Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Knox City during CMS and state inspections, most recent first.
Posted Incontinence Care List Exposed Resident Privacy: A list of 14 residents who received incontinence care services was posted on a hallway wall at the nurse charting station, visible to passersby near the dining room doorway. The ADON stated she posted the list without considering resident privacy, and the DON and ADM acknowledged the posting was not appropriate because it exposed private care information and was a dignity issue.
Unsafe and Unhomelike Environment Due to Unrepaired Room and Dining Area Deficiencies: Surveyors observed missing vertical blind slats in multiple resident rooms, broken and/or cracked flooring tiles and planks, and a broken window covered with cardboard and duct tape. The dining room also had broken flooring across the middle of the floor, missing blind slats, and a blanket used as a window covering. The MS, ADON, DON, and ADM acknowledged awareness of several of these issues, and record review showed limited work order documentation for the repairs.
Grievance information was not made accessible to residents. A resident council of 4 confidential residents stated they did not know how to file a formal grievance, did not have access to grievance forms, did not know who the grievance officer was, and were unaware of any anonymous complaint option. Survey observation found no prominent grievance instructions, no readily available forms, and no anonymous submission process. The DON and ADM both acknowledged the forms were not readily accessible and that residents may not have known how to file grievances.
An LPN left a medication cart unlocked and unattended in the hallway after walking away to check on a resident. Surveyors also observed multiple residents' meds stored together in the same cart sections, including inhalers, nasal spray, nitroglycerin tabs, injections, eye drops, and insulin pens. The DON stated carts were expected to be locked at all times and meds separated in the cart, while an LPN said she was not aware the meds needed to be separated by route.
Menu Not Followed and Pureed Bread Not Served: The facility did not ensure the lunch menu was followed and that residents on a pureed diet received pureed bread. Observation showed the posted lunch items differed from the weekly menu, and four pureed meals were served without pureed bread. The DM said he made the pureed bread but forgot it in the refrigerator, while the RD, DON, and ADM stated they were not aware it was not served.
Food Storage and Kitchen Sanitation Deficiencies: Surveyors observed dust and cobwebs on the vent hood above the cooktop and found multiple food items in four walk-in freezers stored in clear plastic bags with no labels or dates. The DM stated he was responsible for dating and labeling the freezer items and said he had forgotten, while the RD, LVN A, and ADM confirmed that food items were supposed to be labeled and dated and that kitchen areas were to be kept clean and sanitary.
Failure to provide full visual privacy in multiple resident rooms. Observations showed missing slats in vertical blinds in several rooms, leaving openings when closed, and some rooms lacked privacy curtains that fully separated bed B from the room or restroom area. In one room, a resident said he changed clothes in the restroom because a hallway surveillance camera was visible from his bed and there was no curtain on his side for privacy. The MS, ADON, DON, and ADM acknowledged the privacy issues and confirmed the broken blinds had been known for months.
Hand hygiene failures occurred during direct resident care when a CNA providing incontinence care touched a trash can and did not sanitize between glove changes, and an LVN providing wound care did not sanitize between glove changes. The CNA cared for a resident with urinary incontinence, and the LVN treated a resident with a stage 2 pressure ulcer and other medical conditions. The ADM said a basic infection prevention and control policy could not be found, while the DON stated staff were expected to sanitize after touching contaminated surfaces and between glove changes.
Failure to maintain an effective pest control program in the kitchen. Surveyors observed about four flies in the food prep area, landing on unused prep stations, the plate warming station, and utensils, with no fly trap tapes observed. The DM, MS, LVN A, and ADM gave conflicting accounts about responsibility and pest control activity, and the MS stated the pest control log had no written documentation for flies.
The facility failed to maintain the required RN coverage of at least eight consecutive hours a day, seven days a week, for 34 days over a three-month period. The DON was the only RN employed and covered some shifts, but recruitment efforts for additional RNs were unsuccessful. The facility faced challenges with their contracted staffing agency, and many agency staff did not show up for shifts. Despite having access to Telehealth and a responsive Medical Director, the lack of RN coverage violated the facility's policy.
