facility policy and resident rights.
A resident with Type 1 DM, multiple neurologic and medical comorbidities, and moderate cognitive impairment had an admission MDS documenting DM and regular insulin injections, along with active orders for Lantus and Humalog. However, the comprehensive care plan only addressed ADL self-care deficits and fall risk related to confusion and did not include the resident's DM, insulin use, or blood glucose monitoring. After the resident sustained a fall and was diagnosed in the ER with a right-sided zygomaticomaxillary complex fracture, the condition was documented in a progress note but never added to the care plan. Interviews with the MDS nurse and Regional Nurse confirmed that the comprehensive care plan was not fully developed or updated as required by facility policy and MDS triggers.
A resident with multiple complex conditions and dysphagia was admitted with a hospital Speech-Language Pathology recommendation for a pureed diet with thin liquids, but nursing communicated a regular-texture, NCS diet with thin liquids to dietary. Dietary staff, who rely on nursing dietary slips and do not routinely review clinical records, provided regular-texture meals for several days until a later slip changed the order to pureed texture. The admitting LVN could not recall the initial diet details, and leadership confirmed the nurse was responsible for transmitting the correct diet from the hospital documentation, with staff acknowledging that receiving regular instead of pureed texture food placed the resident at risk for aspiration, choking, and weight loss.
A resident with multiple complex conditions and moderate cognitive impairment was admitted with physician orders for PT, OT, and ST to evaluate and treat as indicated, and the care plan identified ADL self-care deficits, fall risk, and an intervention for PT to evaluate and treat after any fall. Despite these orders and facility policies requiring therapy screening on all new admissions and PT evaluation after falls, the therapy department did not evaluate the resident at admission and did not complete a PT evaluation after a documented fall and a nursing therapy screen request. The DOR reported she did not perform the admission screening due to perceived lack of payer authorization and did not see the post-fall referral in the electronic system, while the BOM, Administrator, and Regional Nurse stated that all new admissions and post-fall events should be screened by therapy regardless of payer source.
A resident with fragile skin and multiple comorbidities experienced significant bleeding from skin tears that occurred during care. CNAs reported the bleeding to an LVN, who did not assess or intervene, citing being busy with medication administration. The resident continued to bleed until an RN on the next shift discovered the situation and provided necessary wound care. There was no handover or report to the oncoming staff about the resident's condition.
A resident with fragile skin and multiple comorbidities experienced significant bleeding from skin tears that occurred during care. CNAs reported the bleeding to an LVN, who did not assess or intervene before leaving her shift. The resident continued to bleed until an RN on the next shift was notified and provided care. There was no handover or report to the oncoming staff, resulting in a delay in intervention and physician notification.
Two medication carts containing prescription drugs, over-the-counter medications, and prescription creams were found unlocked and unattended near the nurses' station. Nursing and administrative staff confirmed that facility policy requires medication carts to be locked when not in use, and acknowledged the carts should have been secured. Despite staff training and monitoring practices, the carts were left accessible to unauthorized individuals, in violation of the facility's medication storage policy.
A resident with fragile skin, cognitive impairment, and a history of skin tears developed new skin tears with significant bleeding on a lower leg while two CNAs were providing care. The CNAs immediately reported the ongoing bleeding to an LVN, who stated she was busy passing medications and would assess the resident later, and the CNAs applied a towel to the leg before the end of their shift. The LVN did not return to assess or treat the bleeding and did not communicate the situation in shift report, and later called a CNA at home stating she had forgotten to address the wound. At the start of the next shift, an RN was alerted by a CNA and found the resident with heavy bleeding from multiple skin tears, blood-soaked linens, and saturated bandages, and then provided wound care and monitoring. The facility’s own policy requires competent nursing care, including timely response to changes in condition and proper communication, but the LVN’s failure to promptly assess and intervene for active bleeding led to this deficiency.
A resident with dementia, fragile skin, and bilateral leg edema experienced multiple new skin tears with profuse, ongoing bleeding during morning care. CNAs reported the bleeding to an LVN, who stated she was busy with medication administration and did not promptly assess or treat the resident before the end of the night shift, and no handoff about the bleeding was given to the oncoming staff. At the start of the next shift, a CNA and RN found the resident bleeding heavily with blood‑soaked linens and multiple saturated dressings, and the RN had to change several bandages to contain the bleeding. The facility did not immediately consult the resident’s physician regarding this significant change in condition, resulting in a cited deficiency related to failure to promptly respond to and report a substantial change in status.
Surveyors found a medication cart and a treatment cart unlocked and unattended near the nurses’ station, with prescription drugs, OTC medications, narcotics, and prescription creams accessible. An LVN admitted he left a cart unlocked when going to the medication room, and a treatment nurse confirmed carts are supposed to be locked whenever staff are away but could not explain why the treatment cart was left open. The DON and ADM both stated that only authorized staff should access carts and that carts must be locked when not in use, yet neither could explain why these carts were unlocked, in violation of the facility’s written medication labeling and storage policy.
