Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Mineola during CMS and state inspections, most recent first.
A CNA physically abused a resident during incontinent care on the secured unit, forcibly pushing the resident onto the bed, striking the chest, and placing hands and forearm around the throat while the resident resisted and gasped for air. The resident had advanced cognitive impairment, dementia, and was fully dependent for care, and later showed bruising to the chest and arms with petechiae noted on the chest and lower arms. Family video, police review, and facility records documented the assault and the resident’s inability to reliably describe the event.
The facility employed a cook who had a prior felony conviction for aggravated assault with a deadly weapon, despite state law barring such individuals from employment and the facility’s own abuse/neglect policy prohibiting hiring persons found guilty of abuse, neglect, exploitation, misappropriation, or mistreatment. The cook’s personnel file showed multiple criminal history checks, and the cook reported serving four years in jail for the offense. The HR Director reviewed the criminal history and identified both a deferred adjudication and a subsequent conviction with a four-year confinement term, concluding this created a lifetime employment bar. The DON stated the HR Director was responsible for criminal history checks and the Administrator for oversight of that process, while the Administrator maintained his belief that the cook remained eligible for employment based on his interpretation of the criminal history and deferred adjudication.
A resident with Alzheimer’s disease, moderate cognitive impairment, and a known history of falls experienced an unwitnessed fall in a secured unit hallway, resulting in a forehead bruise and subsequent hematoma and facial bruising. An LVN documented that the physician had been notified and initiated neuro checks, and the resident’s family and nursing leadership were informed; however, the LVN later admitted she had not actually contacted the physician. The physician stated he first learned of the fall the next day when notified of the resident’s increased facial pain and bruising and said he would have sent the resident to the ER immediately had he been informed at the time of the fall. This sequence of events occurred despite a facility policy requiring prompt physician notification after accidents or incidents involving a resident.
RN coverage was not maintained for at least 8 consecutive hours every day. After the DON left, the facility relied on an acting DON and a weekend RN, but interviews showed the acting DON was not in the building every weekday and the weekend RN did not work during the week. Staff and the Administrator acknowledged the facility had not met the RN hours requirement, and records showed multiple days without the required RN coverage.
Unsafe Bathroom Conditions and Damaged Window Blinds: A resident with severe cognitive impairment was found with a dirty bathroom floor, water on the tile, and a leaking sink after reporting the issue had persisted for weeks. In addition, multiple resident rooms on the secured unit had blinds missing pieces, and two residents with severe cognitive impairment said sunlight entered their rooms and interfered with daytime sleep. Staff acknowledged the wet floor, leaking sink, and damaged blinds were unacceptable and affected comfort and safety.
Nurse staffing data was not posted daily and was not readily visible to residents and visitors. Surveyors found the staffing sheet behind a Christmas tree on a table near the front door, and it was still dated from an earlier month. The ADON and ADM stated the DON had been responsible for posting staffing before leaving, and no one had been assigned until later, when the ADON was told to post it daily.
A facility failed to maintain infection control practices when an LPN administered medications to two residents without sanitizing her hands between residents, and a resident room remained soiled with feces, urine, and unidentified black marks on the floor and bathroom area. The residents involved had diagnoses including dementia, Parkinson's disease, ESBL, and incontinence, and staff observed the room to be sticky, malodorous, and not fully cleaned, with housekeeping and CNA staff acknowledging the condition.
Failure to refer a resident with a psychosis diagnosis for PASRR Level II review. The resident’s record showed unspecified psychosis, severe cognitive impairment on MDS, unclear speech, and routine antipsychotic and antianxiety use, but the PASRR Level I screening marked mental illness as no. Staff interviews showed the MDS coordinator, ADON, Administrator, and RNC/Acting DON all identified that a positive Level I or 1012 form should have been completed, yet no referral for Level II review was made.
A resident with pneumonia and moderate cognitive impairment was receiving oxygen via nasal cannula, but the oxygen concentrator filter was observed covered in gray debris on two separate observations. The order required the filter to be changed weekly and as needed, and the ADON, Administrator, and RNC/Acting DON stated it should have been cleaned; they identified infection control, illness, airflow issues, and respiratory complications as concerns.
A resident with pain and multiple chronic conditions had a PRN hydrocodone-acetaminophen tablet not properly accounted for in the narcotic count. One LPN said she gave the dose but forgot to document it, and the oncoming LPN did not reconcile the controlled substance count at shift change. The ADON confirmed the count discrepancy and noted the PRN order had been entered on the wrong MAR in PCC, preventing documentation.
A resident’s albuterol inhaler was observed on the bedside table, and a bottle of nystatin topical powder was observed on top of a medication cart in plain view instead of being secured in locked storage. The resident said he used the inhaler daily and left it on the table. Interviews with the ADON, LVN, Administrator, and Acting DON confirmed that these medications should have been locked in the medication cart and not accessible to residents.
A CNA and an LVN were found in a secured unit living room with a blanket covering the overhead light, which was done because the light could not be turned off and shined into a resident's room. The CNA kept the resident's door open due to a history of wandering. The Maintenance Director confirmed the light switch had been intentionally disconnected, and both he and the Administrator acknowledged that covering lights with cloth is a fire hazard. The facility lacked a policy on this issue.
Three medication carts were found unlocked and unattended in hallways, with staff and residents passing by or sitting near the carts. LVNs admitted to leaving the carts unlocked while working, despite facility policy requiring secure storage accessible only to authorized personnel. The Administrator and ADON confirmed that carts should only be unlocked when staff are actively retrieving medications or standing directly in front of them.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that restrained their ability to function, resulting in a deficiency related to medication management.
A nurse aide worked for several months with an expired certification, providing direct care to residents. The facility lacked a policy for monitoring certification renewals, and administrative staff were unaware of the lapse until notified by another employee. The aide believed the facility would handle her renewal, and the monitoring system in place failed to identify the expired status.
Staff did not immediately inform a resident, the resident's doctor, and a family member about incidents such as injury, decline, or room changes that affected the resident, as required by policy.
A resident with a history of edema, hypertension, and CHF developed a weeping blister and swelling on her leg. Nursing staff applied dressings and wraps without notifying the physician or obtaining orders, and the DON was unaware of the treatment. The physician was not informed of the change in condition, and facility policy requiring prompt notification was not followed.
Two residents with chronic pain had their prescribed hydrocodone-acetaminophen tablets replaced with extra strength Tylenol after being admitted with pill bottles from outside sources. The misappropriation was discovered by a nurse during medication administration, and an internal investigation could not determine when the switch occurred or who was responsible. Both residents reported effective pain management and no complaints at the time of assessment.
