Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Magnolia during CMS and state inspections, most recent first.
Two residents with cognitive and physical impairments were subjected to physical abuse and neglect by a CNA, including being exposed to soap in the eyes and being physically restrained and verbally abused during care. Witnesses failed to report the incidents immediately due to fear of retaliation, despite having received training on abuse reporting. These failures placed vulnerable residents at risk.
Two staff members failed to immediately report alleged abuse incidents involving a CNA, including placing soap in a resident's eyes and physically restraining another resident, despite being trained to do so. The delay in reporting was due to fear of retaliation and concerns about social media threats, resulting in a late notification to the abuse coordinator and delayed investigation.
Two residents with significant cognitive and physical impairments were involved in separate alleged abuse incidents that were not thoroughly investigated or promptly reported by the facility. Staff delayed reporting the incidents due to fear of retaliation, and the facility failed to identify when the incidents occurred or notify law enforcement in a timely manner. Investigation documentation was incomplete, and the abuse coordinator was not informed immediately, resulting in a deficiency in the facility's response to allegations of abuse.
A deficiency was cited for not ensuring a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report does not provide further details about the specific circumstances or individuals involved.
Surveyors found that kitchen staff failed to label and date refrigerated food items and did not follow proper hand hygiene or sanitation protocols during meal preparation. Staff handled food and utensils without washing hands or wearing gloves, and equipment was not adequately sanitized between uses, despite having received training on these procedures.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
A resident with multiple mental health diagnoses was admitted without the required PASARR Level I screening being completed prior to admission. Staff interviews revealed confusion about the PASARR process and submission timelines, and documentation review confirmed the absence of the necessary screening report, resulting in a deficiency.
A resident with end stage renal disease who received dialysis three times weekly did not have this treatment addressed in their care plan, despite it being identified in their assessment. Nursing staff prepared the resident for dialysis based on experience rather than a documented plan, and the omission was acknowledged by the MDS nurse as an oversight.
A deficiency was found due to the facility's failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, as well as inadequate catheter care and insufficient measures to prevent UTIs.
The facility did not ensure an RN was on duty for at least 8 hours daily and failed to assign a full-time RN as DON, as evidenced by staffing records and facility documentation.
A medication cart was found unlocked and unattended in a hallway while an LVN was assisting a resident in a nearby room. The LVN, DON, and ADM all confirmed that facility policy requires medication carts to be locked when unattended, and that staff had been trained on this policy. Monitoring is conducted through compliance and walking rounds to ensure medication security.
A resident with dementia and a known history of elopement risk exited the secured memory care unit undetected by breaking a window and climbing over a fence. The resident was not discovered missing until a routine check, and was later found a mile away. The care plan identified elopement risk, but supervision and environmental safeguards were insufficient to prevent the incident.
A resident with a history of dementia, diabetes, and recurrent UTIs experienced a significant delay in receiving prescribed antibiotics after a positive urine culture for Escherichia coli. The resident reported increased pain and dysuria during the delay, and the medication administration record showed a gap in antibiotic administration with no documented explanation. Staff interviews revealed lapses in communication and adherence to policy regarding timely notification of the nurse practitioner and medication administration.
A resident with a history of UTIs experienced a significant delay in receiving prescribed antibiotics after a positive urine culture for Escherichia coli. Nursing staff did not promptly notify the practitioner of the abnormal lab results, resulting in the resident receiving her antibiotic seven days after the results were available. The resident reported increased pain and dysuria during this period, and documentation did not explain the delay or missed doses, contrary to facility policy requiring timely medication administration.
A resident with a history of heart issues experienced shortness of breath and chest pain, but the facility failed to notify the MD due to normal vital signs. The resident was later found unresponsive. The facility's policy requires immediate MD notification for any condition changes.
A resident with a mechanically altered diet due to dysphagia was given a peanut butter sandwich by a staff member, contrary to dietary orders specifying no bread. The resident, who required close supervision during meals, experienced distress and expired. The staff member admitted to not knowing the specific diet, revealing a gap in dietary management and staff training.
The facility failed to meet the nutritional needs of residents due to inadequate food supplies and improper menu substitutions. Observations revealed that the facility did not have sufficient food from 07/31/2024 to 08/06/2024, leading to menu changes without consulting the RD. The DS had to purchase food daily using the Administrator's personal credit card, and the facility lacked emergency food supplies. This deficiency placed residents at risk for inadequate nutrition.
