Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Longview during CMS and state inspections, most recent first.
A resident with a Stage IV right hip pressure injury and a history of chronic osteomyelitis, incomplete quadriplegia, and an ostomy did not receive ordered wound care on multiple shifts after returning from the hospital for surgical debridement. MAR/TAR review showed missed treatments, and the resident reported he had not been getting wound care as ordered. The wound was documented as worsening in size, and the DON stated nurses were expected to provide wound care as ordered.
PICC Dressing Not Changed as Ordered: A resident with chronic osteomyelitis was receiving IV piperacillin tazobactam through a PICC line, but the clear dressing remained dated from the hospital stay and no PICC dressing changes were documented in the MAR/TAR. The resident stated the dressing had not been changed since returning to the facility. Staff gave inconsistent answers about PICC care, while the DON said PICC dressings were to be changed every 7 days and that an order set should have been entered on admission.
The deficiency centers on misappropriation and poor control of controlled medications for four residents with significant pain and neurologic conditions. In separate instances, Hydrocodone and Acetaminophen-Codeine counts did not match records, doses were signed out on narcotic sheets but not documented on the MAR, and an LPN who appeared impaired was observed falling asleep during narcotic counts and failing to respond promptly to residents’ pain requests. Two other residents reported being told their pain medications had not been received or experiencing delays, while the DON and ADON acknowledged that, during a pharmacy change, nurses signed for bags of medications without verifying contents, packing slips were not used, and staff were uncertain whether some narcotics, including Hydrocodone and Pregabalin, had ever been delivered. Staff interviews also revealed delayed reporting of suspected impairment, inconsistent handling and storage of delivered narcotics, and lack of timely investigation and reconciliation of drug discrepancies, contrary to the facility’s own diversion policy.
A resident with multiple chronic conditions and moderate cognitive impairment experienced a dignity and respect violation when an LPN attempted to administer medication, then exited the room stating, “I don’t have to take this” with explicit language, which was captured on the resident’s electronic monitoring device. The resident, who reported depression and feeling that only a few nurses made her feel worthwhile, stated that some staff screamed at her, told her to “knock it off,” and were rude. The resident’s representative reported the video incident as mental abuse to facility staff and administration. In interviews, the LPN acknowledged making the explicit statement while leaving the room but claimed it was directed to a CNA and related to a prior conversation, while a CNA recalled the LPN’s difficulty giving medications and noted the LPN wore an earpiece and could have been on the phone. Staff interviews and facility policies confirmed that residents were to be free from verbal and mental abuse and to be treated with kindness, respect, and dignity.
A resident admitted with a nondisplaced hip fracture and orders for PRN Hydrocodone-Acetaminophen 5-325 mg never received this prescribed opioid because the medication was not successfully obtained from the pharmacy or Pyxis. The resident arrived without hospital medications, and attempts by an LVN and NP to access Hydrocodone-Acetaminophen were blocked due to an unsigned prescription by the medical director. Nursing staff used OTC pain medications initially, and the NP later ordered Acetaminophen-Codeine 300-30 mg, which was administered instead. The ADON cited possible pharmacy and prescription transmission issues during a pharmacy change, while the Administrator and DON stated that nursing management was responsible for ensuring timely procurement and availability of ordered medications, consistent with the facility’s medication administration policy.
Multiple residents and staff reported persistent odors of urine and fecal matter in rooms and hallways, with observations confirming unclean conditions and inadequate housekeeping. Residents with complex medical needs were affected, and family members sometimes cleaned rooms themselves due to lack of regular cleaning. Staff cited insufficient housekeeping coverage and increased workload as contributing factors to the ongoing cleanliness issues.
Several dependent residents did not receive timely assistance with ADLs, including showers and brief changes, due to inadequate staffing and incomplete care plan documentation. Reports from residents, families, and staff indicated that residents were left in soiled briefs for extended periods and sometimes went weeks without bathing, contributing to a high rate of UTIs and multiple grievances.
A resident with heart failure and dementia was incorrectly marked as 'expired' on a Medicare UB form instead of 'discharged to another facility.' The Business Office Manager made the error and was the only person reviewing the forms, with no secondary review or policy in place to ensure accuracy. The resident's transfer was properly documented in progress notes, but the discharge status on the billing form was not verified.
A resident's care plan was found to be incomplete, missing measurable timetables and specific actions to address all assessed needs. Documentation did not reflect a comprehensive approach to planning the resident's care.
Surveyors observed that the kitchen handwashing sink was soiled and the floor was sticky with debris, indicating that cleaning tasks were not completed as required. Staff interviews revealed confusion over cleaning responsibilities and discrepancies between cleaning records and actual conditions. Both administrative and dietary staff acknowledged the unsanitary state of the kitchen, which did not meet facility policy for infection control.
Two residents were incorrectly coded as receiving anticoagulant medications on their MDS assessments, when they were only on low-dose aspirin therapy. This error was identified through record review and staff interviews, which confirmed that neither resident was prescribed an anticoagulant, and the MDS assessments did not accurately reflect their medication status.
Two residents did not have their care plans updated to reflect changes in medical orders, including the removal of a PICC line, discontinuation of wound care, and advancement of diet from pureed to mechanical soft. Staff interviews and record reviews revealed discrepancies between care plans and actual care provided, with care plans not matching current orders or interventions. The facility had recently transitioned to a new EMR system, but care plans were not consistently updated, leading to confusion among staff regarding residents' current care needs.
A resident with multiple medical conditions and no cognitive impairment was found with a bottle of hydrogen peroxide topical solution in her room, a prohibited item according to staff. The resident was unaware of how the item came to be in her possession. Facility staff, including an LVN, the ADON, and the Administrator, confirmed that such items are not allowed in resident rooms and should be removed by staff, but no policy on this issue could be produced when requested.
A resident with severe cognitive decline and chronic respiratory conditions did not receive appropriate respiratory care, as staff failed to change oxygen tubing weekly and did not keep the oxygen concentrator's water reservoir filled. Multiple observations confirmed the tubing was not changed as scheduled and the reservoir remained empty, despite facility policy and staff acknowledgment of their responsibilities.
A resident with Alzheimer's and moderate cognitive impairment was repeatedly exposed to an unclean shared bathroom, with feces, urine, soiled briefs, and debris left unaddressed for weeks. The resident and her responsible party reported the issue, and photos documented the unsanitary conditions. Staff interviews revealed confusion about cleaning responsibilities after housekeeping hours, and the facility's policies for maintaining a clean environment were not consistently followed.
A resident requiring continuous oxygen therapy was found with an empty portable oxygen tank, despite staff assurances that it was full. The ADON changed the tubing but did not replace the empty tank, contrary to facility policy and physician orders. Interviews with facility leadership confirmed the responsibility of nursing staff to maintain oxygen supply, highlighting a lapse in care that could risk respiratory complications.
The facility failed to maintain effective infection control practices, as staff did not adhere to enhanced barrier precautions during wound care for two residents with pressure ulcers. The ADON and a CNA did not wear PPE while assisting with care, and a resident was left on a soiled brief, risking contamination. Despite training and available PPE, staff did not follow the facility's policy, potentially exposing residents to infection.
A facility failed to provide pharmaceutical services to a resident, resulting in missed doses of diltiazem and lisinopril due to unavailability and lack of documentation. Staff interviews revealed inconsistencies in documenting reasons for not administering medications, and the DON noted the absence of progress notes for the resident in March.