A nurse failed to sanitize a blood pressure cuff and medication cart surface between uses on four residents with various medical conditions, despite facility policy and staff knowledge requiring disinfection of reusable equipment between residents to prevent cross-contamination.
Surveyors identified a medication error rate of 9.38% after observing an LVN crush an extended-release antidepressant against orders and manufacturer guidelines for a resident with cognitive impairment, omit a prescribed anti-anxiety tablet, and provide an incorrect dose of a fluid pill to another resident. Staff interviews confirmed that medications were not administered as ordered, contributing to the elevated error rate.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week on 10 of 15 days reviewed for RN coverage. Review of the daily HR total employee hours reports provided by the ADM showed zero RN hours worked on 10/05/25, 10/15/25, 10/18/25, 10/19/25, 10/23/25, 11/01/25, 11/06/25, 11/16/25, 12/27/25, and 12/28/25. The report stated the facility failed to ensure RN coverage on those dates and that this could place residents at risk of missed nursing assessments, interventions, care, and treatment. During interview, the DON stated she was not the DON during the dates with no RN coverage and could not explain why there was no RN coverage because she started in February 2026. She stated the facility was required to have 8 consecutive hours every day, 7 days a week of RN coverage and that being without an RN was unacceptable. During interview, the ADM stated he did not know why there were no RN hours on the listed dates because he started as administrator in March 2026, but acknowledged the expectation of at least 8 RN hours daily and stated it was ultimately the administrator's responsibility to ensure staffing coverage. He also stated he could not find documentation showing an RN was in the facility for the required 8 hours and that there was no facility policy specific to RN hours, only state and federal guidelines.
Unappealing and Poor-Tasting Meals Served to Residents
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for residents. During interviews, Resident #7 said the food was not good and that she rarely ate it, stating she often had to get the backup meal, mainly salads, and had reported the food as a problem. Resident #13 also said the food was not good and that he rarely ate it, stating he would have to get the backup meal, mainly salads. Resident #28 said he liked living in the facility but reported that he got the same food over and over, that there were times when the food was unappealing, and that it often did not taste good. During observation of a lunch tray, the meal consisted of black beans, corn, carnitas, and a tortilla. The carnitas did not look appealing and appeared to have been boiled, and it had little flavor and tasted like it was boiled. A cook stated that the food shown did not look appealing and that residents could have lost weight if they did not eat it. The ADM also stated that the food did not look good and that he would not eat it unless someone made him. He further stated that they were in the process of getting a different food provider and that there was no policy for food palatability.
Food Storage, Hand Hygiene, and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen reviewed. During an observation of Refrigerator #1, juice in a single-serve cup was not labeled with a name or date on the tray, jello in a clear container was dated 5-25 with no use-by date, ketchup had an open date of 4-20 with no use-by date, cheese in a zip lock bag had no open date or use-by date, pudding in a single-serve container was not dated, and single-serve sugar, mayo, tartar, and tater sauce were in a bin without dates or labels. In the kitchen, the storage shelf that held food trays had food debris on it, an onion in a clear container dated 5-20-2026 had no use-by date, a bin with serving utensils had food debris in the bottom, and a tray of coffee mugs had food debris on it. During breakfast tray distribution in the secured 400 hall dining room, CNA B and RN G passed out trays without sanitizing their hands between residents. During a later observation, CK A rinsed the thermometer with water, wiped it with her glove, and used the same thermometer and gloves to take temperatures of multiple foods, with the thermometer inserted into the food and the top portion that was not cleaned left in contact with the food. In interview, CK A stated she was supposed to change gloves when starting another task and returning to temperature checks, and that each food temperature should be taken with a thermometer cleaned with an alcohol pad between items. She stated she was not supposed to use water to clean the thermometer and that her gloves should not have contacted food after other kitchen tasks. The DM, DON, and ADM stated that staff were responsible for labeling and dating food, cleaning the kitchen, and sanitizing hands between residents when passing trays. The facility's Food and Storage policy stated refrigerated foods are to be labeled, dated, and monitored for use-by dates, food preparation items should be sanitized before use, and the kitchen should be cleaned regularly.