The facility failed to label and date prepped food items in the kitchen, as observed during a survey. Milk, juices, cheese, and other items were not properly labeled or sealed, posing a risk of contamination. Interviews with dietary staff and the administrator highlighted the importance of labeling to track food freshness and prevent bacterial growth, as per the facility's policy.
A facility failed to conduct an updated PASRR evaluation for a resident with mental illness, despite new diagnoses of major depressive disorder and mood disorder unspecified. The resident's care plan included interventions for psychotropic drug use, but the only PASRR evaluation on record was from 2018, indicating a negative result for mental illness. Interviews with staff revealed a lack of clarity regarding the need for updated PASRR assessments, with the administrator acknowledging that a new evaluation should have been conducted.
A newly admitted resident with complex medical needs did not have a baseline care plan implemented upon admission, as required by facility policy. The resident's care plan was left blank initially and was only completed several days later, despite the facility's policy to complete it on the day of admission. Interviews with staff, including an LVN and the DON, confirmed the delay, which could risk improper care and decreased quality of life for the resident.
Two residents in a facility did not receive necessary assistance with personal hygiene, including bathing and nail care, over a period of several days. One resident, with hemiplegia and other conditions, was not bathed for five days, resulting in strong body odor and dirty fingernails. Another resident reported embarrassment due to facial hair and untrimmed nails, which were not addressed despite requests. Staff interviews confirmed that these care responsibilities were not fulfilled, leading to potential health risks and a decline in residents' quality of life.
The facility failed to develop an activity program based on the preferences of two residents, leading to boredom and increased risk of depression. A resident with severe cognitive impairment and limited vision reported dissatisfaction with repetitive activities and lack of suitable reading materials. Another resident with moderate cognitive impairment expressed boredom and a lack of engaging activities, leading to fabricating stories for entertainment. The activity calendar showed scheduled activities that were not conducted, and the environment was not conducive to group engagement.
A resident with asthma and on oxygen therapy was found with an aerosol air freshener in their room, which is against facility policy. Staff were unaware of its presence, and the facility lacked a clear policy on allowed materials in rooms.
The facility failed to adhere to its oxygen therapy protocols, as observed in two residents requiring oxygen. A resident's tubing was not changed weekly as per policy, with outdated tubing and an empty humidifier reservoir noted. Despite the facility's policy, the tubing was not replaced until later, potentially risking respiratory infections. Interviews with staff revealed discrepancies in documentation and execution of the oxygen administration policy.
A resident was given anti-acid medications without a physician's order, and the facility failed to ensure the resident swallowed the medication before leaving the room. The resident, with a history of dyspepsia, was found with four tablets of anti-acid medicine at his bedside, which were not listed on his MAR. The med aide admitted to providing the medications upon request without verifying a physician's order or ensuring immediate consumption, violating the facility's medication administration policy.
A dietary aide began working in the kitchen without receiving necessary orientation and training, lacking a food handler's certificate. The Dietary Manager admitted to the oversight, and the Human Resource Manager confirmed that all staff should be trained before starting work. The aide assisted with food service and preparation tasks unsupervised, contrary to facility protocol.
Failure to Protect Residents from Physical Abuse and Neglect
Penalty
Summary
The facility failed to protect two residents from physical abuse and neglect by a certified nursing assistant (CNA). In the first incident, a female resident with moderate cognitive impairment, blindness in one eye, and other significant medical conditions was subjected to physical abuse in the shower room. Two nursing assistants (NAs) witnessed the CNA put soap directly on the resident's face, causing soap to run into her eyes and resulting in the resident expressing discomfort and irritation. The incident was not reported immediately by the witnesses due to fear of retaliation from the CNA. In the second incident, a male resident with severe cognitive impairment, hemiplegia, and a history of aggressive behaviors was physically restrained by the same CNA during peri-care. Witnesses described the CNA using her knee and hands to pin the resident's arms and chest, and placing a hand around his throat while verbally abusing him. The resident was observed to become distressed, repeatedly asking for the CNA to stop. Again, the incident was not reported immediately by the staff present, citing fear of the CNA and her connections outside of work. Both incidents were eventually reported to the facility's abuse coordinator after a delay. Interviews and witness statements confirmed that staff were trained to report abuse immediately but failed to do so in these cases. The residents involved had significant cognitive and physical impairments, making them particularly vulnerable. The facility's failure to ensure timely reporting and protection from abuse constituted noncompliance and placed residents at risk of harm.