The facility failed to ensure a safe environment and adequate supervision, leading to multiple incidents of self-harm, falls, and injuries among residents. Harmful items were not removed from a resident's room, and proper monitoring was not initiated. Additionally, residents were transferred without gait belts, resulting in injuries.
The facility failed to provide necessary behavioral health services to a resident, leading to multiple incidents of self-harm and severe anxiety. Despite orders for counseling and psych evaluations, the resident's care plan was not updated, and staff did not follow suicide prevention policies. This resulted in an Immediate Jeopardy situation, which was later removed, but the facility remained out of compliance.
The facility failed to ensure a resident who primarily spoke Spanish was fully informed and able to participate in her care. Despite having communication tools like a communication board and an iPad with Google Translate, staff did not use these effectively, leading to misunderstandings and inadequate care. The resident's family and staff interviews highlighted ongoing communication barriers and insufficient use of provided tools.
A resident with severe cognitive impairment was verbally abused by an LVN, who told her that no one liked her and made derogatory comments about her eating habits. The resident's roommate and family members corroborated the incident, leading to the LVN's termination after an investigation by the facility.
The facility failed to provide necessary care and services in a resident's primary language, leading to communication barriers and a decline in the resident's quality of life and ability to perform activities of daily living. Staff struggled to communicate with the resident, and provided communication tools were not effectively used.
The facility failed to provide RN coverage for 8 consecutive hours on four specific dates, leaving the facility without supervisory nursing staff for RN-specific activities and emergency coordination. The DON acknowledged the difficulty in securing RN coverage, and the newly employed Administrator confirmed the requirement for RN coverage.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards, leading to multiple deficiencies. Observations revealed improperly sealed and undated food items, inappropriate thawing of raw chicken, items stored on the floor, and unclean food preparation equipment. Temperature logs for refrigerators and freezers were incomplete, and the dishwasher lacked the correct chemical solutions. Staff interviews confirmed these issues, highlighting a lack of adherence to food safety protocols.
The facility failed to implement gradual dose reductions for antipsychotic medications for two residents and did not ensure an appropriate diagnosis for another resident's use of Seroquel. These lapses led to the continued use of psychotropic medications without proper dose reduction attempts and incorrect medical documentation.
The facility failed to follow its policies to report and investigate allegations of neglect and abuse for two residents. One resident experienced a fall resulting in fractures, which was not reported to HHSC for nearly a month. Another resident alleged intentional harm by a CNA, but the incident was not reported within the required timeframe, and the CNA continued to care for the resident until the investigation was completed.
The facility failed to report allegations of abuse and neglect within the required timeframe. One resident's fall resulting in fractures was not reported to the state until nearly a month later, and another resident's allegation of abuse by a CNA was reported two days late. Communication failures and oversight were cited as reasons for the delays.
The facility failed to ensure accurate MDS assessments for a resident, incorrectly documenting a diagnosis of dementia instead of Schizophrenia. The error was identified by the MDS Coordinator and Regional MDS Nurse, but not corrected in a timely manner, leading to inaccurate documentation and potential risk for the resident.
A resident with Alzheimer's disease, depression, and anemia developed a urinary tract infection due to the facility's failure to provide routine incontinent care. The resident was found lying in bed with a strong smell of ammonia and saturated in urine and feces. The CNA assigned to the resident admitted not having time to provide care before going on lunch break. The hospice nurse assessed the resident and started antibiotics. The facility's policy emphasized the importance of keeping the skin clean to prevent infections.
The facility failed to provide timely pharmaceutical services for two residents, leading to missed and delayed doses of critical medications. One resident with COPD and lung neoplasm missed multiple doses of her inhalers, while another resident with hemiplegia and congestive heart failure experienced delays in receiving her pain medication. The facility's policy required medications to be administered within one hour of their prescribed time, but this was not adhered to, affecting the residents' well-being.
The facility had a medication error rate of 6.06%, involving two residents. One resident did not receive their prescribed artificial saliva due to unavailability, and another resident was given a crushed extended-release guaifenesin tablet, which clogged the gastric tube port. The interim DON and administrator expected proper medication management and availability.
The facility failed to follow their smoking policy for a resident, who was observed keeping and charging her electronic vape in her room and vaping outside unsupervised. Staff confirmed that vapes should be stored at the nurse's station and residents should be supervised while smoking.
Missed Ordered Wound Care for Stage IV Pressure Injury
Penalty
Summary
The facility did not ensure a resident with a Stage IV pressure injury received ordered wound care after returning from the hospital for surgical debridement of the right hip wound. The resident had a history of chronic osteomyelitis of both femurs, incomplete quadriplegia, an indwelling catheter, an ostomy, and pressure injuries present on admission. The admission MDS indicated he was cognitively intact, had no behavior of rejecting care, and required extensive assistance with many activities of daily living. The resident’s care plan identified a Stage IV pressure injury to the right hip and directed staff to administer treatments as ordered and monitor for effectiveness. A physician order initially required Dakins-moistened gauze wound care twice daily, and a later order required cleansing with wound cleanser, packing with Vashe-moistened gauze, applying skin prep to surrounding skin, and covering with a superabsorbent dressing every shift. The wound care notes documented the right hip wound as Stage IV, with measurements increasing over time, including a 4.5 cm by 2.5 cm by 2.4 cm wound on 4/7/26 and a 5 cm by 9 cm by 3 cm wound on 4/21/26 after the hospital return. Record review of the MAR/TAR showed missed wound care on the pm shift of 4/24/26, the pm shift of 5/1/26, the am shift of 5/2/26, and the pm shift of 5/3/26. Nursing progress notes identified the nurses assigned to those shifts, and the resident stated during interview that he had not received wound care twice a day as ordered since returning from the hospital and that it had happened more than three times. During observation on 5/6/26, RN B performed wound care and noted the wound bed was bright red with scant light yellow slough and measured 6.2 cm by 8.5 cm by 0.5 cm. The DON stated nurses were expected to perform wound care as ordered, and the wound care policy required documentation of when wound care was given and by whom.
PICC Dressing Not Changed as Ordered
Penalty
Summary
The facility failed to provide safe, appropriate administration of IV fluids for a resident with a PICC line by not ensuring the PICC dressing was changed at least every seven days. The resident was re-admitted with diagnoses including chronic osteomyelitis of the right femur and chronic osteomyelitis of the left femur. Hospital outpatient antibiotic infusion orders dated 4/20/26 indicated the resident was to receive IV piperacillin tazobactam 4.5 grams every 8 hours through 6/9/26, and the order noted PICC/midline care weekly and as needed. Record review showed the resident’s care plan revised on 4/30/26 did not address PICC line access. The physician order summary report dated 5/5/26 showed no orders for PICC line dressing changes. Review of the MAR/TAR for April 2026 and May 2026 showed no documented PICC line dressing changes from 5/1/26 to 5/6/26. During observations on 5/5/26 and 5/6/26, the resident had a clear dressing on the right upper arm dated 4/20/26, and the resident stated the dressing had not been changed since returning to the facility. Staff interviews showed inconsistent understanding of PICC care. One LVN said she did not know whether the line was a standard peripheral IV or a PICC line. Another RN stated PICC dressings should be changed every 7 days and said she had not performed a dressing change on the resident. Other nurses gave different answers about the frequency of PICC dressing changes, including every 24 hours and every 3 days. The DON stated PICC dressings were to be changed every 7 days and said an order set should have been entered when the resident was admitted with a PICC line. The facility policy on IV therapy did not address the frequency or procedure for PICC dressing changes, and the Administrator stated the facility had no additional policy and procedure pertinent to PICC lines.