A facility failed to maintain an effective infection control program when an LVN did not sanitize a multi-use wrist blood pressure device between residents during medication administration. The DON admitted that staff were not trained to sanitize these devices between residents, as the facility's policy did not require it. The ADM was unaware of this practice and could not quote the facility's policy on sanitizing multi-use devices.
A resident with COPD did not have their oxygen tubing replaced weekly as ordered, posing a risk for infection. Despite the facility's policy, the tubing had not been changed since 09/22/24. Interviews with staff revealed a lack of adherence to the policy, with the DON acknowledging the increased infection risk.
A facility failed to accurately document an oxygen tubing change for a resident with multiple health conditions, including COPD. The resident's records inaccurately showed a tubing change that did not occur, as confirmed by LVN A, who admitted to pre-charting and failing to update the record. The facility's policy requires accurate documentation, which was not followed, leading to potential risks for the resident.
The facility failed to maintain a clean and safe environment in the North patio smoking area, as surveyors observed trash and cigarette butts over two days. The Housekeeping and Maintenance Supervisors, responsible for cleaning, did not perform their duties due to survey obligations. The Administrator acknowledged the issue but attributed it to frequent winds. The facility's policy requires immediate debris cleanup, which was not followed.
A facility failed to properly store and label medications when an LVN took a blister pack of Depakote from one resident and placed another resident's label on it to prevent a missed dose. This action was against facility policy and occurred due to a delay in medication delivery. The DON confirmed that emergency supplies were available, making the LVN's actions unnecessary.
A resident with bilateral below-knee amputations fell during an improper transfer by an LVN using a bear hug method, resulting in a bleeding surgical wound. The incident was not documented as a fall, and facility policies on safe lifting and fall prevention were not followed.
A resident's medication was misappropriated by an LVN who took Synthroid/Levothyroxine from an unlocked medication cart for personal use. The LVN admitted to taking the medication due to a shortage in her own prescription, despite being aware of the facility's policy against such actions. The incident was witnessed by another nurse and reported to the appropriate authorities.
A medication cart in the facility was left unlocked and unattended, allowing an LVN to access and take medication for personal use. The LVN, under investigation by the Texas Board of Nursing, admitted to taking Levothyroxine from the cart due to a shortfall in her own prescription. Despite in-service training on medication security, the cart was not secured, violating facility policy.
A resident with multiple medical conditions, including a recent leg amputation, experienced a fall during an improper transfer by an LVN, resulting in bleeding from the incision site. The incident was not documented in the medical records, violating professional standards and facility policy.
Posted Incontinence Care List Exposed Resident Privacy
Penalty
Summary
The facility failed to respect resident privacy when a list of 14 residents who received incontinence care services was posted on the wall in a hallway at the nurse charting station on the secured unit. The posting was visible to potential passersby and was located across from the doorway of a dining room. During observation, surveyors saw the list displayed in the hallway, exposing resident names and care-related information in a public area. During interviews, the ADON stated she had posted the incontinence care list on the wall in the hallway at the charting station and did not think about how it affected resident privacy. She stated she did not remember when she posted it there and acknowledged it may have caused residents to feel embarrassed. The DON stated the list was not appropriate because it gave information residents may not want known and was a dignity issue. The ADM also stated residents have a right to privacy and was not aware of the list being posted in the hallway. The facility policy on Resident Rights stated residents have the right to privacy and confidentiality and that unauthorized disclosure of resident information is prohibited.