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse were reported immediately, but not later than two hours after the allegations were made, to the abuse coordinator for two residents. Staff members witnessed or were aware of incidents involving a certified nursing assistant (CNA) allegedly placing soap in a resident's eyes during a shower and physically restraining another resident by pinning him with her knee and hand during care. Despite being trained to report abuse immediately, the staff members involved did not report these incidents to the abuse coordinator as required. The residents involved had significant cognitive and physical impairments. One resident was a female with moderate cognitive impairment, depression, dementia, epilepsy, blindness in one eye, and required substantial assistance with activities of daily living. The other resident was a male with severe cognitive impairment, hemiplegia, dementia with mood disturbance, seizures, and was dependent on staff for toileting hygiene. Interviews and record reviews indicated that the residents did not report feeling unsafe, and family members did not express concerns about their care. However, staff interviews revealed that the incidents were not reported promptly due to fear of retaliation from the CNA involved and concerns related to social media threats. Multiple staff members, including nursing assistants and nurses, confirmed they were trained to report abuse immediately to the abuse coordinator, whose contact information was made available to all staff. Despite this, the delay in reporting was attributed to fear of the CNA and lack of comfort in approaching supervisory staff. The abuse coordinator was eventually notified several days after the incidents, which delayed the initiation of an investigation into the alleged abuse. The facility's policy required immediate reporting of suspected abuse, neglect, or exploitation, which was not followed in these cases.
Failure to Thoroughly Investigate and Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to thoroughly investigate and report two separate allegations of abuse involving two residents. In both cases, the facility did not identify the specific timeframe when the alleged abuse occurred and did not notify local law enforcement in a timely manner. The investigation documentation was incomplete, lacking essential details such as the date and time of the incidents, and there was no immediate notification to the abuse coordinator by the staff who witnessed or were aware of the alleged abuse. The facility's self-reporting template and investigation report reflected missing or delayed information, and the police were not promptly notified, with no case number or documentation initially provided. The first resident involved was an elderly female with diagnoses including depression, dementia, epilepsy, blindness in one eye, and cognitive communication deficit. She required substantial assistance with activities of daily living. The second resident was an elderly male with severe dementia, hemiplegia, seizures, diabetes, and a history of agitation and combative behavior, requiring total staff assistance for toileting and hygiene. Both residents were the subjects of allegations that a staff member had either put soap in the female resident's eyes or physically restrained and verbally abused the male resident during care. Multiple staff members witnessed or were aware of these incidents but delayed reporting them due to fear of retaliation from the accused staff member. Interviews with staff revealed that the incidents were not reported immediately as required by facility policy and regulatory expectations. Staff cited fear of the accused staff member, who was known for making threats, as the reason for the delay. The facility's abuse coordinator and administrator were not informed until days after the incidents, and the subsequent investigation was hampered by the lack of timely reporting and incomplete information. The facility's failure to promptly and thoroughly investigate and report the allegations, as well as to notify law enforcement, constituted a deficiency in responding appropriately to alleged violations of abuse and neglect.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included in the report.
Failure to Follow Food Safety and Hand Hygiene Protocols in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and distribution within the facility's kitchen. Four chocolate flavored creme pies were found in a spare refrigerator without any labeling or dating, contrary to facility policy requiring all refrigerated foods to be labeled and dated. Additionally, a staff member was observed preparing pureed meals without washing her hands at the start of the process or wearing gloves. She handled various utensils and retrieved ingredients from the refrigerator without performing hand hygiene or donning new gloves between tasks. The same staff member was also seen licking her finger to remove excess food and failed to properly wash and sanitize equipment, only rinsing the blender cup instead of using the dishwasher as required. Interviews with the kitchen manager and the staff member confirmed that both had been trained on hand hygiene and food labeling protocols. The kitchen manager acknowledged that improper hand hygiene and failure to label and date food could result in residents becoming ill. Review of facility policies confirmed the requirements for hand hygiene and proper food labeling and dating, as well as the expectation that all staff adhere to these standards to prevent the spread of infection and ensure food safety.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Complete PASARR Screening Prior to Admission
Penalty
Summary
A resident with a history of schizoaffective disorder, insomnia, depression, and generalized anxiety disorder was admitted to the facility without the completion of the required PASARR Level I screening prior to admission. Record review showed that the resident's care plan addressed depression related to schizoaffective disorder, and a psychiatric evaluation documented ongoing mental health concerns, including increased depression and anxiety. However, there was no evidence in the resident's electronic health record of a completed PASARR Level I Am screening report, as required by facility policy and federal regulations. Interviews with facility staff, including the MDS Coordinator, DON, and ADM, revealed a lack of clarity regarding the PASARR submission process and timelines. The MDS Coordinator acknowledged the requirement to submit the PASARR after the IDT meeting within 14 days, while the DON and ADM were uncertain about the specific timeframe for submission. The facility's PASRR policy mandates that the Level I screening be completed before admission, but this was not done for the resident in question, resulting in a deficiency related to the PASARR screening process.