Failure to Obtain Current Medication Consents and Match Diagnoses for Psychotropic Orders
Penalty
Summary
The facility failed to ensure that two residents were fully informed and able to participate in their treatment related to psychoactive medications, including obtaining current active consents and matching diagnoses for the medications ordered. For one resident, the record showed active orders for Quetiapine Fumarate, Buspirone, Depakote ER, Paroxetine, and Donepezil, with medication administration continuing from November 2025 through May 2026. The chart contained only limited or expired consents for some of these medications, and there was no consent at all for Donepezil. The resident’s MDS reflected severe cognitive impairment and active use of an antipsychotic, antianxiety, antidepressant, and anticonvulsant, but psychiatric or mood disorders such as anxiety and depression were not listed as active diagnoses. The same resident’s care plan did not include a focus for the use of antipsychotic, antidepressant, or antianxiety medications. During interview, the DON stated she could not find the needed consents in the chart or consent binder and did not know why the existing Seroquel consent stated the resident did not have the psychiatric condition required for the medication while the medication continued to be given. The ADM stated he expected consents to be on file so the family or RP would be aware of what was being used and could ask questions or refuse the medication. The NP stated psychotropic medications required consents and that if a consent was only obtained for a limited period, it should have been revisited if the medication was still needed. For the second resident, the physician orders included Trazodone for insomnia and Quetiapine Fumarate for depression, but the resident’s diagnoses did not include insomnia or depression. The MD stated he would not treat depression with Seroquel and said that if the Quetiapine order stated it was for depression, then the order was entered incorrectly. He also stated he may have missed the error when reviewing the verbal orders before signing them. The facility’s Resident Rights policy stated residents have the right to be free from chemical restraints not required to treat symptoms and to be informed of and participate in care planning and treatment.
Failure to Knock Before Entering Resident Room
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the housekeeping staff member entered Resident #50’s room without knocking. Resident #50 was a [AGE]-year-old female admitted to the facility with diagnoses including acute and chronic respiratory failure, type 2 diabetes, psychotic disturbance, and mood disturbance. Her admission MDS assessment dated 03/18/2026 showed a BIMS score of 11, indicating moderate cognitive impairment. The resident’s care plan dated 05/21/2026 did not include anything about her not wanting staff to knock before entering her room. During an observation and interview on 06/26/26 at 8:36 AM, the HK entered Resident #50’s room with laundry without knocking on the door. Resident #50 stated that staff usually knock, but sometimes they do not, and said it bothered her when staff failed to knock. RN G stated that staff were expected to knock on residents’ doors or announce their arrival and identified this as a resident rights issue. The DON and ADM both stated that all staff should knock before entering residents’ rooms and that staff were trained to do so. The facility’s Resident Rights policy stated that residents are to be treated with respect, kindness, and dignity.
Psychotropic Medications Lacked Current Consent and Supporting Diagnoses
Penalty
Summary
The facility failed to ensure that two residents’ drug regimens were free from unnecessary drugs and that psychotropic medications were supported by current consent and corresponding diagnoses. For one resident with severe dementia and severe cognitive impairment, the record showed active orders for quetiapine fumarate for agitation/anxiety, buspirone for anxiety, paroxetine for depression, Depakote ER for dementia-related symptoms, and donepezil for dementia. The chart review also showed that psychiatric or mood disorder diagnoses such as anxiety, depression, and psychotic disorders were not listed as active diagnoses on the MDS, and the care plan did not include a focus for the use of antipsychotic, antidepressant, or antianxiety medications. For that resident, the facility had only limited and expired consents on file. The consent for quetiapine was signed by the NP without resident or family signatures and stated the resident did not have the psychiatric condition required for the medication; there were no other valid consents for the continued 25 mg or increased 50 mg quetiapine orders. The buspirone, paroxetine, and Depakote consents were each time-limited and had expired while the medications continued to be administered, and there was no consent at all for donepezil. The DON stated she could not find the needed consents in the chart or consent binder, and the ADM stated he expected consents to be on file. The NP stated psychotropic medications required consent and that if a consent was only obtained for a limited period, it should have been revisited if the medication was still needed. A second resident admitted for rehab after a left hip fracture had physician orders for trazodone at bedtime for insomnia and quetiapine at bedtime for depression, but the record did not list diagnoses of insomnia or depression. The physician stated he used psych medications for dementia behaviors, agreed that medications such as Seroquel, trazodone, and Depakote needed consent, and stated he would never treat depression with Seroquel. He also stated that if quetiapine was ordered for depression, the order was entered incorrectly and that he may have missed the error when reviewing the verbal order in the chart. The facility policy cited in the record stated residents have the right to be free from chemical restraints not required to treat symptoms and to be informed of and participate in care planning and treatment.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident struck another with a cane, causing injury. Resident #1, a male with non-Alzheimer's dementia, alcoholic liver disease, chronic pain, cataracts, and constipation, had a BIMS score of 9 indicating moderately impaired cognition. His care plan, dated 10/14/25, addressed moderately impaired decision-making related to dementia but did not include any interventions for potential aggressive or combative behaviors. Prior to the incident, Resident #1 had exhibited increased confusion and paranoia, and the charge nurse had notified the physician and initiated lab tests and referrals, but the behavior escalated before further interventions were implemented. On 04/20/26 at 10:45 PM, staff heard yelling and observed Resident #1 striking Resident #2 with a cane two times to the head and two times to the arm while threatening to kill him. Resident #2, a male with Alzheimer's disease, muscle wasting, and impaired memory, sustained two superficial scratches to the posterior scalp, reported pain to his head and arm, and exhibited guarding of the right upper extremity. Resident #2 later confirmed he had been struck in the head with a cane by another resident. The facility's abuse prevention policy states that residents have the right to be free from abuse, including physical abuse, but the lack of care plan interventions addressing Resident #1's potential for aggressive behavior and the subsequent assault on Resident #2 constituted the identified deficiency.