Unsafe and Unhomelike Environment Due to Unrepaired Room and Dining Area Deficiencies
Penalty
Summary
The facility failed to ensure residents had a safe, clean, comfortable, and homelike environment and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 1 of 2 common dining rooms and 10 of 33 resident rooms reviewed for environment. Surveyors observed multiple environmental issues, including missing vertical blind slats in several resident rooms, broken and/or cracked flooring tiles and planks, and a broken window that had been covered with doubled cardboard and duct tape. During observations, one resident room had 2 broken and/or cracked planks that were bowing upward and sticking up from the floor, a broken window covered with cardboard and duct tape, and a missing blind slat. Other resident rooms were observed with missing blind slats, including rooms with 1, 2, 3, or 10 missing slats. One resident room had 22 broken and/or cracked flooring tiles, and the dining room had broken and/or cracked tiles extending across the middle of the floor, along with a window blind missing 7 slats and a white blanket used as a window covering. Record review showed an open work order for torn blinds, but there were no open or closed work orders documented for the broken or cracked floor tiles, broken planks, or broken window. In interviews, the MS stated he walked the building daily, used the Tels system to track repairs, and considered the broken window a high priority repair, but he also stated there had been funding issues after the ownership change and he had not followed up on the status of funding. He acknowledged awareness of several rooms with missing blind slats and rooms with cracked or broken flooring, and stated he had not received training on maintenance or the importance of residents having a comfortable homelike environment. The ADON, DON, and ADM each stated they were aware of various broken blinds, flooring, and the broken window, and described the issues as hazards or serious repairs, while also stating that repairs should have been documented in the Tels system.
Grievance Information Not Made Accessible to Residents
Penalty
Summary
The facility failed to provide residents and their representatives with information about their rights related to filing grievances or concerns for 4 of 4 confidential residents. During observation, the facility did not have instructions regarding the grievance procedure in any prominent posting, grievance forms were not readily available to residents, and there was no accommodation to submit a grievance anonymously. The report states that the grievance procedure, access to grievance forms, information about the grievance officer and contact information, and anonymous grievance options were not provided through prominent postings as required by facility policy. During a confidential interview with the resident council, 4 confidential residents stated they did not know how to file a formal grievance. The residents said they did not have access to grievance forms, did not know where the forms were kept, were not aware of who their grievance officer was, and did not know the process to resolve grievances. They also stated they had not seen any posting in the facility about grievances and did not know how to file anonymous grievances or that anonymous complaints were an option. The DON stated grievance forms were on her door and that residents could tell any staff member about a grievance and staff would fill out the form. She also stated she was not sure whether grievance information was posted on the bulletin board and acknowledged the process should be posted for residents to see. The ADM identified herself as the grievance officer and stated the grievance process was posted by the nurse station, but also stated the forms on the DON's door were not readily accessible, there was no current procedure for residents to obtain a form on their own or submit one anonymously, and residents may not have known how to file a grievance or who the grievance officer was. The facility policy required written information upon admission, a posted grievance procedure, oral or written grievances including anonymous submissions, and contact information for the grievance officer.
Unlocked Medication Cart and Improper Medication Storage
Penalty
Summary
Medication Cart A was left unlocked and unattended in the hallway by the nurse's station when LVN B walked away to check on a resident. During interview, LVN B stated she knew the cart was supposed to be locked when unattended but forgot to lock it. She also stated a potential negative outcome was that residents could get into the medication cart. The DON later stated she expected medication carts to be locked at all times and that LVN B had simply forgotten to lock it. During observation of Medication Cart A with LVN A and the DON, medications for different residents and different routes were stored together in the same sectioned areas of the cart. Examples included an inhaler stored next to a nasal spray, nitroglycerin tablets stored next to injections and eye drops, and eye drops stored next to insulin pens. LVN A stated she was not aware the medications needed to be separated by route, and the DON stated the cart should have medications separated. The facility policy required medication carts to be locked when not in use and each resident's medications to be assigned to an individual cubicle, drawer, or other holding area to prevent mixing medications of several residents.