A resident's medical record was not accurately maintained when the DON edited a wound care progress note originally written by an LVN, removing information about the previous dressing date without having performed the care herself. The LVN had documented the date found on the dressing, and the DON later acknowledged that the note should not have been changed. Facility policy requires accurate and complete documentation.
A shower room was found with black grime on the walls, a pink stain on the floor, and missing tiles that had not been repaired for over a month. Staff interviews revealed confusion over cleaning responsibilities and a lack of maintenance work orders, despite awareness of the issues by housekeeping and maintenance staff. Facility policy required daily cleaning and prompt repairs, but these were not consistently carried out.
Multiple residents with cognitive and behavioral impairments were not protected from physical abuse, including incidents where one resident slapped another after being startled, a CNA slapped a resident during a transfer, and a family member struck a resident during a dispute over discharge. These events involved both resident-to-resident and staff- or family-initiated abuse, with injuries and emotional distress documented.
The facility did not maintain an effective pest control program, as multiple residents and staff reported ongoing sightings of roaches and water bugs in resident rooms, the dining area, and other areas. Although staff were instructed to document pest sightings in designated binders, they relied on verbal reports, resulting in no written records. The pest control technician confirmed ongoing pest issues despite regular treatments, and the facility's policy requiring an effective pest control program was not followed.
A resident with multiple mental health diagnoses, who was cognitively intact, received Seroquel for bipolar disorder without a signed written consent form as required. Although the resident was aware of the medication, the facility did not obtain the necessary written consent acknowledging the risks and benefits, as confirmed by staff interviews and policy review.
Two residents with intact cognition reported missing personal clothing items—one after a laundry fire and another after her pants went missing. Both informed staff, but no formal grievance was filed, and the items were not replaced. Staff interviews revealed a lack of communication and understanding of the grievance process, and review of records confirmed no grievances were documented as required by facility policy.
A resident with multiple medical conditions and intact cognition did not receive scheduled showers as outlined in his care plan, despite not refusing care. Documentation and staff interviews revealed missed and irregularly timed showers, with staff citing time constraints and workload as reasons for the lapse. Facility policy required assistance with ADLs, but the resident did not consistently receive necessary hygiene care.
The facility failed to ensure a clean, comfortable, and homelike environment due to a shortage of clean bed and bath linens. Observations revealed inadequately stocked linen closets and carts, with staff confirming the shortage and attributing it to staffing limitations and linen being hidden or destroyed. The Housekeeping/Laundry Supervisor noted insufficient staffing and the Administrator acknowledged the risk to residents.
The facility failed to resolve grievances related to missing clothing for four residents, including those with Alzheimer's and dementia. Despite reports from family members, grievances were either not documented or inadequately resolved, leading to ongoing issues with missing personal items. Family members expressed frustration and resorted to handling laundry themselves or purchasing new clothing.
The facility failed to properly label, date, and dispose of food items, leading to potential risks of food contamination. Observations revealed expired and unlabeled items in the kitchen's refrigerator and freezer. Despite regular walk-throughs by the Dietary Manager, these issues were not addressed, and the Administrator was unaware of the deficiencies.
The facility failed to coordinate hospice care effectively for residents, resulting in missing or outdated hospice documentation. This deficiency involved three residents whose hospice binders lacked essential documents like care plans and medication profiles. Interviews revealed that the hospice companies were responsible for providing these updates, but lapses in communication and coordination led to potential risks in resident care.
The facility failed to maintain proper infection control practices, including staff not wearing PPE during care for a resident on enhanced barrier precautions, improper hygiene during incontinent care for a resident with cerebral palsy, and inadequate storage of clean and dirty linens. Additionally, a resident's catheter bag was found on the floor, and a linen cart was left uncovered, all of which pose infection risks.
A resident in an LTC facility was administered Klonopin without documented informed consent from the resident or their responsible party. The LVN assumed consent was unnecessary due to the resident's prior use of the medication. The ADON and DON confirmed the oversight, highlighting the importance of consent for psychotropic medications. The facility's policy requires informed consent and education on medication risks and benefits, which was not followed.
A resident with Alzheimer's disease and a history of falls did not have their care plan updated after three falls, despite interventions being in place. The facility's staff, including the ADON and DON, acknowledged the oversight, which was contrary to the facility's policy requiring care plan revisions after assessments.
A resident requiring moderate assistance with personal hygiene was observed with unaddressed chin hair, despite expressing discomfort. Facility staff, including a CNA and LVN, failed to provide necessary grooming, impacting the resident's dignity and self-esteem. The facility's ADL policy was not followed, leading to a deficiency in care.
A resident with multiple diagnoses, including Alzheimer's, did not have a required Depakote level test conducted as ordered, due to inconsistent nurse staffing and oversight. The ADON acknowledged responsibility, and the DON and Administrator recognized the risk of potential toxicity from the missed lab test.
A resident's bathroom was found to be consistently dirty and unsanitary, with brown stains, sticky floors, and a strong urine odor. The resident, who required assistance with toileting, reported dissatisfaction with the cleanliness. Housekeeping staff admitted to cleaning the bathroom only once a day, and the Housekeeping Supervisor cited staffing shortages as a challenge. The facility's policy emphasized maintaining a clean environment, which was not met in this case.
A facility failed to maintain an effective pest control program, resulting in roaches in a resident's bathroom. Despite multiple pest sightings documented in logs, the Pest Control Technician was unaware of the issue in resident areas, as he only treated the exterior and kitchen. Interviews revealed that the Maintenance Supervisor and Administrator were also unaware of the complaints, highlighting a breakdown in communication and oversight.
Physical abuse of a cognitively impaired resident during incontinent care
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse when a CNA handled the resident in a rough manner during incontinent care on the secured unit. The resident had diagnoses including anxiety disorder, neurocognitive disorder with Lewy bodies, depressive disorder, and vascular dementia, and was described as having unclear speech, severely impaired cognitive skills for daily decision-making, and a need for extensive assistance with bed mobility, transfers, dressing, eating, personal hygiene, and toileting. The resident was incontinent of bowel and bladder, used a manual wheelchair, and was receiving hospice services. According to the report, video footage provided by the resident’s family showed the CNA forcibly pushing the resident backward onto the bed, striking the resident in the chest with an open hand, and repeatedly placing his hands and forearm around the resident’s throat while the resident struggled and gasped for air. The police report also stated the CNA made threatening and intimidating statements during the encounter. Facility documentation and the police report described the resident as fully dependent for care and unable to provide a reliable account of the incident because of late-stage dementia and poor cognition. The resident was later found to have bruising to the chest, right forearm, and left forearm, along with bruising to the upper arms and petechiae to the chest and lower arms. The resident’s family member reported being upset after viewing the video and stated the resident had shown increased confusion, incoherence, fearfulness, emotional distress, and loss of trust in caregivers after the incident. The resident could not be interviewed about the event due to cognitive impairment, and the report states the incident occurred in the resident’s room on the secured unit.