Failure to Notify Resident Representative After Fall Event
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition following a fall. A male resident with multiple complex diagnoses, including Type 1 DM with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension, was admitted with moderate cognitive impairment as evidenced by a BIMS score of 09. His care plan, initiated 12/31/2025, identified an ADL self-care performance deficit related to confusion and a moderate risk for falls related to confusion. An incident report dated 01/17/2026 at 9:00 p.m., completed by LVN A, documented that the resident was found on the floor near the nurses’ station after he slipped. The report noted that vital signs, neuro checks, and blood sugar were obtained, glucose was given, and his post-treatment blood glucose was 118, and that he was ambulatory without assistance. The incident report section for agencies/people notified reflected “No Notifications found,” and review of the resident’s progress notes for 01/17/2026 showed no evidence that the resident’s family was notified of the fall. The resident’s face sheet listed a responsible party, and facility policy stated that residents have the right to be notified of their medical condition and any changes in condition, and to be informed of and participate in care planning and treatment, including through a legal representative appointed in accordance with state law. During an interview on 01/27/2026 at 10:40 a.m., the resident’s family reported they were not notified of the fall and only learned of it the following day when visiting. This sequence of events formed the basis for the cited deficiency related to failure to inform the resident’s representative of a change in condition.
Failure to Care Plan Diabetes and Post-Fall Facial Fracture
Penalty
Summary
Surveyors identified a failure to develop and implement a person-centered comprehensive care plan that addressed all of a resident's medical, physical, mental, and psychosocial needs. The resident was an adult male admitted with multiple diagnoses, including Type 1 DM with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension. The admission MDS documented a BIMS score of 09 (moderate cognitive impairment) and an active diagnosis of DM, with Section N indicating the resident received insulin injections five days a week. Despite this, the care plan initiated on 12/31/2025 only addressed an ADL self-care performance deficit related to confusion and a moderate risk for falls related to confusion, and did not include the resident's Type 1 DM or insulin use. Record review showed active physician orders for Lantus (insulin glargine) 15 units subcutaneously once daily starting 12/28/2025 and Humalog (insulin lispro) per sliding scale before meals starting 12/29/2025 for DM management. These active insulin orders and the documented DM diagnosis were not reflected in the resident's care plan, meaning there were no care-planned interventions for blood glucose monitoring or insulin administration. The facility's own policy required that the comprehensive, person-centered care plan include measurable objectives and timeframes and describe services to meet the resident's physical, psychosocial, and functional needs, derived from the comprehensive assessment and completed no more than 21 days after admission. In addition, the facility failed to update the care plan after the resident experienced a fall on 01/10/2026, was sent to the ER, and was diagnosed via CT maxillofacial imaging with a right-sided zygomaticomaxillary complex fracture. A progress note documented the resident's return from the ER with a diagnosis of facial fractures and no new orders, with a plan to continue monitoring, but this new condition was never added to the care plan. Interviews with the MDS nurse and Regional Nurse confirmed that the resident's comprehensive care plan was incomplete, that the DM diagnosis and facial fracture should have been care planned, and that the comprehensive care plan should have been developed and updated in accordance with facility policy and MDS triggers, but this did not occur.
Failure to Follow Hospital Dysphagia Diet Recommendation for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a prescribed therapeutic diet for one resident with significant medical conditions and dysphagia. The resident, an older male admitted from the hospital with diagnoses including Type 1 diabetes with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension, had a hospital Speech-Language Pathology recommendation for a diet of thin liquids and pureed consistency. The admission MDS showed a BIMS score of 09, indicating moderate cognitive impairment, and the care plan later reflected ADL self-care deficits and moderate fall risk related to confusion. The facility’s policy required therapeutic diets to be prescribed by the attending physician or delegated dietitian and that diet orders match food and nutrition services terminology, including altered consistency diets. On admission, the communication of the resident’s diet from nursing to dietary was incorrect. A dietary communication slip dated 12/27/2025, completed by LVN B, indicated a regular/liberalized, no concentrated sweets (NCS), regular texture diet with thin liquids, rather than the pureed texture recommended by the hospital. The Dietary Manager stated that for new admissions, dietary relies on the dietary communication slip from nursing and does not review the clinical record directly. Based on this initial slip, the resident received regular texture food from 12/27/2025 through 12/31/2025. During this period, the physician order dated 12/31/2025 later reflected a regular diet with pureed texture and regular liquid consistency, and the care plan initiated 01/05/2026 documented an NCS diet with pureed texture and thin liquids. Interviews confirmed that the admitting nurse and dietary staff depended on the information transmitted via the dietary communication slip rather than verifying the hospital discharge recommendations. LVN C, identified as the admitting nurse, stated she would have looked at the discharge papers to determine the diet but could not recall the resident’s admitting diet or whether she received a nurse-to-nurse report. The Dietary Manager confirmed that the resident’s meals were prepared as regular texture until a subsequent dietary communication slip dated 12/31/2025 changed the diet to pureed texture with thin liquids. The Regional Nurse stated that the admitting nurse was responsible for sending the correct diet order to dietary based on the hospital clinical information and should have called the hospital for clarification if unsure. Staff interviews noted that providing regular texture food instead of pureed for a resident requiring pureed texture created a risk for aspiration, choking, and weight loss.