Menu Not Followed and Pureed Bread Not Served
Penalty
Summary
The facility failed to ensure that the lunch menu met residents’ nutritional needs and was followed for the 12/16/2025 lunch meal. Review of the weekly menu for Tuesday lunch showed beef goulash, squash medley, tossed salad, cornbread, margarine, dressing of choice, a fresh baked cookie, and a beverage, but during observation from 12:15 PM to 12:30 PM in the secured unit dining room, a white board listed lunch as goulash, green beans, bread slice, and fruit. Four pureed meals were observed being served with pureed goulash, pureed green beans, and pureed mixed fruit, but pureed bread was not observed with any of the meals. During interviews, the DM stated he was responsible for making the pureed bread, that residents on that diet were supposed to get it, and that he had made it but forgot it in the refrigerator. He also stated he informed the ADM, RD, and residents that the menu was being substituted. The RD stated she was not aware that pureed bread was not served and said the DM was responsible for following that and documenting it. The DON and ADM both stated they were not aware that pureed bread was not served on the lunch meal and identified the DM as responsible for ensuring it was served. The facility policy stated menus are to be planned in advance, posted, followed, and that temporary changes are to be noted on a menu substitution sheet and posted so staff are aware of changes.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen reviewed for food safety. During a kitchen tour, surveyors observed that the vent hood located directly above the cooktop on the right side of the kitchen had dust and cobwebs. Surveyors also found multiple items in four walk-in freezers that were not labeled or dated, including what appeared to be chicken breasts, ground beef, chicken wings, sausage, Chinese rice, French fries, mixed vegetables, okra, chicken drumsticks, and egg rolls, each stored in clear plastic bags with no label and no date. In interviews, the DM stated he was responsible for dating and labeling all food items in the freezers and said he must have forgotten to do so. He also stated he had spoken to maintenance about the dusty vent hood, but the issue had not yet been addressed. The RD, LVN A, and ADM each stated that dietary staff or the DM were responsible for ensuring food items were properly labeled and dated, and that unlabeled or undated food could cause residents to get sick. The facility policy required all foods stored in refrigerators or freezers to be covered, labeled, and dated, and required kitchen areas to be kept clean and sanitary.
Failure to Provide Full Visual Privacy in Resident Rooms
Penalty
Summary
The facility failed to respect residents’ right to personal privacy in 10 of 33 resident rooms reviewed. Rooms 24, 25, 26, 28, 30, 31, 32, 33, 34, and 35 had missing slats in the vertical window blinds, leaving openings of approximately 3 inches wide from top to bottom when the blinds were closed. In addition, several rooms did not have privacy curtains that provided full visual privacy for the resident in bed B, including curtains that did not extend all the way to the wall and left an approximately 4-foot gap. During observations, the missing blind slats were documented in multiple rooms, including rooms where 1 slat, 2 slats, 3 slats, or 10 slats were missing. In one room, the resident in bed B also had no privacy curtain on that side of the room and could be seen from the hallway surveillance camera visible outside the room. In that same room, the resident stated he changed clothes in the restroom because the camera in the hallway was watching him and he did not have a privacy curtain on his side of the room to close for privacy from the camera or his roommate. Interviews with the MS, ADON, DON, and ADM confirmed awareness of the broken blinds and privacy concerns. The MS stated he knew several rooms were missing blind slats and that repairs were delayed due to funding issues after the ownership change. The ADON, DON, and ADM stated the broken blinds had been reported and that residents should have privacy, but they were not aware that several rooms lacked full visual privacy. The facility policy on Resident Rights stated residents have the right to dignity, respect, privacy, and confidentiality.
Hand Hygiene Failures During Incontinence and Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During observation of incontinence care for a resident who was dependent for toileting hygiene and had urinary incontinence, CNA A washed her hands, touched and moved the trash can with bare hands, then began handling wipes and a clean brief. CNA A used ABHR and gloves, but after removing gloves during care, she did not perform hand hygiene before putting on new gloves. CNA A later stated she had been trained on hand hygiene between glove changes and after touching a trash can, but thought it was acceptable to touch the trash can because it was clean and said she got nervous during the observation. During observation of wound care for a resident with metabolic encephalopathy, depression, and a stage 2 pressure ulcer of the right buttock, LVN A washed her hands, donned gloves, cleansed the wound, removed her gloves, and put on clean gloves without performing hand hygiene between glove changes. LVN A then applied collagen and covered the wound with a foam dressing. In interview, LVN A stated she had been trained to perform hand hygiene between glove changes but could not remember when, and said it had slipped her mind. She also stated the risk to residents was possible infection. The ADM stated she was unable to find a basic Infection Prevention and Control Program policy and that the policy provided was the most relevant. The DON stated staff were expected to sanitize their hands between glove changes and after touching a trash can, and that she was responsible for ensuring staff followed infection control policies. The ADM and DON both stated the staff had been trained on hand hygiene, and the facility record showed Hand Hygiene Basics training had been completed by both CNA A and LVN A.