Employment of Staff Member With Disqualifying Aggravated Assault Conviction
Penalty
Summary
The deficiency involves the facility’s failure to prevent the employment of an individual with a disqualifying criminal conviction for aggravated assault with a deadly weapon. The employee, referred to as Cook A, was hired with a documented hire date of 11/04/24 and worked in the facility until 04/24/26. Her personnel file showed that criminal history checks were conducted on three occasions: at hire and on two later dates. During interviews, Cook A stated she had been convicted of aggravated assault with a deadly weapon in the late 1990s, served four years in jail from 1998 to 2002, and was released in 2002. The HR Director reported that she had pulled and reviewed Cook A’s criminal history and stated that, based on the report, Cook A would not be eligible for hire if she applied at the time of the survey because she had a felony from 1996. The HR Director later reviewed the criminal history in detail, noting an arrest for aggravated assault with a deadly weapon under Texas Penal Code 22.02(a)(2), classified as a second-degree felony. The record showed an initial court disposition of deferred adjudication, followed by another court entry reflecting a conviction for aggravated assault with a deadly weapon, a four-year term of confinement, and a sentence expiration date in 2002. The HR Director concluded that this constituted a lifetime bar to employment. Other facility staff provided information about the hiring and background check process. The Dietary Manager stated that the HR Director and Administrator review background checks and inform department heads whether an applicant is acceptable for hire, and that the prior HR Director had indicated Cook A was acceptable. The DON stated that the HR Director was responsible for ensuring criminal history checks on new hires and annually, and that the Administrator was responsible for ensuring the HR Director reviewed criminal history correctly. The Administrator stated his belief that Cook A was eligible for hire and that his understanding of her criminal history was that she was convicted, served time, and then likely received deferred adjudication. The report cites the Texas Health and Safety Code, Chapter 250.006, which bars employment of persons convicted of aggravated assault under Penal Code 22.02, and the facility’s own abuse/neglect policy, which prohibits employing individuals found guilty of abuse, neglect, exploitation, misappropriation, or mistreatment by a court of law.
Failure to Notify Physician After Resident Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of a significant change in condition following a fall with head injury. The resident was an elderly female with Alzheimer’s disease, dysphagia, lack of coordination, and a cognitive communication deficit, with a BIMS score of 08 indicating moderate cognitive impairment. Her MDS and care plan documented a history of falls and risk factors including unsteady gait, wandering, and psychotropic medication use, with interventions such as keeping the bed in the lowest position, call light within reach, and providing reminders not to ambulate without assistance. On the date of the incident, an unwitnessed fall occurred on the secured unit, and the resident was found on the floor in the hallway. A progress note documented that the resident was lying on her side, moving all extremities as prior to the fall, with a light bruise to the left side of her forehead measuring 2.5 cm by 2 cm. Neuro checks were initiated per protocol, vital signs and neurologic results were described as unremarkable, and the resident reportedly denied pain. The nurse documented on the fall incident report that the physician had been notified of the fall that day, and the resident’s son, DON, and ADON were notified of the incident. Subsequent interviews and record review revealed that the physician had not actually been notified at the time of the fall, despite the documentation stating otherwise. The LVN who completed the documentation admitted she did not call the physician and stated she forgot to do so during the excitement of managing this resident and another resident with issues at the same time. The physician later reported he first learned of the fall the following day when contacted about the resident’s increased facial pain and bruising, at which time he ordered the resident sent to the hospital. The facility’s policy on change in condition required prompt notification of the attending physician when there was an accident or incident involving the resident, but this did not occur at the time of the fall with head injury.
RN Coverage Not Maintained Daily
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. The report states the facility did not provide RN coverage for 8 consecutive hours daily on multiple days between 10/06/25 and 12/05/25, and that the previous DON quit on 10/05/25. During interviews, the ADON said the facility had not had a DON since 10/05/25 and that the corporate nurse serving as acting DON was not in the building 8 hours a day during the week. The RNC/acting DON said he was not in the facility at all during the week of 11/30/25 through 12/06/25 and was only present 3 days for 8 hours during the week of Thanksgiving. Additional interviews confirmed that the facility only had two RNs working: the RNC/acting DON and a weekend nurse, and that the weekend nurse did not work during the week. The MDS Coordinator said she was not aware of any other RN working in the facility. The Administrator said the facility had not met the RN hours requirement and acknowledged the risk of no RN hours and that some assessments may not be completed. Record review of the staffing schedule and RN E's timecard showed the specific days when the RNC/acting DON and RN E were present, reflecting that RN coverage was not maintained every day for the required 8 hours. The facility policy stated that a registered nurse provides services at least eight hours every 24 hours, seven days a week.
Unsafe Bathroom Conditions and Damaged Window Blinds
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents. Resident #28, a female with severe cognitive impairment, dementia, depression, anxiety, epilepsy, muscle weakness, dyspnea, and unsteadiness on feet, was observed with a bathroom floor that had unidentified black track marks and water on the tile floor while the sink was leaking. Resident #28 stated she had told staff about the leaking sink and that the bathroom floor had been dirty for several weeks before it was finally cleaned. Staff interviews confirmed the floor had been dirty for several days and that the wet floor and leaking sink were a safety issue and fall risk. The facility also failed to replace missing pieces from the window blinds in resident rooms on the secured unit. Resident #63, a male with severe cognitive impairment, cerebral infarction, epilepsy, and impaired temporal orientation, and Resident #66, a male with severe cognitive impairment, TIA, subdural hemorrhage, dementia, malaise, headache, and major depressive disorder, were both affected by the damaged blinds. Observations over two days documented multiple rooms with blinds missing pieces. Resident #63 stated sunlight got in his eyes and made it hard to sleep during the day, and Resident #66 stated the sunlight sometimes bothered him when he tried to sleep. Staff interviews acknowledged the conditions. A CNA said residents had complained about the damaged blinds because of sunlight coming in during the day. An LVN said the bathroom floor in Resident #28's room was a safety issue and that the damaged blinds affected residents who slept during the day. Maintenance and administrative staff agreed the leaking sink, dirty bathroom floor, and damaged blinds were unacceptable and not consistent with a homelike environment. The facility policy stated residents are to be provided with a safe, clean, comfortable, and homelike environment.