Misappropriation and Poor Control of Controlled Medications for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of medications and to follow its own drug discrepancy and diversion policy. For one cognitively intact female resident with osteomyelitis, diabetes, malnutrition, and trauma-related pain, Hydrocodone-Acetaminophen (Norco) tablets were missing from her narcotic supply. An LPN reported that the narcotic count showed 18 Norco tablets the previous night but only 17 in the bottle the next morning, while the narcotic count sheet reflected that a dose had been administered at 9:00 p.m. even though the medication was not documented as given in the electronic MAR. The resident stated there was a night when she fell asleep and was not awakened for medications and did not receive her pain medication, although she otherwise reported receiving medications when requested. The LPN also observed that the nurse from the prior shift appeared "off" and was falling asleep during narcotic counts but did not notify the administrator, only the weekend supervisor. A male resident with a history of cerebral infarction, spinal stenosis, subarachnoid hemorrhage, and diabetes, who received scheduled and PRN pain medications including Gabapentin and Acetaminophen-Codeine (Tylenol #3), was also affected by narcotic discrepancies. An LPN reported that after new medication cards for Tylenol #3 and Lyrica were delivered, she returned the next morning to find one Tylenol #3 card with four tablets missing and two Tylenol #3 tablets left in a medication cup on the cart. She stated that the same LPN who had appeared impaired during narcotic counts was falling asleep and seemed odd, and that she herself was later drug tested and disclosed her own prescribed Tylenol #3 use. A CNA reported that this LPN moved fast, had difficulty with motor skills, left resident rooms messy, did not promptly respond to residents’ requests for pain medication, and told residents she would get there when she could. The CNA stated she reported these concerns to another nurse. The DON later acknowledged receiving reports that the nurse appeared impaired, including tripping over herself and wasting a tube feeding in a resident’s bed, and that there was a delay in these concerns being reported. Two additional residents experienced issues related to missing or potentially undelivered controlled medications. A cognitively intact female resident with COPD, UTI, overactive bladder, diabetes, and polyneuropathy, who was on scheduled Hydrocodone-Acetaminophen for chronic pain, reported that on a couple of occasions she was told the facility had not received her pain medications, though she did not specify dates and stated the medications were effective when received. Another resident with Parkinsonism, polyneuropathy, muscle wasting, and diabetes, who took Pregabalin for pain, reported that her pain medication was effective but that there were delays in receiving medications at times and that she had to ask for pain medications because they were not scheduled. The DON and ADON described that, during the period when medications for these residents went missing, the facility had changed pharmacies, did not initially have packing slips, and nurses would sign for bags of medications without verifying contents. Staff interviews indicated uncertainty about whether certain narcotic medications for these residents were ever actually received, inconsistent handling of delivered medications (including hospice narcotics left in a box for weeks), delays of up to two weeks before staff were drug tested after medications were reported missing, and lack of in-service training on drug diversion and abuse/neglect for some staff. The facility’s own policy required immediate notification of administration and pharmacy, prompt investigation, reconciliation, and notification of appropriate agencies for any discrepancies or suspected diversion, but staff accounts showed delays in reporting, incomplete documentation, and inconsistent implementation of these procedures. Across these events, multiple nurses and CNAs described the same LPN as appearing impaired, falling asleep during narcotic counts, and failing to respond promptly to residents’ pain complaints, while narcotic counts for Hydrocodone, Acetaminophen-Codeine, and Pregabalin were found to be off or medications were reported as not received. The DON stated that she expected nurses not to accept a medication cart with unresolved narcotic discrepancies and to report impaired staff immediately, but interviews revealed that counts were sometimes accepted despite discrepancies, that concerns about impairment were reported late, and that the DON did not come to the facility on the day of the diversion because supervisors were present. The DON and ADON also acknowledged that, prior to implementation of a new process, there was no clear protocol with the new pharmacy for verifying receipt of medications, packing slips were not used, and it was unclear whether some missing medications for the affected residents had ever been delivered. These combined actions and inactions resulted in misappropriation or unexplained loss of controlled medications for four residents and failure to ensure that physician-ordered medications were consistently available and properly safeguarded.
Failure to Treat Resident With Dignity and Respect During Medication Encounter
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be treated with dignity and respect when a nurse used explicit language while exiting the resident’s room. The resident was an older female with diagnoses including UTI, Parkinsonism, polyneuropathy, muscle wasting and atrophy, and type II diabetes. Her quarterly MDS showed she was usually able to make herself understood and understand others, with a BIMS score of 10 indicating moderate cognitive impairment. She required moderate assistance with toileting, lower body dressing, and bathing, and her care plan identified potential for pain related to polyneuropathy with multiple monitoring and reporting interventions. Evidence from an undated electronic monitoring video, reviewed on 3/23/2026, showed an LPN walking to the resident’s bedside with a small cup in her hand, attempting to hand the resident a medication cup, then turning away and exiting the room. As the nurse exited, she stated, “I don’t have to take this (explicit language),” after which the resident placed her hands on top of her head. In an interview, the resident reported that some staff treated her with dignity and respect, but that staff also screamed at her, told her to “knock it off,” and were rude to her. She stated she had depression, took medication for it, and had reported a staff member who treated her poorly, though she could not identify the nurse other than that she worked on a different hall. The resident said there were only a few nurses who made her feel that she was worth something. The resident’s representative reported having a video from the resident’s electronic monitoring device from 12/12/2025 at 10:00 p.m. and stated she had reported the incident to a nurse and the previous administrator, describing the incident as abuse “in a sense” and more mental abuse because the resident needed care. In a telephone interview, the LPN involved stated that on 12/12/2025 the resident was complaining of nausea and felt she was going to get sick, and that while walking out of the room she said, “I am sick of this (explicit language).” The LPN claimed the statement was directed to a CNA and related to a previous conversation, declined to discuss the lead-up to the statement, and could not recall if she administered the resident’s medication. A CNA interviewed later said she had not heard anyone talking rudely to residents, recalled the LPN attempting to give the resident medications and then stating she did not know what was wrong because the resident would not take them, and noted there was no conversation outside the door before or after the LPN entered the room. The CNA mentioned the LPN wore an earpiece and could have been on the phone, and acknowledged that if a resident overheard something, they could think staff were talking to them. Other staff interviews confirmed expectations that residents be treated with dignity and respect and that disrespectful interactions could negatively affect residents emotionally. An LPN stated she had been in-serviced on abuse, neglect, exploitation, dignity, and respect, and recognized that overheard statements could make a resident feel disliked and depressed. The ADON, who was not employed at the time of the incident, reported hearing about the video and that the facility had to report it, and stated that everyone was responsible for ensuring residents felt safe and were treated with dignity and respect. The administrator stated the LPN’s statement could be taken wrong and could be abuse, and that she expected staff to talk to residents in a manner that showed dignity and respect and to report any disrespect immediately. Review of the LPN’s personnel file showed she was hired on 8/14/2025 and terminated on 12/17/2025 for “Resident Interaction.” Review of grievance/complaint logs for December 2025 did not show a grievance related to this incident or other concerns about the LPN, and the facility’s policies on abuse prevention and resident rights required that residents be free from verbal and mental abuse and that employees treat all residents with kindness, respect, and dignity.