Failure to Control Flies in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program in its only kitchen, and survey observations found flies present in the food preparation area. Record review of the pest control binder showed the facility received bi-weekly pest control services in 2025, with the kitchen last treated for rats on 06/11/2025 and no mention of flies. During an observation of the kitchen on 12/16/2025 at 11:16 AM, approximately four flies were seen flying around while the DM prepared the meal before lunch service. The flies were observed landing on food preparation stations that were not in use, on top of the plate warming station, and on cooking utensils, and no fly trap tapes were observed. During interviews, the DM stated maintenance personnel were responsible for pest control and said pest control had been at the facility the prior month, but he did not know why the flies were present. He also stated he had spoken to the maintenance person, who promised to contact pest control. The MS stated he was responsible for making sure flies were controlled in the kitchen and environs, and said pest control had been at the facility a week earlier but nothing was written on the pest control log. The MS and LVN A both stated flies in the kitchen could spread disease on food and make residents sick. The ADM stated the opened back door was believed to be the reason flies kept entering the kitchen because it was used for trash removal and deliveries, and she stated pest control was used monthly and as needed for flies.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required registered nurse (RN) coverage of at least eight consecutive hours a day, seven days a week, for 34 days over a three-month period. This deficiency was identified through interviews and record reviews, which revealed that there were no RNs scheduled on specific days in April, May, and June 2024. The Director of Nursing (DON) confirmed that she was the only RN employed during this time and covered some shifts herself, but there were no other RNs available to meet the coverage requirement. The DON stated that the facility was actively trying to recruit RNs through various means, including online recruitment, job fairs, and communication with the Texas Workforce Commission. Despite these efforts, the facility struggled to hire RNs, and their weekend RN had quit. The facility also faced challenges with their contracted staffing agency, which was inconsistent, and many agency staff did not show up for their assigned shifts. The DON was aware of the coverage gaps and informed the corporate office, but was not required to fill all the shifts herself. The Administrator (ADM) acknowledged the issues with RN coverage and mentioned that a Performance Improvement Plan was implemented. The ADM and DON both noted that the facility had access to Telehealth and a responsive Medical Director, and they believed that the Licensed Vocational Nurses (LVNs) and other staff could meet residents' needs. However, the facility's policy required RN coverage, and the lack of RNs on certain days was a clear violation of this policy.
Inadequate Infection Control Practices with Multi-Use Devices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during medication administration. LVN A did not sanitize a multi-use wrist blood pressure device between residents, which was observed during medication pass observations. Specifically, LVN A used the device on three residents consecutively without cleaning it before or after each use. During an interview, LVN A acknowledged the failure to sanitize the device and admitted that she had been trained on cross-contamination through her nursing education. She also mentioned that she received training from the DON on infection control practices as needed. The Director of Nursing (DON) admitted that staff had not been trained to sanitize multi-use blood pressure cuffs between residents, as the facility's policy did not require it. The DON stated that blood pressure cuffs were considered non-critical items, and the facility's policy only required sanitizing them at the end of each shift or when they became soiled. However, the DON acknowledged that the best practice would be to sanitize all multi-use devices between residents to prevent infection. The DON was responsible for conducting staff training on infection control practices, which was usually done on a one-to-one basis. The facility's Administrator (ADM) was unaware that staff were not sanitizing multi-use blood pressure devices between residents. The ADM could not quote the facility policy for sanitizing multi-use devices and stated that nursing administration was responsible for staff training on infection control practices. The facility's policy on cleaning and disinfection of non-critical resident-care items outlined the use of intermediate and low-level disinfectants for such items, but it did not specifically require sanitizing blood pressure cuffs between residents. The ADM expected staff to follow orders regarding proper sanitization practices.
Failure to Replace Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically by not replacing the resident's oxygen tubing every seven days as per the physician's orders. The resident, a cognitively intact male with multiple health conditions including Chronic Obstructive Pulmonary Disease, was observed using oxygen therapy with tubing that had not been changed since 09/22/24, despite the order to change it weekly. This oversight was confirmed through multiple observations and interviews with the resident, who could not recall when the tubing was last changed. Interviews with facility staff, including the Administrator and the Director of Nursing (DON), revealed a lack of clarity and adherence to the facility's policy on changing oxygen tubing. The Administrator was unsure of the policy details, while the DON stated that the tubing should be changed every Sunday night and as needed, with the night shift nurse responsible for this task. The DON acknowledged that failure to change the tubing as ordered could increase the risk of infection. The facility's policy on oxygen administration, revised in October 2010, was reviewed but did not appear to be followed in this instance.