Nurse Staffing Posting Not Updated or Visible
Penalty
Summary
The facility failed to ensure nurse staffing data was posted daily and was readily accessible to residents and visitors with all required information. Surveyors observed on 12/8/25 that the nurse staffing data was posted on a table behind a Christmas tree and was dated 10/3/25. On 12/9/25, the staffing information was again found by the front door on a table behind a Christmas tree and was still dated 10/3/25, showing it had not been updated since that date. During interviews, the ADON stated the staffing had not been posted or updated since 10/3/25 and said the DON had been responsible for posting staffing before leaving on 10/5/25. She said no one had been assigned after the DON left, then later stated she was assigned to post staffing daily and showed the surveyor the staffing sheet for 12/9/25. The BOM, ADON, acting DON, and ADM all stated the staffing information should be updated daily and visible where everyone could see it. The ADM also stated that prior to 12/9/25, the last staffing post had been 10/3/25.
Infection Control Failures During Medication Pass and Room Cleaning
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three residents reviewed for infection control practices. One failure involved hand hygiene during medication administration, and another involved a resident room that remained contaminated with feces, urine, and unidentified black marks on the floor and bathroom area. Resident #38 was a female with diagnoses including dementia, candidiasis, Alzheimer's disease, seasonal allergic rhinitis, and shortness of breath. Her quarterly MDS reflected a BIMS score of 9, indicating moderate cognitive impairment, and she was always continent of bladder and bowel. Resident #60 was a female with diagnoses including dysphagia, Parkinson's disease, nonrheumatic aortic valve disorder, and ESBL. Her quarterly MDS reflected a BIMS score of 15, indicating she was cognitively intact, and she was always incontinent of bladder and bowel. During an observation of medication pass, LVN A gave Resident #38 Geri-Tussin oral liquid and gave Resident #60 Tylenol tablets without sanitizing her hands between residents. Resident #17 was a male with diagnoses including cerebral infarction, muscle wasting and atrophy, and chronic pain. His quarterly MDS reflected a BIMS score of 10, indicating moderate cognitive impairment, and he was frequently incontinent of bowel. During observation, his room had black streaks of an unknown substance on the tile floor, the floor was sticky, the room smelled of urine and feces, and there was yellow and brown liquid around the toilet. CNA C stated the floor had been filthy for at least 5 days and that housekeeping had not been seen on the hall in several days. The Housekeeping Supervisor stated the resident's room was very dirty and needed to be cleaned every day, and also stated that the resident rooms on the hall were not getting cleaned every day. Later observation showed only the immediate area around the toilet had been mopped, while the rest of the room remained covered with black streaks of an unknown substance.
Failure to Refer Resident With Psychosis for PASRR Level II Review
Penalty
Summary
The facility failed to refer a resident with a newly identified psychosis diagnosis for PASRR Level II resident review after a significant change in status assessment. Resident #9’s record showed an unspecified psychosis diagnosis dated 11/06/24, while dementia was not listed as a diagnosis or primary condition. A quarterly MDS assessment dated 11/21/25 showed a BIMS score of 00, indicating severe cognitive impairment, and the resident was documented as usually able to make himself understood and usually understand others, with unclear speech. He also received a routinely scheduled antipsychotic and antianxiety medication. The resident’s PASRR Level I Screening dated 10/18/24 marked Mental Illness as no. During interviews, the MDS coordinator stated she did not think the Level I should be positive because the admitting facility may not have provided all diagnoses, but acknowledged that if the psychosis diagnosis was received after admission, a 1012 form may have been submitted to the local authority. The ADON stated she did not deal with PASRR or review PASRR forms. The Administrator said he was not aware of the psychosis diagnosis and stated the Level I should have been marked yes for mental illness or a 1012 form should have been completed. The RNC/Acting DON also stated his expectation was for a positive Level I or a 1012 form to be completed. The facility policy stated that Level I screening determines if an individual may have a mental illness or intellectual disability and that residents admitted under PASRR guidelines may undergo periodic reviews.
Oxygen concentrator filter left dirty for resident on oxygen
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met for Resident #6. Resident #6 was a male admitted to the facility with diagnoses including pneumonia and had a quarterly MDS assessment showing a BIMS score of 09, indicating moderate cognitive impairment. His order summary included oxygen at 2 liters per minute via nasal cannula and an order to change the oxygen filter for placement and cleanliness weekly on Sunday night and as needed, with a start date of 12/09/25. During observations on 12/08/25 and 12/09/25, Resident #6 was in bed with oxygen in place via nasal cannula, and the oxygen concentrator filter was observed to be covered in gray debris on both occasions. During interviews, the ADON stated the filter was washed on 12/10/25 and said it should be cleaned every Sunday night and checked each shift by the nurse. The Administrator and RNC/Acting DON stated the filter should have been cleaned and identified the risk as infection control, possible illness, airflow issues, and respiratory complications. The facility policy on Oxygen Administration, last revised October 2010, did not mention the oxygen concentrator filter or its cleanliness.
Controlled Substance Count and Documentation Failure
Penalty
Summary
Pharmaceutical services failed to meet the needs of one resident when the facility did not accurately account for a prescribed hydrocodone-acetaminophen tablet. The resident was an older female with diagnoses including cerebral infarction, chronic atrial fibrillation, myelodysplastic syndrome, and pain. Her MDS indicated she was cognitively intact with a BIMS score of 15, and her care plan noted generalized pain with pain medications to be given per physician orders. The resident had an order for hydrocodone-acetaminophen 5-325 mg, 1 tablet by mouth every 4 hours as needed for pain. During observation of the medication cart, the surveyor found 27 tablets in the punch card while the narcotic count sheet reflected 28 tablets. The LVN on duty stated she had not given the resident any of the tablets that morning or during her shift, and she had not counted or reconciled the narcotics when taking over the cart from the previous nurse. The ADON reviewed the narcotic sheet and medication card and confirmed the discrepancy. Interview and record review showed the prior nurse stated she had given the resident a hydrocodone tablet the night before shift change but had forgotten to document it. Both nurses stated they did not reconcile the narcotic count at shift change. The ADON and other facility leaders stated the PRN hydrocodone had been entered in PCC on the wrong MAR, which prevented it from populating for documentation, and the nurses had not reported the issue. The controlled substances policy required nursing staff to count controlled medication inventory at the end of each shift, with the oncoming and off-going nurses making the count together and documenting discrepancies.