Failure to Obtain and Administer Ordered Opioid Analgesic for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered pain medication was accurately acquired, received, and available for administration to a resident following admission. The resident, an elderly female with a nondisplaced intertrochanteric fracture of the left femur, bipolar disorder, and anxiety disorder, was admitted without her medications from the hospital. An order dated 1/19/26 for Hydrocodone-Acetaminophen 5-325 mg to be given by mouth as needed for moderate to severe pain was in place, but review of the medication administration record for January 2026 showed that this medication was never administered at any time during her stay. Staff interviews and record review showed multiple points of failure in obtaining the ordered Hydrocodone-Acetaminophen. The NP stated she attempted to pull the medication from the Pyxis system on the night of admission but was denied because the prescription was not signed by the physician, and the resident instead received over-the-counter pain medications. LVN B confirmed that the resident arrived without medications, that an attempt to obtain Hydrocodone-Acetaminophen from Pyxis was denied due to the lack of the medical director’s signature, and that the family was notified and declined transfer to the emergency room for pain management. LVN B reported sending a message to the NP about the medication issue on 1/19/26 but stated the NP did not respond until early the next morning. Further interviews revealed uncertainty and breakdowns in communication and pharmacy processing. The NP later learned on 1/21/26 that the Hydrocodone-Acetaminophen prescription had not reached the facility and then called in an order for Acetaminophen-Codeine 300-30 mg, which was subsequently administered multiple times as documented on the MAR. The ADON suspected a pharmacy error related to a recent pharmacy change and possible incorrect physician contact information. The Administrator stated he expected nurses to obtain pain medications quickly and that the nurse should have contacted the DON or Administrator so the medical director could provide a valid prescription. The DON stated that nursing management was responsible for ensuring ordered medications were procured and available and that residents could be placed at risk of uncontrolled pain if prescribed pain medications were not available. The facility’s medication administration policy required medications to be administered safely, timely, and as prescribed, under the supervision of the DON.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for several residents, as evidenced by persistent odors of urine and fecal matter in resident rooms and hallways. Observations on multiple occasions revealed strong, unpleasant odors in various areas, including the entry hallway and several resident rooms. Residents and their families reported that rooms were not cleaned regularly, dirty linens and briefs were left in rooms, and family members sometimes had to clean the rooms themselves. These conditions were corroborated by direct observation and interviews with staff and residents. Several residents affected by these deficiencies had significant medical histories, including conditions such as gastroparesis, constipation, neuromuscular dysfunction of the bladder, Parkinson's disease, dementia, and recurrent urinary tract infections. Care plans indicated that some residents required total or moderate assistance with activities of daily living and had specific needs for skin care and infection control. Despite these needs, the facility did not consistently maintain cleanliness or address odors, and care plans were sometimes incomplete or not fully implemented. Interviews with housekeeping and nursing staff revealed concerns about inadequate staffing and increased workload, particularly after the implementation of weekend rotations. Staff reported being overwhelmed and unable to keep up with daily cleaning tasks, leading to unclean environments and persistent odors. Multiple staff members and a family member confirmed that the facility was only cleaned thoroughly when investigators were present, and that complaints about cleanliness had been voiced to administration without resolution.
Failure to Provide Timely ADL Care and Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide necessary care and assistance with activities of daily living (ADLs), including grooming and personal hygiene, for several residents who were unable to perform these tasks independently. Multiple residents, all of whom were dependent on staff for ADLs due to various medical conditions such as gastroparesis, neuromuscular dysfunction of the bladder, Parkinson's Disease, and dementia, did not receive scheduled showers, timely brief checks, or changes as needed. Family members, hospice staff, and residents themselves reported that staff did not consistently check or change briefs every two hours as required, and that residents sometimes remained in soiled briefs for extended periods. Photographic evidence and direct observations supported these claims, with one resident's brief remaining unchanged for an entire day despite visible soiling and blood. Interviews with staff, including CNAs, nurses, and the DON, revealed that the facility was experiencing significant staffing shortages following the elimination of medication aides and a reduction in CNA numbers. Staff consistently reported that the workload was unmanageable, making it impossible to complete two-hour rounds and provide timely care for all residents. As a result, residents were not being checked or changed as scheduled, and some went weeks without a bath or fresh linens. Staff also noted that the lack of adequate staffing led to delays in responding to call lights and providing water to residents. Documentation review showed that care plans were not always completed or updated in a timely manner, and that grievances had been filed by residents and families regarding missed showers and infrequent brief changes. The facility's infection surveillance report indicated a high number of urinary tract infections over a three-month period, which staff and administration acknowledged could be related to residents being left in soiled briefs. The facility's own policies defined neglect as the failure to provide necessary goods or services to avoid physical harm or emotional distress, and the events described in the report met this definition.
Inaccurate Completion of Medicare UB Form for Discharged Resident
Penalty
Summary
The facility failed to ensure that the medical record for one resident was complete and accurately documented, specifically regarding the completion of the Medicare UB form. The Business Office Manager incorrectly marked the resident's discharge status as 'expired' (code 20) instead of 'discharged to another facility' (code 03) on the Medicare UB form. This error was not identified or corrected because the Business Office Manager was the only person reviewing the UB forms, and there was no process in place for a secondary review. The resident in question was a male with diagnoses of heart failure and dementia, who was transferred to another facility, as documented in the progress notes. During interviews, the Business Office Manager acknowledged the mistake and stated she was unaware of the potential impact, as she was not informed of any issues by the resident or family. The Administrator confirmed that there was no policy addressing the accurate documentation of Medicare claim forms and that the Business Office Manager was solely responsible for reviewing these forms. The facility's Month End Close Cheat Sheet included a step to verify discharge status, but this process did not prevent the error in this instance.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records, which did not contain comprehensive or measurable interventions to address the resident's assessed needs.
Failure to Maintain Kitchen Sanitation and Cleanliness
Penalty
Summary
The facility failed to maintain proper sanitation and cleanliness in its kitchen, as evidenced by observations and staff interviews. During an initial tour of the kitchen, surveyors noted that the handwashing sink had a brown substance on its sides and in the bowl, and the kitchen floor was sticky with visible debris such as wrappers and crumbs in multiple locations. Staff present at the time confirmed that the handwashing sink and kitchen floor were not clean, attributing the lack of cleanliness to the previous shift's failure to perform required cleaning tasks. Further interviews with dietary aides and other staff revealed inconsistencies in cleaning responsibilities and understanding of the cleaning schedule. Some staff stated that the kitchen was clean when they left their shifts, while others acknowledged specific spills, such as a bag of juice that had burst, which may have contributed to the sticky floor. The cleaning schedule for the relevant date had been initialed as completed, but direct observation contradicted these records, indicating that cleaning tasks were either not performed or not performed adequately. The facility's own policies require that all kitchen areas, equipment, and utensils be kept clean and sanitary to prevent contamination and infection control issues. Despite these policies, both administrative and dietary staff acknowledged that the kitchen was not in a sanitary condition during meal preparation, with the administrator and dietician specifically noting the potential for infection control problems due to the unsanitary environment. No residents were directly mentioned as being affected at the time of the deficiency.