Inaccurate Documentation of Oxygen Tubing Change
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically regarding the documentation of an oxygen tubing change for Resident #28. Resident #28, a cognitively intact male with multiple health conditions including Chronic Obstructive Pulmonary Disease, was observed using oxygen therapy. The facility's records indicated that an oxygen tubing change was documented by LVN A on a specific date, but the change did not occur. The resident's oxygen tubing was observed to have not been changed for over a week, contrary to the weekly change order. During interviews, LVN A admitted to pre-charting her initials for routine tasks and failing to update the record when the tubing change was not performed. The facility's policy requires accurate and complete documentation, which was not adhered to in this instance. The Director of Nursing (DON) was unaware of the inaccurate documentation and emphasized the importance of accuracy in health records. The facility's policy on charting and documentation stresses the need for objective, complete, and accurate records, which was not followed in this case.
Failure to Maintain Cleanliness in Smoking Area
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the North patio smoking area, as observed during a survey. On multiple occasions, surveyors noted the presence of trash, including a plastic spoon, miscellaneous pieces of trash, and cigarette butts in the grass area of the smoking section. These observations were made over two consecutive days, indicating a lack of regular maintenance and cleanliness in this area. Interviews with the Housekeeping Supervisor (HS) and Maintenance Supervisor (MS) revealed that both were responsible for keeping the grounds clean but had not done so due to survey duties. The HS admitted that the area had not been cleaned since the previous Wednesday, and both supervisors were unaware of any potential negative outcomes for residents due to the trash. The Administrator (Adm) also confirmed the responsibility of the HS and MS for maintaining cleanliness but attributed the trash to frequent winds in the area. The facility's policy on maintenance emphasized the immediate cleanup of debris to prevent hazards, yet this was not adhered to in the smoking area.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored and labeled according to professional principles, specifically involving two residents. The issue arose when an LVN took a blister pack of Depakote, a medication for mood and behavior, from one resident and placed another resident's pharmacy label on top of it. This action was taken to prevent the first resident from missing their medication due to a delay in delivery from the pharmacy. The LVN did not notify the physician or the Director of Nursing (DON) about this action, which was against the facility's policy. The first resident, a female with schizophrenia, mild cognitive impairment, and generalized anxiety disorder, was prescribed Divalproex for mood and behavior. Her medication was running low, and the pharmacy had not delivered the refill on time. The second resident, a male with neuroleptic parkinsonism and schizoaffective disorder, had a supply of the same medication. The LVN borrowed from this supply without proper authorization or notification to ensure the first resident did not miss her dose. The facility's policy requires that all medications be properly labeled and only the dispensing pharmacy can alter labels. The DON was informed of the situation and confirmed that the StatSafe, an emergency medication kit, had enough supply to cover the shortage, making the LVN's actions unnecessary. The pharmacist and physician involved confirmed that the medication was not administered incorrectly, but the administrative handling of the medication was inappropriate.
Improper Transfer Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for a resident who experienced a fall during an improper transfer. The resident, who had multiple medical conditions including bilateral below-knee amputations, was dependent on staff for transfers. Despite this, a Licensed Vocational Nurse (LVN) attempted to transfer the resident using a bear hug method, which was not an approved or safe technique according to facility policy. During the transfer, the LVN lost balance and both she and the resident fell, resulting in the resident's surgical wound bleeding. The incident was not documented in the resident's progress notes, and there was no immediate medical treatment or emergency assistance provided. The facility's Director of Nursing (DON) and other staff were aware of the incident but did not document it as a fall, citing it as a transfer issue instead. Interviews with staff and the resident revealed that the resident typically used a sliding board or mechanical lift for transfers, and the bear hug method was not appropriate given the resident's condition. The facility's policies on safe lifting and fall prevention were not followed, and there was a lack of communication and documentation regarding the incident, which could have placed the resident at risk for further harm.