Medications Left Unsecured on Bedside Table and Medication Cart
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments and accessible only to authorized personnel for one resident and one medication cart. Resident #2 had a physician order for albuterol sulfate inhaler, and during observation the inhaler was found on the resident’s bedside table. Resident #2 stated he used the inhaler every day and left it on the bedside table rather than putting it away in a drawer. The resident’s record showed a BIMS score of 14, indicating normal cognitive function, and the care plan identified assistance with ADLs but did not indicate that he used an albuterol inhaler. During another observation, a bottle of nystatin topical powder was seen on top of the B hall medication cart in plain view rather than inside a locked drawer. Interviews with the ADON, LVN, Administrator, and Acting DON confirmed that residents were not supposed to have access to albuterol inhalers and that both the inhaler and nystatin powder should have been secured in the locked medication cart. The facility policy stated that all medications and biologicals are to be stored in locked compartments and accessible only to authorized personnel.
Fire Hazard Created by Covering Overhead Light with Blanket in Secured Unit
Penalty
Summary
Staff failed to ensure the resident environment in the secured unit living room was free from accident hazards when a blanket was observed covering the overhead light. On the date of observation, an LVN and a CNA were present in the living room with the blanket covering the light, and the LVN removed the blanket upon the surveyor's entry. The LVN acknowledged that covering the light was unsafe and stated that the CNA typically covered the light in the dining room as well. The CNA explained that the blanket was used because the overhead light could not be turned off and shined directly into a resident's room, and that the resident's door was kept open due to a history of wandering. The CNA was unsure if covering the light with a blanket was safe. The Maintenance Director confirmed that the light switch in the living room had been intentionally disconnected prior to his employment to prevent staff from turning off the light and sleeping during shifts. He stated that staff should not hang blankets over lights, as it is a fire hazard. The Administrator was unaware of the disconnected switch and agreed that covering lights with cloth is a fire hazard. The facility did not have a policy regarding covering lights with cloth or other items.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that three medication carts (Medication Cart #1, #2, and #3) were left unlocked and unattended in various hallways of the facility. On multiple occasions, the carts were found unsupervised with residents and staff passing by, and in some cases, residents were sitting near the unlocked carts. Interviews with LVNs revealed that the carts were left unlocked because staff were actively using them or had recently accessed them, but the carts were not secured immediately after use. Staff acknowledged the importance of keeping medication carts locked to prevent unauthorized access but admitted to leaving them unlocked during their shifts. The facility's policy requires that medications and biologicals be stored securely and only accessible to authorized personnel. Despite this, the medication carts containing medications, including PRN medications, were accessible to unauthorized individuals when left unlocked and unattended. Both the Administrator and ADON confirmed that medication carts should only be unlocked when staff are actively retrieving medications or standing directly in front of the cart, which was not consistently followed during the survey observations.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Ensure Nurse Aide Maintained Current Certification
Penalty
Summary
The facility failed to ensure that a nurse aide, CNA E, had a current and valid nurse aide certification while employed and actively providing care to residents. Record review showed that CNA E's nurse aide certification had expired, and she continued to work her normal full-time shifts, except for four days of paid time off, during the period her certification was not valid. The Business Office Manager (BOM) and Administrator were unaware of the expired certification until it was brought to their attention by another staff member. The facility did not have a policy in place regarding nurse aide certification renewal, expirations, or registry verification, and relied on an annual employee checklist that was supposed to be completed for all employees. Interviews revealed that CNA E was unaware her certification had expired, believing the facility would handle the renewal as her previous employer had done. She also indicated that her work schedule prevented her from seeking assistance with the renewal process. The Administrator confirmed that the facility and corporate office monitor for expiring certifications, but CNA E did not appear on their lists, and there was no explanation for why her certification was not renewed on time. The lack of a clear policy and monitoring process contributed to CNA E working for several months with an expired certification.
Failure to Promptly Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The report specifically notes that the required notifications were not made promptly when events impacting the resident occurred, as mandated by regulations.
Failure to Notify Physician and Obtain Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, staff did not notify the physician of the resident's weeping edema, redness, and blister on her right leg, nor did they obtain physician orders for wound care or the application of dressings prior to applying them. The resident, who had a history of edema, hypertension, and congestive heart failure, was observed with a nonstick dressing and gauze wrap on her right leg, which was swollen and red. The resident reported that nurses had applied these dressings due to a weeping blister and to prevent her sheets from getting wet. Interviews revealed that the physician was not aware of the resident's condition or the need for a dressing, and the Director of Nursing (DON) was also unaware that a dressing had been applied. The DON confirmed that staff had not notified the physician or obtained orders for the ace wrap or for the treatment of the swelling and weeping. Nursing staff admitted to applying dressings and wraps without physician notification or orders, despite facility policy requiring prompt notification of changes in a resident's condition, including skin conditions and swelling.
Misappropriation of Controlled Medication from Resident Supplies
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their prescribed hydrocodone-acetaminophen 5-325 mg tablets. Both residents had a history of chronic pain and were admitted with pill bottles containing this controlled medication, which had been brought from home or another facility. Upon review, it was discovered that a significant number of these tablets had been replaced with extra strength Tylenol, as identified by a nurse during medication administration. The nurse used a pill identifier to confirm that the pills in the bottles were not hydrocodone-acetaminophen but Tylenol, and this was found to be the case for both residents. The facility's investigation revealed that six nurses had access to the locked medication cart from which the pills were taken. Drug testing was conducted on the nurses who had access during the relevant period, and one nurse tested positive for the medication but provided evidence of a personal prescription. However, further testing to determine if the medication in her system was within prescribed limits was inconclusive due to a lab error. The facility was unable to determine exactly when the pill swap occurred or to substantiate which staff member was responsible for the misappropriation. The police were notified, and a report was filed, but the investigation could not confirm whether the hydrocodone was present in the bottles at the time of admission. Both residents involved were assessed and reported that their pain had been well managed, with no complaints or evidence of unrelieved pain at the time of interviews and observations. The facility's policies on abuse, neglect, exploitation, and controlled substances required verification of controlled medications upon receipt, but did not specifically address the verification of medications brought in pill bottles from outside sources or the use of pharmacy blister packs for such medications. This gap in procedure contributed to the failure to prevent the misappropriation of resident property.
Inaccurate Medical Record Documentation Due to Unauthorized Note Editing
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented in accordance with accepted professional standards. Specifically, the Director of Nursing (DON) edited a progress note originally written by an LVN regarding wound care provided to a resident. The LVN's original note indicated that the previous dressing was dated three days prior to the wound care, suggesting a possible lapse in daily wound care. Five days after the original entry, the DON altered the note to remove the reference to the previous dressing date, despite not having performed the wound care herself. Interviews revealed that the LVN documented the date found on the dressing during the wound care and was unaware of why the DON changed her note. The DON admitted to editing the note because she perceived it as a red flag and suspected the LVN of falsifying documentation, but acknowledged that she should not have changed the note and should have addressed her concerns differently. Facility policy requires documentation to be concise, accurate, and complete, and the administrator confirmed the expectation for accurate records.