Inaccurate MDS Coding of Anticoagulant Use for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the medication status of two residents. For both residents, the MDS indicated that they were receiving anticoagulant medications, such as warfarin or heparin, when in fact neither resident was prescribed or taking an anticoagulant. Instead, both residents were on low-dose aspirin therapy, which was incorrectly coded as an anticoagulant on their MDS assessments. This error was confirmed through interviews with the MDS nurse, the Regional MDS nurse, and the ADON, all of whom acknowledged that the residents should not have been marked as receiving anticoagulants. The affected residents had significant medical histories, including hemiplegia, hemiparesis, cerebral infarction, Type 2 Diabetes, hypertension, and a coagulation deficit. The physician's orders and care plans for both residents did not include any anticoagulant medications, only aspirin therapy. The MDS nurse, who was new, stated she was unsure about the correct coding, and the Regional MDS nurse confirmed the assessments were coded incorrectly. The facility's policy required accurate and comprehensive assessments, but this was not followed in these cases.
Failure to Update and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in care plans that did not reflect current medical orders or the residents' actual care needs. For one resident, the care plan was not updated to reflect the removal of a PICC line and the discontinuation of wound care to the right femur and hip. Despite the discontinuation of these treatments, the care plan continued to list interventions related to the PICC line and surgical wounds, which created confusion among nursing staff regarding the resident's current care requirements. Interviews with nursing staff revealed that they relied on both care plans and medical orders, and discrepancies between the two could lead to uncertainty about the care to be provided. For another resident, the care plan was not updated to reflect a change in dietary orders from a pureed to a mechanical soft diet, as recommended by the speech therapist and documented in the medical record. The care plan continued to list interventions for a pureed diet, even though the resident was receiving and consuming a mechanical soft diet with thin liquids. Staff interviews confirmed that the resident's diet had been advanced, but the care plan did not match the current orders or the diet being provided. This discrepancy was acknowledged by the MDS nurse and other facility leadership, who indicated that care plans should be updated to match current orders to ensure appropriate care. The facility had recently transitioned to a new electronic medical record (EMR) system, and staff interviews indicated that care plans were expected to be updated in the new system. However, the process for updating care plans was not consistently followed, and responsibilities for updating care plans were shared among the MDS nurse, DON, ADON, and treatment nurse. The lack of timely updates to care plans resulted in documentation that did not accurately reflect the residents' current needs or the care being provided, as confirmed by multiple staff members and observations during the survey.
Prohibited Chemical Found in Resident Room
Penalty
Summary
A deficiency was identified when a resident was found to have a bottle of hydrogen peroxide topical solution in her room, which is a prohibited item according to facility staff. The resident, who had diagnoses including heart failure, urinary tract infection, and pneumonia, and who was assessed as having no cognitive impairment and requiring minimal assistance with activities of daily living, stated she did not know where the hydrogen peroxide came from or whether she was allowed to have it. The item was observed among other general hygiene products in the resident's bathroom. Interviews with facility staff, including an LVN, the Assistant Director of Nurses, and the Administrator, confirmed that hydrogen peroxide is not permitted in resident rooms due to potential danger if used improperly or accessed by other residents. All staff interviewed stated that it is their responsibility to remove such prohibited items from resident rooms. When requested, the Administrator was unable to provide a policy regarding accidents, hazards, or prohibited items in resident rooms.
Failure to Change Oxygen Tubing and Maintain Water Reservoir for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident requiring continuous oxygen therapy. Specifically, staff did not change the resident's oxygen tubing according to the facility's policy, which requires weekly changes and documentation in the electronic health record. Observations over several days showed that the oxygen tubing in use was dated more than a week prior, indicating it had not been changed as required. Additionally, the oxygen concentrator's water reservoir was found empty on multiple occasions, despite the need for it to be filled to ensure proper humidification during oxygen therapy. The resident involved had a history of chronic obstructive pulmonary disease (COPD), pneumonia, and hypokalemia, and was assessed as having severe cognitive decline. Orders were in place for continuous oxygen via nasal cannula, with specific parameters for titration and monitoring. Interviews with facility staff confirmed that nursing staff were responsible for changing tubing and maintaining the water reservoir, but these tasks were not completed as required, resulting in a failure to follow professional standards of practice for respiratory care.
Failure to Maintain Clean and Safe Resident Bathroom Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident with Alzheimer's disease, hypertension, urinary tract infection, and insomnia, who was moderately cognitively impaired and required supervision with toileting. Over a period of several weeks, the resident's shared bathroom was repeatedly found to be unclean, with brown substances on the toilet and floor, soiled briefs left in the trash can, and toilet paper and other debris scattered on the floor. These unsanitary conditions were documented through multiple photographs provided by the resident, showing persistent issues such as feces, urine, dirty clothing, and other waste in the bathroom area. Interviews with the resident and her responsible party revealed ongoing concerns about the cleanliness of the bathroom, with reports that the adjoining roommate was contributing to the mess and that the resident often felt compelled to clean the bathroom herself. The resident expressed feelings of stress, being unheard, and a diminished sense of self-worth due to the unclean environment. Staff interviews indicated a lack of clarity regarding responsibility for cleaning after housekeeping staff left for the day, with some staff stating that aides were responsible for cleaning after hours, but also noting that they did not have access to cleaning chemicals, only basic supplies like towels and wipes. Housekeeping staff confirmed that no housekeepers were present after 4 pm, and that aides were expected to clean up messes during those times. However, some nursing staff were unaware of the ongoing issues, and there was no documentation of grievances or concerns in the facility's log until after the situation escalated. The facility's own policies required a clean, sanitary, and orderly environment, and standard precautions for handling soiled materials, but these were not consistently followed, resulting in the resident being exposed to an unclean and potentially unsafe environment for an extended period.
Failure to Ensure Adequate Oxygen Supply for Resident
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required continuous oxygen therapy. The resident, a cognitively intact female with a history of a displaced fracture, cognitive impairment, and urinary tract infection, was observed with an empty portable oxygen tank attached to her wheelchair. Despite the resident's report of feeling out of breath and the observation of the empty tank, the Assistant Director of Nursing (ADON) only changed the tubing and did not replace the empty tank. This oversight occurred despite the resident's need for continuous oxygen to maintain oxygen saturation levels above 92% as per the physician's order. Interviews with the Director of Nurses and the Administrator confirmed that it was the responsibility of the nursing staff to ensure that residents' oxygen tanks were full and replaced when empty. The facility's policy on oxygen administration, dated September 2017, outlined the need for verifying physician orders and ensuring safe oxygen administration. The failure to replace the empty oxygen tank could place residents at risk of respiratory complications, as acknowledged by the facility's leadership.
Inadequate Infection Control Practices During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of adherence to enhanced barrier precautions during wound care for two residents. On February 20, 2025, the Assistant Director of Nursing (ADON) did not wear the required personal protective equipment (PPE) while assisting with the wound care of a resident with a Stage III pressure ulcer. This resident, a 90-year-old female with severe cognitive impairment and multiple health issues, including a pressure ulcer, was at risk due to the ADON's failure to apply enhanced barrier precautions. Similarly, on February 26, 2025, a Certified Nursing Assistant (CNA) failed to wear PPE while assisting with the wound care of another resident with a Stage IV pressure ulcer. This resident, who had moderate cognitive impairment and was dependent on staff for dressing, toileting, and bathing, was left lying on a soiled brief after wound care. The CNA and the Treatment Nurse did not ensure the resident was clean and dry, which could lead to contamination of the wound dressing. Interviews with staff, including the Treatment Nurse, ADON, Director of Nursing (DON), and Administrator, revealed a lack of compliance with the facility's enhanced barrier precautions policy. Despite being in-serviced on these precautions, staff failed to consistently apply them, potentially exposing residents to cross-contamination and infection. The facility had adequate PPE supplies, but staff did not utilize them appropriately during high-contact care activities, as outlined in the facility's policy.
