Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Park Bend during CMS and state inspections, most recent first.
A resident with dementia, a right femur fracture, adult failure to thrive, and GERD, who required complete assistance with toilet hygiene, received incontinent care from a CNA while the room door remained open and the privacy curtain only partially closed, allowing the care to be visible to anyone entering the room. The resident reported satisfaction with the care but was unable to understand or answer questions about comfort with potential observers. The CNA, with over a year of experience, admitted not fully closing the door or curtain and acknowledged this compromised the resident’s privacy and dignity. The DON stated that facility practice and policy require doors and privacy curtains to be fully closed during personal care to uphold resident rights to privacy and dignity.
Two residents with COPD and other serious comorbidities, both on O2 therapy and ordered nebulizer treatments, had their nebulizer masks and tubing left openly on bedside tables instead of being cleaned and stored in protective bags as required by care plans and physician orders. In one case, the equipment was mixed with personal belongings; in the other, the mask was placed next to a urine bottle. The charge RN and DON acknowledged that nursing staff were responsible for cleaning and bagging respiratory equipment after use and monitoring storage during rounds, yet there were no in-services or facility policies addressing safe handling and storage of nebulizer equipment.
Surveyors found that an RN left a charting computer on a hallway workstation unlocked and unattended with a resident’s clinical information visible on the screen, where it could be seen by unauthorized individuals passing by. The RN acknowledged having received HIPAA training that instructed staff to lock or minimize computer screens when stepping away and admitted fault for not doing so before responding to a call light. The ADM and DON confirmed that staff receive HIPAA training at hire and annually, and that facility policies require maintaining privacy of patient health information and prohibit unauthorized access or disclosure of resident information.
A resident with multiple comorbidities and a history of a MRSA-infected flank wound was on contact precautions and later under EBP orders requiring gown and glove use during high-contact care. Over multiple observations, staff repeatedly provided wound care and incontinence care wearing only gloves, without gowns, and failed to perform hand hygiene between glove changes or after glove removal. Staff used the same wipes on infected and non-infected skin, placed a trash can from the floor onto the bed, applied patches and skin products without changing gloves, and handled items such as markers, bedside tables, bed controls, drinking glasses, wound care trays, and a mechanical lift without cleaning or disinfecting them before leaving the room. The resident’s door lacked an EBP sign while EBP orders were active, and a CNA acknowledged knowing the hand hygiene and gown requirements but did not follow them, despite facility policies and training on infection control and hand hygiene.
A resident with multiple psychiatric and medical diagnoses, including dementia, anxiety disorder, PTSD, and bipolar disorder, reported feeling labeled due to her bipolar diagnosis and experiencing high anxiety, crying, and skin-picking behavior. Her primary language was documented as English, yet she stated a medication aide spoke to her only in Spanish, leading her to feel obligated to speak Spanish to receive her medications and to show respect to the aide’s preferred language. She was unaware of her right to be spoken to in her primary language and reported having previously raised concerns with facility leadership. Staff interviews confirmed that residents have the right to communication in their preferred language, and facility policy requires that resident rights be communicated in a language understandable to the resident.
A CNA applied a lidocaine patch to a resident with severe cognitive impairment and multiple medical conditions, despite facility policy requiring only licensed staff to administer medications. The incident was discovered after the resident's family reported video evidence, and interviews confirmed the CNA was not authorized to perform this task.
A resident with significant medical and cognitive needs, who was dependent on staff for all ADLs, was not provided a shower when requested outside of his scheduled days. Despite being observed with a strong urine odor and reporting soiled clothing, staff told him it was not his shower day, leaving him feeling neglected and unclean. Facility policy and the DON confirmed that such requests should be accommodated to maintain resident dignity.
A resident with a colostomy and multiple comorbidities did not receive care in accordance with enhanced barrier precautions, as two CNAs provided peri and colostomy care wearing gloves but not gowns, despite clear signage and available PPE. Interviews revealed inconsistent understanding and application of EBP among staff, and leadership could not provide recent documentation of EBP training, resulting in a lapse in infection control protocols.