Failure to Maintain Clean and Safe Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment in one of its shower rooms, specifically the B hall shower room. Observations revealed thick black grime on the walls, a pink stain on the floor, and missing tiles on the shower floor. Staff interviews indicated that the shower had not been cleaned recently, and the missing tiles had been present for approximately 40-45 days. Housekeeping staff were unclear about their responsibilities for cleaning the shower, and the Maintenance Director acknowledged awareness of the missing tiles for several months, but no work order had been submitted for repairs. The Administrator was only made aware of the condition on the morning of the survey. Record reviews confirmed that no maintenance work orders had been logged for the shower room in question for several months. Facility policy requires daily cleaning of showers by housekeeping and weekly deep cleaning by the Housekeeping/Laundry Supervisor, but these procedures were not consistently followed. Staff interviews highlighted the importance of cleanliness for infection control and resident safety, but also revealed lapses in communication and follow-through regarding cleaning and maintenance responsibilities.
Failure to Protect Residents from Abuse by Peers, Staff, and Family
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse, including physical abuse by other residents, staff, and a family member. Several incidents were documented where residents with cognitive impairments, such as Alzheimer's disease, dementia, and schizophrenia, were involved in altercations resulting in physical harm. For example, one resident was slapped by another after being startled awake, and another was struck in the face by a peer who believed his foot was at risk. In another case, a resident was hit on the cheek by a fellow resident during a dining room altercation. These incidents occurred despite care plans and staff awareness of the residents' behavioral risks and cognitive limitations. Staff also failed to prevent abuse by facility personnel. In one incident, a CNA slapped a resident on the back of the hand during a transfer when the resident became combative. The event was witnessed by another CNA, and the action was acknowledged as abuse by the facility's administrator. The resident involved was dependent on staff for most activities of daily living and had a history of combative behavior, which was documented in her care plan. The staff member involved was suspended and subsequently terminated, but the incident itself demonstrated a lapse in protecting the resident from staff-initiated abuse. Additionally, the facility did not prevent abuse by a family member. In one case, a resident with severe cognitive impairment was slapped in the face by a family member during a dispute over discharge against medical advice. The incident resulted in visible injury and required intervention by staff and law enforcement. The resident expressed a desire to remain in the facility and not leave with the family member, but the abuse occurred before the situation was de-escalated. These failures to prevent abuse placed residents at risk of physical harm, mental anguish, or emotional distress, as documented in the report.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches and water bugs in resident rooms, the dining area, and other parts of the building. Multiple residents, all with intact or moderately impaired cognition, reported seeing roaches and water bugs in their rooms and common areas, particularly around the dining room coffee area and in bathrooms. These sightings were reported to various staff members, including housekeepers, CNAs, and nurses, who acknowledged the complaints and stated they would report the issues. Staff interviews confirmed the ongoing presence of pests, with CNAs and housekeepers observing roaches in shower rooms and on the unit, and reporting these verbally to the Maintenance Director. However, the required documentation in the pest control binders was not completed by staff, as confirmed by both the Maintenance Director and a review of the binders, which showed no staff entries regarding pest sightings. The Maintenance Director stated that staff were instructed to document pest sightings, but instead relied on verbal reports, leading to a lack of written records. The pest control technician confirmed that the facility was being treated twice a month and identified American roaches and water bugs coming from plumbing areas, as well as German roaches in the kitchen, which were nearly resolved. Despite these treatments, residents and staff continued to observe pests. The facility's policy required an effective pest control program, but the lack of consistent documentation and ongoing pest sightings indicated the program was not effectively implemented.
Failure to Obtain Written Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided written consent prior to the administration of an antipsychotic medication, Seroquel. Record review showed that the resident, who had diagnoses including personality disorder, bipolar disorder, major depression, and anxiety, was cognitively intact and able to understand and communicate. The resident's care plan and physician orders documented the use of Seroquel for bipolar disorder, and medication administration records confirmed that the medication was being given as prescribed. However, the required Consent for Antipsychotic or Neuroleptic Medication Treatment (Form 3713) was not signed by the resident, despite her being her own responsible party and aware of the medication. Interviews with the resident, ADON, and Administrator confirmed that the consent should have been obtained and signed at the time the medication was ordered, in accordance with facility policy. The absence of a signed consent form indicated that the resident had not formally acknowledged the risks and benefits of the medication as required.
Failure to Promptly Address and Document Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for two residents regarding missing personal clothing items. One male resident with intact cognition and a history of dementia and chronic obstructive pulmonary disease reported that all his underwear had been destroyed in a facility laundry fire. He stated he had informed several CNAs, nurses, and laundry staff about the loss, but no one provided information or resolution regarding his missing underwear. Interviews with laundry staff and the Housekeeping/Laundry Supervisor confirmed awareness of the loss, but no formal grievance was filed, and the items were not replaced. A female resident with intact cognition and diagnoses including personality disorder, bipolar disorder, major depression, and anxiety reported missing a pair of pants valued at $40. She stated she had informed the Administrator, but no action was taken, and her pants were neither found nor replaced. The Housekeeping/Laundry Supervisor acknowledged being aware of the missing pants and that extensive searches had been conducted without success, but again, no grievance was filed. Interviews with facility staff, including the Administrator and Social Worker, revealed a lack of communication and understanding regarding the grievance process. Staff members were either unaware of the need to file a grievance or did not convey the information to the appropriate personnel. Review of the facility's grievance log confirmed that no grievances were recorded for either resident during the relevant period, despite the facility's policy requiring all grievances to be documented and resolved within three working days.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
A deficiency was identified when a resident who required assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, did not receive showers as scheduled according to his care plan. The resident, an adult male with diagnoses including myocardial infarction, hypertension, muscle weakness, and chronic obstructive pulmonary disease, was cognitively intact and did not refuse care. His care plan specified that he preferred showers on Tuesday, Thursday, and Saturday, and required assistance from staff to complete these tasks. Record reviews showed inconsistencies in the documentation of showers provided, with some days showing no shower and others indicating showers at irregular times, including multiple entries on the same day. During interviews, the resident reported not receiving a shower in over a week and expressed feeling bad about not receiving regular showers. Staff interviews confirmed that the resident did not refuse showers and that it was the responsibility of CNAs and nurses to ensure showers were provided as scheduled. One CNA admitted to not providing a shower due to time constraints and being busy with other resident needs. The facility's policies required that residents unable to perform ADLs independently receive necessary services to maintain hygiene and grooming. Despite these policies, the resident did not consistently receive scheduled showers, and staff acknowledged the importance of providing this care to prevent skin issues and maintain resident comfort. The deficiency was further supported by the facility's own documentation and staff statements regarding the failure to provide showers as planned.