Failure to Care Plan Dialysis for Resident with End Stage Renal Disease
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with end stage renal disease who was receiving dialysis three times a week at an external dialysis center. Despite the resident's medical history, which included diagnoses such as end stage renal disease, depression, dementia, muscle wasting, vitamin D deficiency, type 2 diabetes, and hypertension, the care plan did not address the dialysis treatment as required. The resident's annual MDS assessment indicated the need for dialysis, but this was not reflected in the care plan dated after the assessment. Interviews with nursing staff revealed that while routine preparations and checks were performed before the resident was transported for dialysis, these actions were based on the nurse's experience rather than guidance from a documented care plan. The MDS nurse acknowledged that the dialysis treatment should have been included in the care plan and attributed the omission to unintentional negligence. The facility's policy requires that all active problems identified in the comprehensive assessment be incorporated into the care plan, but this was not followed in the case of the resident's dialysis treatment.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder. It also notes failures in providing appropriate catheter care and in implementing measures to prevent urinary tract infections. The deficiency is based on observations or findings that the facility did not consistently ensure proper care practices for these residents, as required by regulatory standards.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for at least 8 hours each day and did not designate a registered nurse to serve as the director of nursing (DON) on a full-time basis. This deficiency was identified through review of staffing schedules and facility records, which showed noncompliance with the required RN coverage and DON assignment.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on the 100 hall was observed to be unlocked and unattended by a resident's room. The nurse responsible for the cart, an LVN, was in a resident's room with the door closed and out of sight of the cart at the time. The LVN confirmed during an interview that she was responsible for the cart and had been trained on the facility's policy, which requires medication carts to be locked whenever unattended. She stated that she forgot to lock the cart because she was rushing to assist a resident. Interviews with the DON and ADM confirmed that all nursing staff had been trained on medication storage policies, which require medication carts to be locked when not in use. Both the DON and ADM stated that monitoring is conducted through compliance rounds and walking rounds to ensure adherence to this policy. Review of the facility's Medication Labeling and Storage Policy further confirmed the requirement for all medications and biologicals to be stored in locked compartments, with access limited to authorized personnel.
Failure to Prevent Elopement of High-Risk Resident from Secured Unit
Penalty
Summary
A resident with a history of dementia, unsteadiness, and high elopement risk was admitted to the facility and placed in the memory care unit due to previous attempts to leave unattended and poor safety awareness. The resident's care plan identified elopement risk and included interventions such as placement in a secured unit and providing diversions. Despite these measures, the resident was able to exit the facility undetected. On the morning of the incident, the resident was last seen asleep in his room by staff. Later, staff discovered the resident missing and initiated a search. It was determined that the resident had escaped through a window in the dining area of the memory care unit, which was found broken with the screen pushed out. The resident's walker was left by a table, and he was later located approximately a mile away from the facility. Interviews with staff confirmed that the resident was not observed leaving, and the escape was not detected until a routine check revealed his absence. The resident later explained that he had loosened screws on the window to facilitate his escape and used a chair in the backyard to climb over the fence. The resident reported being bored and wanting to socialize, and also mentioned seeking cigarettes as a motivation for leaving. Staff interviews indicated that the resident had previously shown stress when out of cigarettes, and that the facility was aware of his high risk for elopement. The deficiency occurred due to the failure to provide adequate supervision and maintain an environment free from accident hazards, allowing the resident to exit the secured unit undetected.