Failure to Provide Ordered Therapy Evaluation at Admission and Post-Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that specialized rehabilitative services were provided by qualified personnel as ordered by a physician and as outlined in the resident’s care plan. A male resident with multiple complex diagnoses, including Type 1 diabetes with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension was admitted with a physician order for PT, OT, and ST to evaluate and treat as indicated. The admission MDS showed moderate cognitive impairment with a BIMS score of 9 and documented that the resident required setup or clean-up assistance for some functional activities. Despite the standing physician order for therapy evaluation and treatment, the therapy department did not screen or evaluate the resident upon admission. The resident’s care plan, initiated on the date of admission, identified an ADL self-care performance deficit related to confusion and a moderate risk for falls, and it documented a fall on a later date with an intervention specifying that PT was to evaluate and treat as needed after a fall. The resident experienced a fall next to the kitchen door, and nursing completed a Nursing to Therapy Screen Request in the electronic record, indicating a post-fall reason and requesting PT due to recent physical function changes. However, the Director of Rehabilitation (DOR) did not act on this request and did not perform a screening or evaluation following the fall, despite the care plan intervention and the facility’s process that a fall triggers a therapy evaluation request. Interviews revealed that the DOR chose not to screen or evaluate the resident upon admission because she believed there was no payer authorization from the hospital and stated that the therapy department usually did not treat residents without funding unless directed by the Administrator. The Business Office Manager (BOM) stated that all new admissions were to be screened or evaluated by therapy unless admitted only for nursing services and that treatment decisions were based on payer source, but also indicated that this resident was to be handled through an administrative authorization process. The Administrator and Regional Nurse both stated that all new admissions should be screened by therapy regardless of payment source and that PT should evaluate after every fall per facility standard, with payer source not preventing evaluation. The DOR later acknowledged that there was a communication in the electronic medical record regarding the resident’s fall that she did not see because she had not been checking the dashboard daily. Facility policies on fall risk assessment, falls clinical protocol, and resident screening guidelines required interdisciplinary assessment of fall risk factors and therapy screening on all new admissions and upon referral, but these processes were not followed for this resident at admission or after the fall. The facility’s fall risk assessment policy required nursing staff, the attending physician, therapy staff, and others to identify and document resident risk factors for falls and to establish a resident-centered fall prevention plan based on assessment data, including evaluation of ambulation, mobility, gait, balance, ADL capabilities, and cognition. The falls clinical protocol required assessment and recognition of fall risk, documentation of recent falls, and evaluation of musculoskeletal function and neurological status after a fall, with staff attempting to define possible causes within 24 hours. The resident screening guidelines policy required that screenings be completed by licensed therapy staff on all new admissions or upon referral to help identify functional loss and the need for rehabilitation services. Despite these written policies, the resident did not receive the ordered therapy evaluation at admission, and the post-fall therapy evaluation and treatment intervention in the care plan was not implemented after the documented fall and therapy referral. The Administrator stated that the therapy department should have assessed the resident when there was a request in the electronic system and that payer source was not a factor in determining the need for assessment. The Regional Nurse stated that once there is a fall, it triggers a form to be sent to therapy to evaluate the resident and that therapy should screen every resident, with further treatment decisions made after evaluation. The DOR stated she was new to the position, was still learning the process, and had only become aware of the nursing communication regarding the fall after the surveyor’s inquiry. These interviews and record reviews collectively showed that the facility failed to ensure that therapy services evaluated and treated a function impaired by illness or injury and failed to increase the resident’s functioning as ordered, by not conducting the required therapy evaluations at admission and after the fall, contrary to physician orders, the resident’s care plan, and facility policies.