Failure to Administer and Document Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the accurate acquiring, administering, and receipt of medications. The resident, a female with a history of hypertension, aphasia, cognitive communication deficit, heart disease, and atrial fibrillation, did not receive her prescribed diltiazem and lisinopril on multiple occasions in March 2024. The medications were either not administered due to the resident's condition or were unavailable in the facility. The Medication Administration Record (MAR) indicated that the resident did not receive her diltiazem on seven days and her lisinopril on seven days in March 2024, with some instances due to the medications being unavailable despite being listed in the emergency kit inventory and pharmacy packing slip. Interviews with staff revealed inconsistencies in documenting the reasons for not administering the medications. Medication Aide A stated that if a medication was not administered due to the resident's condition, the specific condition was not documented. Licensed Vocational Nurse B mentioned that medication aides usually reported to nurses when a medication was not given, and the nurse would document the reason in the progress notes. However, the Director of Nursing (DON) indicated that there were no progress notes for the resident for the month of March, except for one regarding COVID testing. The DON also emphasized the importance of documenting blood pressures and reasons for holding medications to recognize acute changes in a resident. The facility's policy on administering medications requires that medications be administered in a safe and timely manner and that any withheld, refused, or delayed medications be documented with the reason. The lack of documentation and the unavailability of medications led to the resident not receiving her prescribed treatments, which could impact her health condition. The failure to document and ensure the availability of medications highlights a significant deficiency in the facility's pharmaceutical services.
Failure to Ensure Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards and provided adequate supervision to prevent accidents for several residents. Resident #38 experienced multiple incidents where harmful items were not removed from her room, leading to self-harm attempts. Despite documented self-harming behaviors, the facility did not immediately initiate 1:1 monitoring or follow their Suicide Threat policy. Additionally, the facility failed to ensure Resident #38 received timely counseling and psychiatric evaluations as ordered, and staff were not adequately in-serviced on suicide prevention after the incidents occurred. Resident #17 was transferred without a gait belt by a CNA, resulting in a fall and back pain that required x-rays. The CNA admitted that gait belts were not provided until recently and that there was confusion among staff regarding the level of assistance required for Resident #17. This lack of proper training and equipment contributed to the unsafe transfer and subsequent injury. Resident #110 was also transferred without a gait belt, resulting in a laceration to the back of his head. Additionally, Resident #35 was transferred using a Hoyer lift by a single CNA, which led to a bruise on her left forearm. These incidents highlight the facility's failure to adhere to safe transfer protocols and ensure that staff were adequately trained and equipped to perform transfers safely, leading to multiple injuries among residents.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to ensure that Resident #38 received necessary behavioral health care services to maintain the highest practicable mental and psychosocial well-being. Despite a counseling evaluation and treatment order placed on 02/15/24 and a psych evaluation referral signed on 03/04/24, the facility did not ensure that Resident #38 was seen. The facility also failed to comprehensively address Resident #38's behaviors and mental distress, and did not update her care plan to reflect her increased anxiety medication needs and behaviors. These failures were identified during an observation, interview, and record review, and led to an Immediate Jeopardy (IJ) situation on 03/28/24, which was removed on 03/29/24, although the facility remained out of compliance due to the need to evaluate the effectiveness of the corrective systems. Resident #38, a female with a history of transient cerebral ischemic attack, hemiplegia, hemiparesis, anxiety disorder, and depression, was admitted to the facility on [DATE]. Her quarterly MDS assessment indicated intact cognition, no behaviors such as psychosis or physical or verbal behavioral symptoms, and the use of antianxiety and antidepressant medications. Despite these assessments, the facility did not adequately address her mental health needs. Incidents included Resident #38 calling 911 due to severe anxiety, being found on the floor with a call light wrapped around her neck, and expressing thoughts of self-harm with scissors. These incidents were not properly documented or addressed in her care plan. Interviews with staff and family members revealed that Resident #38 had expressed suicidal ideations and had difficulty adjusting to long-term care. Staff failed to follow the facility's policies on suicide prevention and mandatory notifications. The social worker, who was responsible for ensuring timely psych evaluations, did not complete the necessary referrals. The facility's failure to provide timely and appropriate behavioral health services placed Resident #38 at risk for emotional trauma and mental distress. The facility's policies on behavioral assessment, intervention, and monitoring were not followed, leading to significant lapses in care for Resident #38.
Failure to Communicate in Resident's Preferred Language
Penalty
Summary
The facility failed to ensure that Resident #17, whose primary language was Spanish, was fully informed and able to participate in her care and treatment. Despite the resident's care plan indicating the need for communication tools such as a communication board and an iPad with Google Translate, these tools were either not used effectively or not used at all by the staff. Multiple progress notes and staff interviews revealed ongoing communication barriers, with staff often unable to understand the resident's needs and the resident unable to communicate effectively with the staff. Resident #17 had a range of medical conditions including a wedge compression fracture, major depressive disorder, cognitive communication deficit, vascular dementia, and generalized anxiety disorder. The resident's preferred language was Spanish, and she had moderate cognitive impairment. Despite these needs, the facility did not consistently provide communication in her preferred language, leading to misunderstandings and inadequate care. For instance, the resident's fall prevention sign was in English, and the communication board was found on the closet floor, unused. Interviews with staff and the resident's family member highlighted the facility's failure to use the provided communication tools. Staff often relied on yes/no questions or gestures, which were insufficient for the resident's needs. The family member expressed dissatisfaction with the facility's efforts, noting that the staff did not seem to care to use the communication tools or get to know the resident. The Interim DON acknowledged that the facility should have used the communication tools and ensured that signs and activities were in the resident's preferred language.
Verbal Abuse by LVN
Penalty
Summary
The facility failed to ensure the right to be free from abuse for one resident, who was verbally abused by an LVN. The incident involved a resident with severe cognitive impairment and multiple diagnoses, including vascular dementia and depression. The resident reported that the LVN told her that no one liked her, causing her emotional distress. The resident also mentioned that the LVN made derogatory comments about her eating habits and allegedly smashed a Twinkie before giving it to her. The resident's roommate corroborated the verbal abuse, stating that she heard the LVN tell the resident that nobody liked her. The resident's family members also reported the incident, noting that the resident was very upset and crying uncontrollably. The family members described the LVN as a night staff member with mid-length loose curled blond hair. The resident's family did not initially notify the facility of the incident, but the state surveyor later informed the administration. The facility's interim DON and ADM were made aware of the incident and began an investigation. During the investigation, the LVN denied the allegations, stating that she did not smash the Twinkie and did not make any derogatory comments. However, the facility terminated the LVN after the interim DON found her to be rude during the interview. The facility also conducted safe rounds to ensure no other residents were affected. The abuse policy of the facility defines verbal abuse as any inappropriate talking about a resident that they can hear, including making jokes or calling them names.