Delay in Antibiotic Administration Following Positive UTI Result
Penalty
Summary
A female resident with a history of dementia, diabetes, muscle wasting, and recurrent urinary tract infections (UTIs) was not administered her prescribed antibiotic, Bactrim, in a timely manner following a positive urine culture indicating a UTI. The resident reported dysuria to the medical doctor, who ordered a urinalysis. The urine specimen was collected and results indicated a high microbial load of Escherichia coli. Despite this, there was a delay of seven days before the resident received her prescribed antibiotic treatment. The medication administration record (MAR) showed that the resident received only one dose of Bactrim initially, with no further doses administered until several days later, and there was no documentation explaining the gap in administration. Interviews with nursing staff revealed uncertainty and lack of recall regarding the delay, with staff acknowledging that the standard process would be to notify the nurse practitioner and obtain orders promptly upon receiving lab results. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not followed in this instance. The resident reported experiencing increased pain and dysuria during the period she did not receive her antibiotics, expressing concern about potential kidney damage. Staff interviews confirmed that the delay in starting antibiotics was not in line with expectations and that the nurse practitioner should have been notified within 24 hours of positive lab results. The facility administration acknowledged that the situation did not meet their standards and could not explain how the error occurred.
Delay in Practitioner Notification and Antibiotic Administration Following Positive UTI Lab Result
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of laboratory results that were outside clinical reference ranges, specifically in the case of a female resident with a history of dementia, diabetes, muscle wasting, and recurrent urinary tract infections (UTIs). After the resident reported dysuria, a urine sample was collected and later confirmed to be positive for a UTI with a high microbial load of Escherichia coli. Despite the positive lab results, there was a delay in notifying the practitioner and obtaining an order for antibiotics. The resident did not receive her prescribed antibiotic, Bactrim, until seven days after the positive UTI results were received. Documentation showed that only one dose was administered initially, with a gap of several days before the full course of antibiotics was started. There was no documentation explaining the delay or the missed doses during this period. Interviews with nursing staff and administration confirmed that the expected protocol was not followed, and the nurse responsible for receiving lab results did not promptly notify the practitioner or obtain timely orders. The resident reported experiencing increased pain and dysuria during the period she was not receiving antibiotics. Staff interviews indicated that the delay was not in line with facility policy, which requires medications to be administered in a safe and timely manner as prescribed. The failure to promptly communicate lab results and administer prescribed medication resulted in the resident not receiving the intended therapeutic benefit in a timely manner.
Failure to Notify MD of Resident's Condition Change
Penalty
Summary
The facility failed to immediately inform a resident's physician when there was a significant change in the resident's condition. A male resident, who was moderately cognitively impaired and had a history of heart failure, hypertension, and other health issues, experienced shortness of breath and chest pain. Despite these symptoms, the Assistant Director of Nursing (ADON) did not notify the facility's Medical Doctor (MD) because the resident's vital signs appeared normal, and he seemed comfortable. The resident was later found unresponsive and without a pulse or respirations. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) on duty was on break during the incident and was not informed of the resident's symptoms. The resident's MD stated that he expected to be notified of any significant changes, such as shortness of breath or chest pain, and would have ordered a STAT chest x-ray if informed. The Director of Nursing (DON) confirmed that the facility's policy required immediate notification of the MD for any changes in a resident's condition. The facility's failure to follow this policy could place residents at risk of illness, injury, and decreased quality of life.
Failure to Adhere to Resident's Dietary Needs Leads to Fatal Incident
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of a resident, leading to a serious incident. The resident, who had a mechanically altered diet due to dysphagia and other medical conditions, was given a peanut butter sandwich by a staff member, contrary to the dietary orders that specified no bread. This incident occurred during snack time when the staff member, unaware of the resident's specific dietary restrictions, provided the sandwich, which was not suitable for the resident's mechanical soft diet. The resident had a history of severe cognitive impairment, dysphagia, and other health issues that required a mechanically altered diet with close supervision. The resident's care plan and dietary orders clearly indicated the need for a mechanically soft diet with no bread, to prevent choking and aspiration risks. Despite these orders, the staff member provided a peanut butter sandwich, which was a dense and dry food item, unsuitable for the resident's dietary needs. The incident resulted in the resident experiencing distress and ultimately expiring. Interviews with staff revealed a lack of awareness and adherence to the resident's dietary orders, as well as inconsistencies in the communication and understanding of the resident's dietary needs. The staff member involved admitted to not knowing the specific diet the resident was on at the time of the incident, highlighting a critical gap in the facility's dietary management and staff training processes.
Removal Plan
- The regional nurse consultant, regional reimbursement consultant, the director of nursing, and the MDS audited all Matrix EHR orders to validate that they matched the RD Dining Meal ticket system and that they were on the Resident Profile so that the CNAs and other facility workers can identify the diet that the resident is on and any precautions that are in place. Any concerns or discrepancies were corrected immediately upon discovery. Snacks ordered for weight loss interventions were audited and all were correct.