Failure to Timely Assess and Intervene for Resident Bleeding from Skin Tears
Penalty
Summary
A licensed vocational nurse (LVN) failed to assess and perform necessary interventions to stop a resident from bleeding due to skin tears. The resident, an elderly female with Alzheimer's disease, muscle weakness, chronic pain, hypertension, and a history of impaired skin integrity, developed new skin tears on her lower leg that resulted in significant bleeding. The resident was known to have very fragile skin, exacerbated by long-term prednisone use and bilateral leg edema, making her prone to skin injuries. On the morning of the incident, certified nursing assistants (CNAs) discovered the resident bleeding from newly developed skin tears while providing care. The CNAs reported the bleeding to the LVN, who was administering medications at the time. The LVN stated she was busy and would attend to the resident after completing her medication pass. The CNAs attempted to control the bleeding by wrapping a towel around the wound, but the LVN did not assess or intervene before the end of her shift. The LVN later contacted one of the CNAs at home to inquire about the severity of the wound, admitting she had forgotten to address the bleeding. The resident continued to bleed until the next shift, when a registered nurse (RN) was notified and promptly intervened to control the bleeding. The RN found the resident with multiple skin tears and significant blood loss, requiring several bandage changes to contain the bleeding. There was no handover or report given to the oncoming staff regarding the resident's condition, and the incident was only discovered during a routine check at the start of the day shift.
Failure to Immediately Notify Physician and Intervene for Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to immediately consult with a resident's physician following a significant change in the resident's condition, specifically when the resident experienced bleeding from multiple skin tears. The resident, an elderly female with a history of Alzheimer's disease, muscle weakness, chronic pain, hypertension, and impaired skin integrity, was known to have very fragile skin due to long-term prednisone use and bilateral leg edema. On the morning of the incident, certified nursing assistants (CNAs) discovered the resident bleeding from newly developed skin tears on her leg while providing care. The CNAs reported the bleeding to the assigned LVN, who was administering medications at the time and stated she would assess the resident after completing her medication pass. However, the LVN did not assess or intervene for the resident's bleeding before leaving her shift. The CNAs attempted to control the bleeding by wrapping a towel around the wound and expected the LVN to follow up. The LVN later contacted one of the CNAs at home to inquire about the severity of the wound, admitting she had forgotten to address the bleeding due to being busy with other tasks. The resident continued to bleed until the next shift, when an RN was notified by another CNA and immediately intervened to control the bleeding, noting that the resident had lost a significant amount of blood and required multiple bandage changes. There was no handover or report given to the oncoming staff regarding the resident's condition, resulting in a delay in care. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, confirmed that the LVN did not assess or provide timely intervention for the resident's bleeding, and that the resident was left unattended and bleeding for approximately two hours. The facility's policies required staff to identify, document, and report changes in resident condition, and to provide detailed shift-to-shift handovers, but these procedures were not followed in this instance. The deficiency was identified through observation, interviews, and record review, which documented the sequence of events and the lack of immediate physician notification and timely nursing intervention.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that two of three medication carts (MC #1 and TC #2) were left unlocked and unattended near the nurses' station. MC #1 contained residents' prescription drugs, over-the-counter medications, and narcotics secured in a locked box within the cart, while TC #2 contained residents' prescription creams. At the time of observation, no nurses or staff were present in the vicinity of either cart. Interviews with nursing staff, the DON, and the administrator confirmed that facility policy requires medication carts to be locked at all times when not in use and that only authorized personnel should have access. Staff acknowledged awareness of the policy and admitted the carts should have been locked when unattended. The facility's Medication Labeling and Storage Policy, reviewed by surveyors, states that all medications and biologicals must be stored in locked compartments and only authorized personnel may access them. Despite this, both nursing and administrative staff could not provide an explanation for why the carts were left unlocked. The staff described monitoring practices that rely on observation by nurses, administrative staff, and peer-to-peer checks, but these measures failed to prevent the carts from being left unsecured and accessible to unauthorized individuals.