Misappropriation of Resident Medication by Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their medication by a staff member. A Licensed Vocational Nurse (LVN B) took Synthroid/Levothyroxine, a thyroid medication, from a medication cart for her personal use. This incident was witnessed by another nurse, LVN C, who observed LVN B taking the medication from the cart. The resident involved was a male with multiple health conditions, including heart failure, diabetes, hypothyroidism, schizoaffective disorder, and kidney failure. He was moderately cognitively impaired, as indicated by his BIMS score. The incident occurred when LVN C left her medication cart unattended and unlocked while attending to another resident. Upon returning, she found LVN B at the cart, who admitted to taking the medication because she was short on her own prescription. LVN B initially intended to consume the pill but later claimed to have discarded it in a sharps container. Despite being trained on the facility's policy against misappropriation of resident property, LVN B took the medication, which was a violation of the facility's procedures. Interviews with the Director of Nursing (DON) and other staff confirmed that LVN B had taken the medication and that such actions were against the facility's policies. The facility's policy clearly prohibits staff from taking or borrowing medications from residents for personal use. The incident was reported to the Health and Human Services Commission (HHSC), and LVN B was suspended pending investigation. The facility's policies emphasize the protection of residents' health, welfare, and rights, including the prevention of abuse, neglect, and misappropriation of property.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, specifically for one of the two medication carts located on the front hall. This deficiency was identified during a period when the medication cart was left unsecured and unattended, allowing unauthorized access to medications. The incident involved a Licensed Vocational Nurse (LVN B) who was reported to have taken medication from the cart for personal use. Interviews revealed that LVN B was under investigation by the Texas Board of Nursing for taking a resident's medication, specifically Synthroid, from the medication cart. The Director of Nursing (DON) stated that LVN B had informed another nurse, LVN C, of her intention to take the medication for herself. LVN C confirmed that she had left the medication cart unlocked and unattended, which allowed LVN B to access it. LVN C witnessed LVN B taking Levothyroxine from the cart, claiming she needed it to make up for a shortfall in her own prescription. The facility's records showed that LVN B had signed in-service training documents that emphasized the importance of not taking medications for personal use and keeping medication carts locked. Despite this training, LVN B admitted to taking a resident's pill but claimed she later discarded it in a sharps container. The facility's policy on administering medications clearly stated that medication carts should be kept locked when out of sight, which was not adhered to in this case.
Failure to Document Resident Fall and Injury
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards, specifically regarding a fall incident involving a resident. The incident involved a Licensed Vocational Nurse (LVN) who attempted to transfer a resident without using the recommended mechanical lift, resulting in a fall. The resident, who had recently undergone a leg amputation, suffered bleeding from the incision site after the fall. Despite the incident, there was no documentation in the resident's medical records or progress notes about the fall or the injury. Interviews with staff members revealed that the LVN attempted to transfer the resident by bear-hugging him, which led to both the LVN and the resident falling. The incident was witnessed by several staff members, who assisted in getting the resident back into bed. The Director of Nursing (DON) was notified, and the resident's wound was treated, but the incident was not documented as a fall in the facility's records. The facility's policy on assessing falls and their causes was not followed, as there was no incident report completed within 24 hours, and the fall was not documented in the resident's medical record. The resident involved in the incident had multiple medical conditions, including chronic obstructive pulmonary disease, heart failure, and chronic kidney disease, and was moderately cognitively intact. The resident typically used a sliding board for transfers and had expressed discomfort with using a mechanical lift. Despite this, the LVN attempted the transfer alone, contrary to the facility's policy and the resident's care plan, which contributed to the fall and subsequent injury.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Knox City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Munday Nursing Center | 11.1 mi | ★★★★★ | 0 | 0 |
| Avir At Haskell | 18 mi | ★★★★★ | 0 | 0 |
| Stonewall Living Center | 30.1 mi | ★★★★★ | 2 | 0 |
| Harmony Care At Stamford | 33 mi | ★★★★★ | 0 | 0 |
| Seymour Rehabilitation And Healthcare | 33.5 mi | ★★★★★ | 1 | 0 |
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