- The director of nursing/designee in-serviced facility staff on where to find the diet information for a resident. Facility staff will receive the information before starting their next assigned shift. Agency staff will receive the information before starting their assigned shift.
- The CNA who fed the resident bread was individually re-educated by the administrator and the director of nursing regarding following the resident diet and where to find diet information.
- The regional nurse consultant in-serviced the administrator and the director of nursing on new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the Resident Profile. New admission orders will be reviewed in the Interdisciplinary Team Meeting (IDT) and corrections made when needed. The RD Dining Meal Ticket system will also be checked at that time to validate that everything matches. The MDS will then develop a care plan for any dietary needs identified per the regulation.
- The RD recommendations will be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders entered per the above processes. The Resident Profile and care plan will be updated at that time. Any concerns will be discussed in the weekly Quality of Care meeting.
- Speech therapy recommendations will be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders will be entered per the above processes. The Resident Profile and care plan will be updated at that time. Any concerns will be discussed in the weekly Quality of Care meeting.
- An Ad Hoc QAPI meeting was held with the facility medical director to discuss the deficiency and actions put in place by the facility.
- The administrator will monitor the new orders for diets from the RD or the Speech Therapist, weekly for one month and randomly thereafter by reviewing the facility activity report, actual food on meal trays, and documenting findings on a log created by the facility. Any concerns or trends will be brought to the monthly QAPI meeting for tracking and trending and new IDT recommendations.
Facility Fails to Meet Nutritional Needs Due to Inadequate Food Supplies
Penalty
Summary
The facility failed to ensure that menus and nutritional adequacy met the nutritional needs of residents in accordance with established national guidelines. This deficiency was observed during two meals where the facility did not have the necessary food supplies to prepare and serve the planned or alternate menu. The facility was found to have insufficient food supplies from 07/31/2024 through 08/06/2024, with only enough food available for lunch, dinner, and the next day's lunch on 08/06/2024. This lack of food supply could place residents at increased risk for inadequate nutrition. During observations and interviews, it was revealed that the facility's menus rarely matched what was served, and residents often did not eat from the facility's kitchen due to dissatisfaction with the food. The Dietary Supervisor (DS) admitted to substituting menus due to unavailable food and residents' dislikes without consulting the Registered Dietitian (RD). The DS also stated that the facility was supposed to have a seven-day supply of food, but the order for 07/31/2024 was not approved by Corporate due to budget constraints. As a result, the DS had to purchase food daily using the Administrator's personal credit card. The Administrator confirmed awareness of the situation and stated that Corporate was not informed about the lack of food until the State Surveyors inquired. The facility did not have emergency food supplies for sheltering in place or evacuations. The RD was not contacted regarding menu changes until after the surveyors' visit, and the facility's menu substitution forms were not signed off by the RD. The facility's failure to maintain adequate food supplies and follow established guidelines for menu preparation and nutritional adequacy led to this deficiency.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in their kitchen, as observed during a survey. Specifically, the facility did not label or date food items that were prepped, which is a critical step in ensuring food safety. Observations revealed that milk, orange juice, and cranberry juice were not dated or labeled with the date they were prepped. Additionally, a pitcher of juice in the refrigerator was covered but not labeled, and a personal drink in a Styrofoam cup was found in the kitchen. Other items, such as a package of cheddar cheese, a large container of Blue Bunny Sherbet, and an opened box of taco shells, were not properly sealed, labeled, or dated. Interviews with dietary staff and the administrator confirmed the importance of labeling and dating food to track how long it has been opened and to prevent contamination. The Dietary Manager emphasized that all food in the refrigerator, freezer, and pantry should be dated and labeled to maintain freshness and prevent bacterial growth. The facility's Food Receiving and Storage Policy also mandates that all food stored in the refrigerator or freezer be covered, labeled, and dated. The failure to comply with these standards placed residents at risk of foodborne illness.
Failure to Conduct Updated PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment. Specifically, the facility did not have an accurate PASRR Level 1 assessment for a resident who had a diagnosis of major depressive disorder and mood disorder unspecified. This resident was admitted with several diagnoses, including Type 2 Diabetes, Dysphasia with Cerebrovascular disease, and Major Depressive disorder. Despite these diagnoses, the only PASRR evaluation on record was from 2018, which indicated a negative result for mental illness. The resident's care plan included interventions for psychotropic drug use, yet no updated PASRR assessment was conducted following the addition of new mental health diagnoses. Interviews with facility staff revealed a lack of clarity and understanding regarding the need for updated PASRR evaluations. The MDS coordinator acknowledged that the resident's diagnoses should have triggered a new PASRR assessment, but stated that only certain diagnoses automatically prompted such evaluations. The Director of Nursing deferred to the MDS coordinator on PASRR evaluation questions, and the Assistant Director of Nursing, who was the charge nurse for the resident, was unaware of the need for psychoactive medications. The facility administrator admitted that a new PASRR evaluation should have been conducted with each new diagnosis, indicating a failure to adhere to state guidelines for PASRR assessments.