Failure to Provide Care in Resident's Primary Language
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless unavoidable due to clinical conditions. Specifically, the facility did not provide care and services in the primary language of a resident whose preferred language was Spanish. This failure was observed in Resident #17, who had multiple diagnoses including vascular dementia, major depressive disorder, and generalized anxiety disorder. The resident's care plan indicated the need for communication tools such as a communication board and an iPad with Google Translate, but these tools were either not used effectively or not accessible to the resident. Observations and interviews revealed that staff struggled to communicate with Resident #17 due to the language barrier. The resident was often found sitting alone and was not engaged in activities that were in her preferred language. Staff members admitted to using Google Translate on their phones or the facility's iPad, but these methods were not always effective. The communication board was found on the floor in the resident's closet, and signs in the resident's room were in English, further complicating communication. Family members and staff interviews highlighted the ongoing issues with communication. The resident's family expressed concerns about the lack of effective communication tools and the staff's inability to understand the resident's needs. Staff members also reported frustration in communicating with the resident and admitted to not using the provided communication tools consistently. The facility's policy on translation and interpretation services was not adequately followed, leading to a decline in the resident's quality of life and ability to perform activities of daily living.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. Specifically, the facility did not provide RN coverage for 8 consecutive hours on four specific dates: 10/07/2023, 10/08/2023, 10/21/2023, and 10/22/2023. This deficiency was identified through record review of nursing staff information sheets and confirmed during interviews with the Director of Nursing (DON) and the Administrator. The DON acknowledged the difficulty in securing RN coverage during those times and mentioned that she had been working weekends since March 2024 to ensure coverage. The Administrator, who was newly employed, was unaware of the lack of RN coverage in October 2023 but confirmed that RN coverage is a requirement for the facility. The absence of RN coverage on the specified dates left the facility without supervisory nursing staff for RN-specific activities and coordination of emergency care and disasters. The facility's policy requires 24-hour licensed nursing and an RN for eight consecutive hours daily, seven days a week. Additionally, the review of an article on appropriate nurse staffing levels highlighted the importance of sufficient nursing staff with appropriate competencies to ensure resident safety and well-being. The lack of RN coverage on the specified dates had the potential to affect residents by leaving staff without necessary supervisory support for critical nursing activities.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed that food items in the storeroom and refrigerator were not properly sealed and were exposed to air. Additionally, food and drink items in the refrigerator, freezer, and drink dispenser were not labeled and dated. Raw chicken was found thawing inappropriately in a sink without a constant flow of cool, running water. Items were also stored on the floor in the storeroom and back area near refrigerators, and a splattered brown substance was noted on the walls near the industrial mixer. Food preparation equipment and drink dispensers were not cleaned after use, and a black metal shelf holding cookware was not at least six inches from the ground. Temperature logs for the freezer and refrigerators were either missing or incomplete, and the dishwasher and compartment sink lacked the correct amount of chemical solutions. Staff also failed to consistently complete chlorine strip test results for the dishwasher and maintain a log for the dishwasher machine's temperature. During lunch meal service, a cook was observed poking through clear wrap to check the internal temperature of the food, which is unsanitary and could lead to contamination. During an initial tour of the kitchen, surveyors observed several deficiencies. A large container with floating pieces of chicken was found in cool water in the wash sink of a three-compartment sink. The sanitizing solution connected to the sink was empty. In the back area, multiple items, including crates, cardboard boxes, and a cooler with milk items, were found on the floor. The freezer contained undated vanilla-flavored shakes, ice cream cups, and magic cups. The black metal rack holding metal cookware was not at least six inches from the ground. Several bags of buns and loaves of bread were not dated. Temperature logs for various refrigerators and freezers were missing dates for both AM and PM shifts. The walk-in refrigerator contained unlabeled and undated items, including shredded yellow and white food items, a bottle of brown liquid, a box of bananas, a box of eggs, green leafy vegetables, cottage cheese, bacon, and margarine. The drink leftover cooler had unsealed, unlabeled, and undated items, including sliced meat, shredded yellow and white food items, relish, thick and easy containers, and a clear container of yellow, crushed food items. The dry storage pantry had items on the floor, including boxes of oil, apple juice, chips, plastic coffee mugs, foam lid containers, and dried beans exposed to air. The main area had undated boxes of thickened water, apple juice, orange juice blend, and pink lemonade connected to the drink dispenser machine. One of the juice dispenser nozzles had a yellow and red stain ring around the spout. The walls above the sink, near the industrial mixer and microwave, had a splattered brown substance. The microwave's clear turntable had a dried brown stain, and the industrial-sized stand mixer had a dried brown substance on its base. Interviews with staff revealed further issues. Cook DD, who had been at the facility for almost eight years, stated that she was responsible for cooking food for breakfast, lunch, and sometimes dinner if other staff did not show up. She also washed dishes and put away deliveries when needed. She admitted that food was supposed to be labeled, dated, and sealed, and that items should not be stored on the floor. She also mentioned that she liked to poke holes in clear wrap to check food temperatures, which she did not know was unsanitary. Dietary Aide EE, who had been at the facility for five months, stated that he was responsible for the dishwasher and the red and blue solutions but did not know he was responsible for the chlorine solution. He admitted to forgetting to log the dishwasher's temperature and pH strip results. The Dietary Manager (DM) stated that she was responsible for ensuring staff followed guidelines and completed their tasks. She admitted that she did not realize the Dietary Aide was not logging the dishwasher's temperatures and PPMs. The DM also mentioned that the black metal rack was already in the kitchen when she started and that it needed to be six inches from the ground to prevent contamination.
Failure to Implement Gradual Dose Reductions and Ensure Appropriate Diagnoses for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that Resident #50 received a gradual dose reduction (GDR) for her Ziprasidone, an antipsychotic medication. Despite the care plan indicating the need for a GDR, there was no evidence of a GDR being attempted or recommended by the pharmacy consultant from August 2023 through March 2024. The medication was discontinued only after surveyor intervention, indicating a lapse in following the care plan and regulatory requirements for GDRs. The facility also failed to ensure that Resident #28 received a GDR for his Risperdal, another antipsychotic medication. The care plan did not include GDR as part of the goals or approaches, and pharmacy recommendations for a dose reduction were not acted upon. The family refused the GDR, and the facility did not pursue it further with the physician, leading to continued use of the medication without appropriate dose reduction attempts. Additionally, the facility failed to have an appropriate diagnosis or indication of use for Resident #56's Seroquel, an antipsychotic medication. The resident was initially documented as having vascular dementia, which was later found to be incorrect. The correct diagnosis of schizophrenia was only verified after the surveyor's intervention. This misdiagnosis led to the inappropriate use of Seroquel without proper documentation and monitoring, highlighting a significant oversight in the resident's medical assessment and care planning.
Failure to Report and Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property. Specifically, the facility did not follow its own policies to report and investigate allegations of neglect and abuse for two residents. Resident #50 experienced an unwitnessed fall resulting in an elbow and pelvic fracture, but the incident was not reported to the Health and Human Services Commission (HHSC) until nearly a month later. The prior Director of Nursing (DON) did not inform the Administrator (ADM) about the fall, leading to a failure in the reporting process. The current DON and other staff members were aware of the incident but assumed it had been reported, which it had not. In another case, Resident #38 alleged that a Certified Nursing Assistant (CNA) intentionally rammed her knees into a bathroom wall during a transfer. The allegation was not reported to HHSC within the required 2-hour timeframe. The ADM and other staff members were aware of the incident but did not take immediate action to report it. The CNA continued to care for the resident until the investigation was completed, contrary to the facility's policy to remove the alleged perpetrator immediately. Interviews with various staff members, including the DON, ADM, and other nursing staff, revealed inconsistencies in communication and adherence to the facility's abuse prevention policies. The failure to report these incidents in a timely manner and to follow established procedures for protecting residents and investigating allegations of abuse and neglect could place residents at risk and decrease their quality of life.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by regulations. Specifically, the facility did not report the neglect allegation for a resident who was found on the floor with an elbow and pelvic fracture within the mandated 2-hour timeframe. The incident occurred on 2/28/24, but it was not reported to the Health and Human Services Commission (HHSC) until 3/25/24. The delay was attributed to a communication failure between the previous Director of Nursing (DON) and the Administrator (ADM), who was unaware of the incident until nearly a month later. The current DON confirmed that the prior DON had conducted an investigation and in-services but failed to report the incident to the ADM or the state in a timely manner. Another incident involved a resident who alleged that a Certified Nursing Assistant (CNA) intentionally rammed her knees into a bathroom wall while assisting her to the toilet. The allegation was made on 03/09/24, but it was not reported to HHSC until 03/11/24. The resident initially reported the incident to an LVN, who documented the complaint and notified the ADM. However, the ADM did not report the incident to the state within the required 2-hour timeframe. Interviews with staff revealed that there was confusion and miscommunication regarding the reporting process, with some staff believing the incident had already been reported. The facility's failure to report these incidents in a timely manner could have affected the investigation and response to the allegations. The ADM and DON acknowledged the lapses in the reporting process and attributed them to communication failures and oversight. The facility's policies clearly state the requirement for immediate reporting of such incidents, but these policies were not followed, leading to delays in addressing the allegations of abuse and neglect.