Deficiency in Providing Clean Linens
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by the lack of clean bed and bath linens. Observations on multiple occasions throughout the day revealed that the clean linen closets and carts across various halls were inadequately stocked, with some containing only a few pillowcases, gowns, or sheets, and others completely devoid of towels and wash rags. This deficiency was confirmed by interviews with staff, including a CNA who reported having to wait for clean linens and a Housekeeping/Laundry Supervisor who acknowledged the shortage and attributed it to staffing limitations and linen being hidden or destroyed. The Housekeeping/Laundry Supervisor noted that the laundry staff had clocked out early, leaving no one to complete the laundry for the rest of the day. The supervisor also mentioned that the facility's laundry PPD only allowed for 1.4 employees per day, which was insufficient for the facility's census of 78 residents. The Administrator confirmed the expectation for clean towels and wash rags to be available and recognized the risk posed to residents by the lack of these items. The facility's policy on supplies and equipment emphasized the need for housekeeping and laundry supplies to be readily available, which was not adhered to in this instance.
Failure to Resolve Grievances on Missing Clothing
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances related to missing clothing for four residents. Resident #46, who had diagnoses including anxiety, depression, and Alzheimer's disease, had lost four wardrobes of clothes since admission. Despite the family member reporting the issue to the facility, no grievance was documented, and the family member resorted to purchasing new clothes due to the facility's inaction. Resident #73, diagnosed with dementia and other mental health disorders, also experienced issues with missing clothing. A grievance was filed, but the resolution did not confirm whether the missing clothes were found and returned. The family member expressed frustration over the repeated need to purchase new clothing and eventually decided to handle the laundry themselves to prevent further losses. Resident #182, who had Alzheimer's disease and other health conditions, had a grievance filed regarding missing clothing and personal items. The grievance report did not indicate if the items were recovered, and the family member confirmed that the clothes were still missing at the time of the resident's passing. Similarly, Resident #10, who was cognitively intact, reported missing clothes, but no grievance was documented. The family member confirmed the loss of a significant number of clothing items, and the facility's staff had been using the roommate's clothes for the resident.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen's handling of food items. During a survey, it was found that the facility did not label and date all food items, and dietary staff did not dispose of expired food items. Additionally, frozen food items were not effectively resealed, labeled, or dated. These lapses were observed in various storage areas, including the kitchen refrigerator, walk-in refrigerator, and walk-in freezer. Specific observations included expired items such as a bottle of white vinegar and a pitcher of tomato juice, as well as unlabeled and improperly sealed items like shredded carrots, thawed bacon, and various frozen goods including chicken, breadsticks, French fries, and pepperoni. The dietary staff, including a cook with five years of experience, acknowledged the responsibility for labeling, dating, and disposing of expired foods but were unaware of the deficiencies until pointed out by the surveyor. The Dietary Manager, who has been in the role for eight years, also conducted regular walk-throughs but was unaware of the issues. The Administrator, who oversees the Dietary Manager, admitted to infrequent walk-throughs in the kitchen and was unaware of the expired and improperly stored food items until the survey. The facility's dietary policy and FDA Food Code guidelines emphasize the importance of labeling, dating, and discarding expired food to prevent foodborne illnesses, but these were not followed, leading to the identified deficiencies.
Deficiency in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was observed in three residents who were reviewed for hospice services. The facility did not maintain the hospice binders for these residents, which should have contained essential documents such as the most recent plan of care, hospice election form, physician recertification, and hospice medication profile. This lack of documentation and coordination could place residents at risk of receiving inadequate end-of-life care. For Resident #27, the facility did not have the necessary hospice documentation in the resident's binder. Interviews revealed that the hospice company was responsible for maintaining these documents, but the binder only contained a sign-out sheet. The hospice RN acknowledged the oversight and planned to deliver the binder. Similarly, Resident #35's binder was outdated, lacking recent IDT meeting notes and medication lists, which could lead to missed orders or treatments. The hospice company was expected to provide updated documents, but this was not consistently done. Resident #15's hospice binder was also missing critical documents, including the most recent plan of care and medication profile. The hospice DON admitted that the documents were not updated due to a lapse in coordination. The facility's policy required obtaining updated hospice documents, but this was not adhered to, resulting in a lack of communication and coordination of care. Interviews with facility staff and the administrator highlighted the expectation for hospice companies to provide updated documents, which was not consistently met, leading to potential medication errors and inadequate care.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) while providing care to a resident on enhanced barrier precautions. This resident had pressure wounds and required specific wound care, yet the staff neglected to wear gowns, which are essential to prevent the spread of infections. The ADON admitted to forgetting to wear the PPE despite knowing its importance. Another deficiency was noted in the care provided to a resident with cerebral palsy, where a CNA failed to follow proper hygiene protocols during incontinent care. The CNA used the same wipe multiple times and did not perform hand hygiene when changing gloves, which is crucial to prevent cross-contamination. The Director of Nursing (DON) and ADON acknowledged the importance of proper PPE use and hand hygiene to protect residents and staff from infections. Additional issues were identified in the facility's laundry room, where clean clothes were found touching the floor, and dirty linens were improperly stored. This improper storage poses a risk of infection. Furthermore, a resident's catheter bag was observed lying on the floor, which could lead to cross-contamination. The facility's linen cart was also found uncovered, exposing supplies to potential contamination. These practices indicate a lack of adherence to infection control policies, putting residents at risk of infection.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident or their responsible party was informed and participated in treatment decisions, specifically regarding the administration of psychoactive medications. The deficiency involved a resident who was cognitively impaired and required antianxiety medication. The resident was administered Klonopin (Clonazepam) without documented informed consent from either the resident or their responsible party. This oversight occurred despite the facility's policy requiring informed consent for psychotropic medications. The Licensed Vocational Nurse (LVN) involved did not obtain the necessary consent before administering the medication, as she assumed it was unnecessary due to the resident already being on the medication, albeit at an increased dosage. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the consent process was not followed, emphasizing the importance of obtaining consent for psychotropic medications due to their potential to alter mental states and cause other risks. The facility's policy mandates that residents or their representatives be educated on the risks and benefits of such medications, which was not adhered to in this case. Interviews with facility staff, including the LVN, ADON, DON, and Administrator, revealed a lack of adherence to the facility's policy on psychoactive medications. The staff acknowledged the failure to obtain informed consent and the potential implications of this oversight. The facility's policy clearly outlines the necessity for informed consent and the role of the attending physician and psychiatric provider in medication management, which was not executed in this instance.