Failure to Implement Timely Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to implement a baseline care plan for a newly admitted resident, identified as Resident #128, which is necessary to provide effective and person-centered care. Upon admission, Resident #128 had several medical conditions, including dysphagia following a cerebral infarction, persistent atrial fibrillation, prostate cancer, flaccid hemiplegia of the right side, and dysarthria. Despite these complex medical needs, the baseline care plan, which should have been completed on the day of admission, was left blank by the MDS Coordinator. This oversight was noted during a review of the care plan dated several days after admission, which eventually included interventions for the resident's swallowing problems, incontinence, prostate cancer, atrial fibrillation, and right-sided hemiparesis. Interviews with facility staff revealed a lack of adherence to the facility's policy regarding the timely completion of baseline care plans. The LVN stated that baseline care plans should be completed before the end of the shift on the day of admission, while the DON confirmed that the care plan for Resident #128 was not completed until several days later. The administrator also acknowledged that baseline care plans are expected to be completed on the day of admission. This delay in creating a baseline care plan could potentially place residents at risk for decreased quality of life, improper care, and injury, as it did not meet the professional standards of quality care required for newly admitted residents.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene. This deficiency was observed in two residents, who did not receive adequate assistance with bathing and nail care. Resident #21, a male with hemiplegia, hemiparesis, and other conditions requiring assistance with personal care, did not receive a shower or bath for a period of five days, despite not refusing such care. Observations noted a strong body odor, oily hair, and blackish substance under his fingernails, which he attributed to bowel matter. He expressed frustration over repeated requests for bathing that were unmet due to staff being too busy. Resident #40, a female resident, also experienced neglect in personal hygiene care. She reported embarrassment due to facial hair and untrimmed nails, which she had requested to be addressed by staff but was told they were too busy. She could not recall the last time she had a shower, estimating it had been over a week. Interviews with staff, including CNAs and the DON, confirmed that nail care and bathing were responsibilities of the nursing staff, with a schedule in place for showers. However, documentation did not indicate any refusals of care by the residents, suggesting a lapse in the facility's adherence to its care policies. The facility's policy on nail care, revised in 2010, emphasizes the importance of regular cleaning and trimming to prevent infections and maintain hygiene. Despite this, the facility failed to ensure that these basic care needs were met for the residents, leading to potential health risks and a decline in their quality of life. The staff interviews highlighted a lack of awareness or action regarding the residents' unmet care needs, contributing to the deficiency observed by the surveyors.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to develop an activity program based on the preferences of two residents, leading to a lack of engagement and increased risk of depression and boredom. Resident #48, a female with severe cognitive impairment, limited vision, and multiple health conditions, expressed dissatisfaction with the activities provided. She reported that the activities were repetitive and not tailored to her needs, such as the lack of reading materials suitable for her vision and the absence of diabetic-friendly food options during events. Observations confirmed that she often sat in her room without engaging in any activities, contributing to her feelings of depression and boredom. Resident #50, a male with moderate cognitive impairment and depression, also reported boredom and dissatisfaction with the activities offered. He noted that the activities were repetitive and did not align with his interests, such as his preference for live music over the music played during meals. He expressed that the lack of engaging activities led him to fabricate stories about staff for entertainment. Observations and interviews confirmed that he spent much of his time alone and did not participate in activities that matched his interests. The facility's activity calendar showed scheduled activities that were not conducted on specific dates, and the activities that did occur were often not conducive to group engagement due to environmental factors like noise. The Activity Director acknowledged these issues, including the lack of variety in the activity calendar and the failure to consider individual resident preferences. The facility's policies on group programs and activities were not adequately followed, contributing to the deficiency.