Failure to Timely Assess and Treat Active Bleeding from Skin Tears
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice when active bleeding from skin tears was not promptly assessed or treated by a nurse. The resident was an elderly female with diagnoses including Alzheimer’s disease, muscle weakness, chronic pain, hypertension, shortness of breath, and gait and mobility abnormalities. Her care plan identified her as having potential for impaired skin integrity and being at risk of bleeding, with interventions including evaluation of skin for integrity and impaired coagulation. She had a documented skin tear on the right distal lower leg with physician’s orders for daily and PRN wound care, and wound assessments showed improvement over time. On the early morning in question, two CNAs were changing the resident and attempting to separate her contracted, crossed legs when a skin tear occurred on her right lower leg, causing significant bleeding. One CNA reported that the resident’s skin was very sensitive and prone to tearing, and that the bleeding from the new skin tears did not stop. The CNA immediately reported the bleeding to LVN A, who was in the same hall administering medications. According to the CNA, LVN A stated she was busy with medication administration and would assess the resident after finishing her medication pass. The CNAs wrapped a towel around the resident’s leg to apply pressure and minimize further damage, but the bleeding continued. The CNA then completed her shift and left, believing that LVN A would address the bleeding. Later that morning, the oncoming RN was informed by another CNA that the resident was bleeding in bed. When the RN entered the room, she observed heavy bleeding from three skin tears on the resident’s right lower leg, with bed sheets visibly wet with blood and multiple bandages saturated with blood before the bleeding was contained. The RN reported that neither she nor the CNA had received any handoff report from the previous shift about the resident’s bleeding. The resident’s representative stated that CNAs had initially noticed the bleeding and reported it to LVN A, but that LVN A did not perform any interventions and left the facility without assessing the resident, leaving the bleeding to be addressed by the next-shift nurse. The DON and the administrator both acknowledged that LVN A did not assess the resident or perform timely interventions to stop the bleeding, and the DON stated that loss of excessive blood is a threat to the resident’s life. The facility’s policy on sufficient and competent nursing staff requires that all nursing staff demonstrate competency in skin and wound care and in identifying, documenting, and reporting resident changes of condition consistent with their scope of practice. The policy also emphasizes that staff must have the skills and techniques necessary to care for resident needs, including basic nursing skills and communication. In this incident, the report describes that LVN A did not promptly triage and prioritize the resident’s active bleeding after it was reported by the CNA, did not provide a handoff regarding the bleeding to the oncoming nurse, and later contacted the CNA at home asking about the severity of the wound, stating she had forgotten to take care of the bleeding. These actions and inactions led to the resident remaining in bed with ongoing, heavy bleeding from multiple skin tears until discovered and treated by the day-shift RN. The resident’s representative reported that the resident had been on long-term prednisone, resulting in very fragile skin and bilateral leg edema, and that her skin was prone to tearing easily. The representative stated that CNAs had thrown a towel on the wound to stop the bleeding and reported it to LVN A, but that LVN A did not intervene before leaving. The representative later met with the administrator, expressing concern about LVN A’s competency and describing that LVN A did nothing to stop the resident from bleeding. The report documents that the resident’s condition was stable at the time of survey, with the wound covered by a dressing and the resident appearing calm and without distress, but the deficiency centers on the earlier failure of LVN A to assess and intervene when the resident was actively bleeding from new skin tears. The investigation also notes that staff had attended in-services on abuse and neglect, reporting concerns, and the importance of shift-to-shift handoff, and that the facility had a policy requiring sufficient and competent nursing staff. Despite this, the events described show that the resident’s change in condition—new skin tears with ongoing bleeding—was not promptly addressed by LVN A, and that there was no communication of this issue to the oncoming nurse. This resulted in the resident being found later with copious blood loss and heavily saturated dressings and linens before appropriate wound care and monitoring were initiated by the day-shift RN.
Failure to Timely Assess and Respond to Significant Bleeding from Skin Tears
Penalty
Summary
The deficiency involves the facility’s failure to immediately assess and appropriately respond to a significant change in a resident’s condition when new skin tears with active bleeding occurred, and the failure to promptly notify the resident’s physician of this significant change. The resident was an elderly female with diagnoses including shortness of breath, Alzheimer’s disease, muscle weakness, chronic pain, hypertension, and gait abnormalities. Her MDS indicated she rarely or never understood interview questions, and her care plan identified her as having potential for impaired skin integrity and being at risk of bleeding, with interventions to evaluate skin for integrity and impaired coagulation. She had very fragile skin, reportedly related to long-term prednisone use, and bilateral leg edema, making her prone to skin tears with even mild pressure. On the early morning in question, two CNAs were changing the resident and separating her contracted, crossed legs when a skin tear occurred on her right lower leg, causing profuse, non‑stopping bleeding from multiple skin tears. One CNA immediately reported the bleeding to the LVN assigned to the same hall, who was administering medications at the time. According to the CNA, the LVN stated she was busy with medication administration and would assess the resident after finishing her medication pass. The CNAs wrapped a towel around the resident’s leg to apply pressure and minimize further damage, but the LVN did not come to assess the resident before the night CNA’s shift ended. The night CNA left at the end of her shift believing the LVN would address the bleeding, and later reported receiving a call around midday from the LVN asking how severe the wound was and stating she had forgotten to take care of the resident’s bleeding. At the start of the day shift, another CNA discovered the resident bleeding profusely in bed and reported this to the day‑shift RN. The RN found the resident with heavy bleeding from three skin tears on the right lower leg, with bed linens visibly wet with blood and multiple saturated bandages that required changing before the bleeding was contained. The RN reported that neither she nor the CNA had received any handoff from the previous shift about the resident’s bleeding, and that the resident had lost a copious amount of blood before the RN intervened. The resident’s responsible party later reported that the LVN had not intervened when notified of the bleeding and had left the facility without even looking at the resident, and the administrator and DON both acknowledged that the LVN did not assess or intervene in a timely manner. The report states that the facility failed to immediately consult with the resident’s physician when there was this significant change in condition involving substantial bleeding from new skin tears.