Failure to Update Resident Care Plan After Falls
Penalty
Summary
The facility failed to ensure that Resident #46's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for one of the 21 residents reviewed for care plans. Specifically, the care plan was not updated following Resident #46's falls on three separate occasions: 07/09/2024, 07/12/2024, and 08/25/2024. The care plan interventions, which were initially set on 06/14/2024, did not reflect any new measures implemented after these incidents. Resident #46, an elderly male with a history of anxiety, unspecified psychosis, depression, and Alzheimer's disease, was admitted to the facility with significant cognitive impairments. His quarterly MDS assessment indicated he had short-term and long-term memory problems and required substantial assistance with daily activities. Despite having a history of falls, the care plan did not include updated interventions after his falls, which included a laceration on 07/09/2024 and a witnessed fall on 08/25/2024. Interviews with facility staff, including an LVN, the ADON, the DON, and the Administrator, revealed that interventions such as a low bed, fall mat, and regular monitoring were in place. However, these were not documented in the care plan. The ADON and DON acknowledged their responsibility for updating care plans and recognized that the failure to do so could lead to continued falls, as staff would not have the latest information on interventions. The facility's policy required the comprehensive care plan to be reviewed and revised after each assessment, which was not adhered to in this case.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a female resident who required moderate assistance with personal hygiene. The resident, who had a mildly impaired cognitive status with a BIMS score of 13, was observed on multiple occasions with chin hair approximately 3-4 cm in length. Despite the resident expressing that the chin hair made her feel bad and wanting it removed, the facility staff did not address this grooming need. Interviews with facility staff, including a CNA, LVN, ADON, DON, and the Administrator, revealed a lack of awareness and action regarding the resident's grooming needs. The CNA admitted not noticing the chin hair, while the LVN acknowledged its presence but did not take action. The ADON and DON emphasized the importance of grooming for the resident's dignity and self-esteem, yet the task was not completed. The facility's policy on ADLs, which includes grooming, was not adhered to, resulting in a deficiency in providing appropriate care and services.
Failure to Obtain Ordered Lab Test for Resident
Penalty
Summary
The facility failed to ensure that laboratory services were obtained to meet the needs of a resident who required monitoring of Depakote levels. The resident, an elderly male with diagnoses including anxiety, unspecified psychosis, depression, and Alzheimer's disease, had a lab order for a Depakote level to be drawn on a specific date. However, the lab result for that date was not found in the resident's electronic medical record, indicating that the test was not conducted as ordered. This oversight was acknowledged by the Assistant Director of Nursing (ADON), who admitted responsibility for ensuring the lab was obtained. Interviews with the ADON, Director of Nursing (DON), and the Administrator revealed that the failure to obtain the lab was attributed to inconsistent nurse staffing, as the facility had been using agency staff to fill nursing positions. The DON and Administrator both expressed that they expected labs to be obtained as ordered and recognized the risk of not obtaining the lab, which could lead to potential toxicity. The facility's policy required staff to process test requisitions and arrange for tests, but this was not followed in this instance.
Failure to Maintain Clean and Sanitary Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in one of the bathrooms used by a resident. The resident, who was cognitively intact and required assistance with toileting, reported that his bathroom was consistently dirty and unpleasant to use. Observations confirmed the presence of numerous brown stains on the bathroom door, sticky floors, and a strong urine odor. The toilet and surrounding areas were covered with brown substances resembling dried feces, and the toilet water was discolored. The resident expressed dissatisfaction with the cleanliness of his bathroom and preferred to use other toilets in the facility. Interviews with housekeeping staff revealed that the bathroom was supposed to be cleaned daily, but the housekeeper responsible for the area admitted to cleaning it only once a day. The housekeeper also noted that picking up dirty clothing was not her responsibility. The Housekeeping Supervisor acknowledged the unsanitary condition of the bathroom and attributed it to being short-staffed, which affected her ability to monitor cleaning activities effectively. Despite these challenges, the expectation was for all rooms and bathrooms to be cleaned daily to ensure a sanitary environment for residents. The facility's Administrator confirmed that the housekeeping staff was expected to clean each room and bathroom daily. The Administrator also stated that department heads were responsible for ensuring that cleaning was completed each day. The facility's Homelike Environment policy emphasized the importance of maintaining a clean, sanitary, and orderly environment, which was not upheld in this instance, leading to the deficiency.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in Resident #2's bathroom on C Hall. Observations and interviews revealed that the resident had noticed roaches in his room and bathroom since his admission. Despite notifying the facility staff, the issue persisted, and the resident expressed dissatisfaction with the cleanliness maintained by the new owners. During an observation, two small brown roaches were found in the resident's bathroom, confirming the resident's complaints. The pest control logs from May to July 2024 documented multiple instances of roach sightings throughout the facility, including in the kitchen, hallways, and resident rooms. Despite these records, the Pest Control Technician reported being unaware of roach activity in the hallways or resident rooms, as he only treated the exterior and kitchen areas during his visits. The technician also noted that he had not had access to the pest control logs for several months and was not informed of the roach sightings by the Maintenance Supervisor or Administrator. Interviews with the Maintenance Supervisor and Administrator revealed a lack of awareness regarding the roach complaints and sightings. The Maintenance Supervisor stated that he was unaware of any complaints and believed the pest control logs were regularly reviewed. The Administrator also expressed unawareness of the issue and emphasized the importance of maintaining pest control to ensure a bug-free environment for residents. The facility's pest control policy, revised in May 2008, indicated an ongoing program to keep the building free of insects and rodents, but the implementation appeared ineffective in this case.
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Illustrative
What surveyors actually found near you
We read the 107 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mineola
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mineola Gardens Wellness & Rehabilitation | 1.1 mi | ★★★★★ | 6 | 0 |
| Quitman Wellness & Rehabilitation | 8.8 mi | ★★★★★ | 11 | 0 |
| Avir At Lindale | 12.1 mi | ★★★★★ | 14 | 0 |
| Avir At Bradburn | 12.4 mi | ★★★★★ | 7 | 2 |
| Colonial Nursing & Rehabilitation Center | 12.5 mi | ★★★★★ | 8 | 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.