Aerosol Air Freshener Found in Resident's Room
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, as evidenced by the presence of a 12-ounce aerosol air freshener bottle at the bedside of a resident with a diagnosis of asthma and who was receiving oxygen therapy. The use of aerosols is contraindicated for individuals with these conditions. The resident, who had mild cognitive impairment and required substantial assistance for transfers, dressing, and bathing, was not aware of how the aerosol came to be in her room. Interviews with facility staff, including an LVN and the DON, revealed that they were unaware of the presence of the aerosol in the resident's room and acknowledged that it was against facility policy to have such items in resident rooms. The facility's admission packet did not contain information on allowed materials in rooms, and the facility was unable to provide a policy on air fresheners when requested. This oversight could potentially place residents at risk of avoidable accidents and injury.
Failure to Adhere to Oxygen Therapy Protocols
Penalty
Summary
The facility failed to provide appropriate respiratory care for residents requiring oxygen therapy, specifically for two residents reviewed for oxygen use. The deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not adhere to its policy of changing, dating, and initialing oxygen humidifiers, tubing, and cannulas weekly. Resident #53's oxygen tubing was observed to be dated 7/01/24, and the humidifier reservoir was found empty, indicating a lapse in the facility's protocol. Despite the facility's policy requiring weekly changes, the tubing was not replaced until 7/14/24, as confirmed by the resident and staff interviews. Resident #53, who was admitted with multiple diagnoses including joint replacement surgery, pneumonitis, and diabetes, was found to have oxygen tubing that was not changed according to the facility's policy. The resident's care plan included interventions for oxygen therapy, yet the tubing was not replaced in a timely manner, potentially placing the resident at risk for respiratory infections. Interviews with the LVN and DON revealed discrepancies in the documentation and execution of the facility's oxygen administration policy, with the DON unable to explain the presence of outdated tubing. The facility's administrator acknowledged the policy breach, confirming that the tubing should have been replaced weekly.
Failure to Administer Medications Safely and as Prescribed
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident, identified as Resident #58, by administering anti-acid medications without a physician's order and not ensuring the resident swallowed the medication before leaving the room. Resident #58, a male with a history of dyspepsia, hypertension, long-term use of antithrombotic/antiplatelets, and anemia, was observed with four tablets of anti-acid medicine at his bedside, which were not listed on his Medication Administration Record (MAR). The resident reported receiving anti-acid medications from the med aide without a physician's order and sometimes taking multiple tablets at once. Interviews with the med aide and the Director of Nurses (DON) revealed that the facility's protocol required a physician's order for all medications, including over-the-counter ones like anti-acids. The med aide admitted to providing the resident with anti-acid medications upon request, without verifying a physician's order or ensuring the resident took the medication immediately. The DON confirmed that it was against best practices to administer medications without reviewing the MAR and to leave medications at the resident's bedside. The facility's policy on administering medications, revised in December 2012, mandates that medications be administered safely, timely, and as prescribed, with proper documentation on the MAR. The med aide's actions of providing anti-acid medications without a physician's order and not observing the resident taking the medication violated this policy, potentially putting the resident at risk of consuming unprescribed medications and experiencing adverse effects.
Inadequate Training for Dietary Aide
Penalty
Summary
The facility failed to provide sufficient support personnel with the appropriate competencies and skills to carry out the functions of the food and nutrition service. This deficiency was identified when a dietary aide, referred to as Dietary Aide H, was found to have started working in the kitchen without receiving the necessary orientation and training. The personnel file for Dietary Aide H lacked a certificate of food handlers' course and any records of orientation or training. On the day of the incident, the Dietary Manager admitted to calling Dietary Aide H to work without prior training or orientation, acknowledging the mistake and stating that he was not qualified to perform any tasks in the kitchen. Further interviews revealed that the Human Resource Manager was unaware of Dietary Aide H working that day and confirmed that all staff were required to undergo training and orientation before starting work. The Dietary Manager later stated that Dietary Aide H was supposed to undergo three days of training and orientation before working alone in the kitchen, which did not occur. Despite being unqualified, Dietary Aide H assisted with food service and some food preparation tasks without supervision. The facility's protocol for dietary staff orientation and training was not provided at the time of the survey exit.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 105 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Luling
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Luling | 1.3 mi | ★★★★★ | 17 | 0 |
| Diversicare Of Luling | 2 mi | ★★★★★ | 0 | 0 |
| Parkview Nursing And Rehabilitation Center | 11.8 mi | ★★★★★ | 8 | 3 |
| Chisolm Trail Nursing And Rehabilitation Center | 13 mi | ★★★★★ | 1 | 0 |
| The Heights Of Gonzales | 16.9 mi | ★★★★★ | 9 | 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 August 2026) and official state health department websites.