Unlocked Medication and Treatment Carts Left Unattended
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices when two of three medication/treatment carts reviewed (Medication Cart #1 and Treatment Cart #2) were found unlocked and unattended near the nurses’ station. On the morning of 11/10/2025, Medication Cart #1, which contained residents’ prescription drugs, over-the-counter medications, and narcotics secured in a locked box within the cart, was observed unlocked with no nurses present. Shortly thereafter, Treatment Cart #2 was also observed unlocked, with residents’ prescription creams in the top drawer and no staff in sight. The facility’s written Medication Labeling and Storage Policy dated 2/2023 requires that all compartments containing medications and biologicals, including carts, be locked when not in use and that transport carts not be left unattended if open or otherwise available to others. In interviews, an LVN stated he had been trained that medication carts must always be locked when not in use and acknowledged he had gone into the medication room without locking the cart, stating he should have locked it when he walked away. A treatment nurse confirmed she had been trained that carts must be locked any time staff are away and that nurses and other staff walking by are responsible for ensuring carts are locked; she did not know why the treatment cart was unlocked or who had used it last. The DON reported that only nurses and medication aides should have access to the carts and that carts must be locked if not within the nurse’s eyesight, but she did not know why the medication and treatment carts were unlocked. The administrator stated he knew from experience that carts must be locked when not actively in use and that administrative staff and peers monitor carts by observation, but he also could not explain why the carts were found unlocked. The report notes that this failure could place residents at risk of unauthorized access to medications, decreased effectiveness of medication, or missing medications.
Failure to Sanitize Equipment and Work Surfaces Between Residents
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a licensed vocational nurse (LVN) during medication administration to four residents. The LVN used a blood pressure cuff on multiple residents without sanitizing it between uses. Specifically, the blood pressure cuff was used sequentially on residents with various diagnoses, including vascular dementia, Alzheimer's disease, chronic pain, diabetes, respiratory failure, colon cancer, and open wounds, and was placed back on the medication cart without cleaning after each use. The medication cart surface was also not sanitized between residents, despite the LVN's hands coming into contact with both the cart and the blood pressure cuff during medication preparation and administration. Observations confirmed that the LVN performed hand hygiene after each medication pass but did not clean the blood pressure cuff or the medication cart surface between residents. This practice was observed repeatedly during the medication pass for all four residents. Interviews with the LVN, certified nursing assistant (CNA), another LVN, the Director of Nursing (DON), and the Administrator confirmed that facility policy required sanitizing reusable equipment and work surfaces between residents to prevent cross-contamination and the spread of infection. All staff interviewed acknowledged the importance of this practice and the potential for negative outcomes if not followed. A review of the facility's infection control policy indicated that reusable items, such as blood pressure cuffs, must be cleaned and disinfected between residents. The failure to follow this policy was directly observed and confirmed through staff interviews, demonstrating a breakdown in the facility's infection prevention and control procedures for multiple residents with significant medical needs.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a calculated error rate of 9.38% based on 3 errors out of 32 observed opportunities. These errors involved two residents during medication administration by an LVN. The first resident, an elderly female with diagnoses including senile degeneration of the brain, anxiety disorder, congestive heart failure, and respiratory failure, had a physician's order for Desvenlafaxine Succinate Extended Release 100mg daily with explicit instructions not to crush the tablet. During observation, the LVN crushed this extended-release medication and administered it to the resident, contrary to both the physician's order and manufacturer guidelines. Additionally, the LVN failed to ensure that a prescribed Lorazepam 0.5mg tablet was present in the medication cup, only discovering the omission after a count discrepancy was noted by the surveyor. The second resident, also an elderly female with chronic pain, repeated falls, diabetes type II, COPD, and bipolar disorder, had an order for three Torsemide 20mg tablets once daily. During medication pass, the LVN placed only two tablets in the medication cup. The error was identified and corrected after the surveyor verified the count, but not before the initial incomplete dose was presented for administration. Interviews with staff, including the LVN, DON, and ADM, confirmed that facility policy requires medications to be administered exactly as ordered by the physician and in accordance with manufacturer instructions. The LVN admitted to being unsure about the appropriateness of crushing the extended-release medication but proceeded regardless. Facility policy and manufacturer guidelines both specify that extended-release tablets should not be crushed, and all staff interviewed acknowledged the importance of following these protocols to ensure resident safety.
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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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Nursing homes near Kingsland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Brixton At Horseshoe Bay | 11.2 mi | ★★★★★ | 0 | 0 |
| Granite Mesa Health Center | 12.9 mi | ★★★★★ | 9 | 0 |
| Llano Nursing And Rehabilitation Center | 14.4 mi | ★★★★★ | 8 | 0 |
| Avir At Burnet | 14.5 mi | ★★★★★ | 5 | 0 |
| Bertram Nursing And Rehabilitation | 24.1 mi | ★★★★★ | 5 | 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.