Failure to Ensure Accurate MDS Assessment
Penalty
Summary
The facility failed to ensure assessments accurately reflected the resident's status for one resident reviewed for MDS assessment accuracy. Specifically, the facility did not code a resident's diagnosis of Schizophrenia on her MDS. The resident, who was cognitively intact with a BIM's score of 13, was incorrectly documented as having non-Alzheimer's Dementia and anxiety. The error was identified by the MDS Coordinator and the Regional MDS Nurse, who found that the diagnosis of vascular dementia was removed from the chart but not corrected on the MDS. Interviews with the resident and staff revealed that the resident did not have a diagnosis of dementia and was on Seroquel for Schizophrenia, which was confirmed by an out-patient psychiatric clinic and a provider. The facility's policy required accurate completion and transmission of MDS assessments, but this was not adhered to in this case. The MDS Coordinator, who was new to the role, admitted that the diagnosis was coded incorrectly and should have been corrected when identified. The DON and other staff members confirmed that the MDS Coordinator was responsible for completing the MDS and verifying proper diagnoses for psychotropic medications. The facility's policy on MDS assessments emphasized the importance of accurate data entry and transmission, but the failure to correct the significant error in the resident's diagnosis led to inaccurate documentation. This deficiency could place residents at risk for not receiving appropriate care and services to meet their needs.
Failure to Provide Routine Incontinent Care
Penalty
Summary
The facility failed to provide routine incontinent care for a resident, resulting in a urinary tract infection. The resident, who had Alzheimer's disease, depression, and anemia, was found lying in bed with a strong smell of ammonia, indicating concentrated urine. The resident reported not being changed since before the day shift started. An LVN confirmed the resident was saturated in urine and feces, with towels tucked between her legs, and noted increased confusion in the resident. The CNA assigned to the resident admitted not having time to provide care before going on her lunch break, leading to the resident's prolonged exposure to urine and feces. The incident was reported to the hospice nurse, who assessed the resident and noted increased confusion and foul-smelling urine. The hospice nurse contacted the MD, who ordered a urinalysis and started the resident on antibiotics. The DON and ADM both stated that it was their expectation for incontinent care to be provided every two hours and more frequently if possible. They emphasized the importance of proper incontinent care for skin protection and reducing the risk of urinary tract infections. The facility's policy on urinary infections highlighted the importance of keeping the skin clean and comfortable to prevent infections. The failure to provide timely incontinent care and the improper use of towels to soak up urine contributed to the resident's urinary tract infection. The CNA involved was terminated, and the incident underscored the need for prioritizing resident care over staff breaks.
Failure to Administer Medications Timely
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of medications for two residents. Resident #46, a female with COPD, pneumonia, and lung neoplasm, missed multiple doses of her prescribed inhalers, Symbicort and Brenya, over several days. Despite a grievance being filed and a resolution to in-service nurses, the resident continued to miss doses, leading to her experiencing tightness in her chest and difficulty breathing. The resident confirmed during an interview that she had not received her inhaler on time, and the ADON had to administer it during the observation. Resident #23, a female with hemiplegia, congestive heart failure, and pain, also experienced delays in receiving her prescribed hydrocodone/acetaminophen. The resident reported not receiving her medication on time, including a missed dose at 3:00 a.m. and a delayed dose at 7:00 a.m., which led to her experiencing pain. The medication aide admitted that it was challenging to administer all medications within the prescribed time frame. The DON acknowledged the importance of timely medication administration for maintaining therapeutic drug levels and stated that the facility had a plan to address the issue. The facility's policy required medications to be administered within one hour of their prescribed time. However, the facility failed to adhere to this policy, resulting in missed and delayed doses for both residents. The DON and ADM both emphasized the need for better communication and a plan to ensure timely medication administration, but the deficiencies persisted, affecting the residents' well-being.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate was not 5 percent or greater, resulting in a medication error rate of 6.06%. This involved two residents, one of whom did not receive their prescribed artificial saliva due to the medication not being available in the facility. The medication aide (MA) checked the medication cart and the storage room but could not find the medication, leading to the resident missing their dose. The interim administrator expected all medication carts to be stocked and locked with the correct medications, and staff were supposed to inform management if medications were low to place an order or buy over-the-counter alternatives. Another resident was administered a crushed extended-release guaifenesin tablet, which clogged the gastric tube port. The licensed vocational nurse (LVN) acknowledged that extended-release medications should not be crushed and contacted the nurse practitioner for an alternative order. The interim director of nursing (DON) expected nurses and MAs to have the correct medications on the cart prior to medication pass and educated the LVN on the proper handling of extended-release medications. The facility had issues with medication availability, partly due to the use of agency staff who might not consistently order medications when they were low.
Failure to Follow Smoking Policy for Resident Safety
Penalty
Summary
The facility failed to follow their established smoking policy regarding smoking safety for a resident. The resident, who had diagnoses including Charcot's joint, acute osteomyelitis, and diabetes mellitus, was observed keeping her electronic vape in her room and charging it on her bed, contrary to the care plan intervention that required the vape to be kept at the nurse's station and charged in non-resident areas. The resident also reported that she could go outside to vape whenever she wanted, without supervision, which was against the care plan intervention that required her to be supervised while smoking. Interviews with staff confirmed that the resident was observed vaping outside by herself and that electronic vapes should not be kept in resident rooms but stored at the nurse's station or on the medication cart. The facility's smoking policy indicated that vape devices should be monitored for safety issues, stored by designated staff, and not charged in resident areas. Despite this, the resident's vape was found in her possession and being charged in her room. The ADON and DON confirmed that the care plan should be implemented, and vapes should be stored on the medication cart or in the medication storage room. The President of Operations also stated that vapes should be kept on the medication cart with the charger. The failure to follow these policies and care plan interventions could place residents at risk for not receiving necessary care and services or having important care needs identified.
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 236 citations issued within 25 miles in the last 12 months — including the 16 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 Longview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage At Longview Healthcare Center | 0.2 mi | ★★★★★ | 1 | 0 |
| The Oaks At Longview | 0.2 mi | ★★★★★ | 8 | 0 |
| Buckner Westminster Place | 0.6 mi | ★★★★★ | 0 | 0 |
| Longview Hill Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 13 | 0 |
| Treviso Transitional Care | 1.6 mi | ★★★★★ | 19 | 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.