Surveyors found multiple medication carts containing loose pills and expired medications, and staff were unaware of these issues despite being required to check carts regularly. A resident with multiple health conditions had expired medication stored in their assigned cart. Documentation of cart audits and recent in-services on medication administration was lacking, and the facility's medication storage policy did not address non-refrigerated medications.
A resident with a diagnosis of Major Depressive Disorder was admitted with a negative PASRR Level 1 screening for mental illness, despite medical records and care plans confirming the mental health diagnosis. Staff interviews and facility policy review confirmed that the screening should have been positive, but the error was not identified or corrected, resulting in the resident not being properly assessed for specialized services.
A resident with a history of seizures, malnutrition, and feeding via gastrostomy tube experienced multiple incidents of tube dislodgement requiring medical intervention, but the facility failed to update the care plan to address management of tube dislodgement. Staff reported a lack of training and care plan guidance for handling the PEG tube during care, and administrative staff confirmed the care plan was not revised after these events.
A resident who was fully dependent on caregivers and had a PEG tube experienced accidental dislodgement of the tube during a bed bath provided by a CNA who had not received specific training or competency assessment for PEG tube care. Staff interviews and record reviews revealed a lack of documented in-services, competency checks, and care plan instructions related to bed baths for residents with PEG tubes. Supervisory staff confirmed the absence of formalized training or assessment for CNAs in this area.
A resident with dementia and other medical conditions was verbally threatened by a CNA during a dressing interaction, as captured on video. The facility was unaware of the incident until it was reported by the resident's family member, who initially withheld the video due to distrust. The facility's abuse prevention policy was not effectively implemented, leading to a delay in addressing the incident.
A facility failed to report an injury of unknown origin for a resident diagnosed with an L1 transverse process fracture. The resident, with severe cognitive impairment, was admitted with multiple diagnoses. Despite hospital discharge paperwork indicating the fracture, the facility did not report it to the State Survey agency. The DON did not consider it reportable due to unknown timing and cause, and the Administrator stated she would have reported it if the fracture was confirmed. The facility's policy requires prompt reporting of such incidents.
The facility failed to ensure call lights were within reach for several residents, including those with cognitive impairments and high dependency on staff. Observations revealed call lights on the floor or out of reach, contrary to care plans and staff policies. This deficiency affected residents' ability to call for assistance, highlighting a lack of consistent adherence to facility protocols.
The facility failed to ensure valid advance directives for three residents, resulting in incomplete MPOA and OOH-DNR forms. A resident's MPOA lacked signatures and witness confirmation, while two residents' OOH-DNR forms were missing physician details, rendering them invalid. Staff interviews revealed inadequate verification and execution of these directives.
The facility failed to ensure privacy in two shower rooms due to incomplete shower curtains, affecting residents' dignity. Observations showed missing hooks on curtains, and staff interviews revealed a lack of training on reporting maintenance issues. The Maintenance Director was unaware of the problem until informed during the survey, and the checklist for daily care rounds did not include shower curtains.
A facility failed to ensure the legs of a mechanical lift were widened during a transfer, resulting in the lift falling on a resident with multiple diagnoses, including dementia and hemiplegia. Video footage and staff interviews revealed inconsistent knowledge and practices regarding the proper use of mechanical lifts, despite facility policies requiring the legs to be widened to prevent tipping.
Failure to Ensure Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure a resident’s right to privacy during personal care when CNA A provided incontinent care without fully closing the room door or drawing the privacy curtain. The resident was an elderly female admitted with a right femur fracture, dementia, adult failure to thrive, and gastro-esophageal reflux, with an initial MDS showing a BIMS score of 03 indicating severely impaired cognition and a need for complete support with toilet hygiene. Her care plan identified an ADL self-care performance deficit related to dementia, impaired balance, right femur fracture, and failure to thrive, with an intervention for assistance by one staff member with personal hygiene. During observation, CNA A performed incontinent care in the resident’s room while the door remained open and the privacy curtain was only partially closed, allowing the care to be fully visible to anyone entering the room. In interviews, the resident stated she believed the CNA performed the care satisfactorily and that she was pleased with the service, but she did not know whether the curtain or door had been closed and was unable to comprehend or answer whether she would feel comfortable if an unidentified bystander observed her during personal care. CNA A, who had over one year of experience, acknowledged that he did not fully close the door or curtain, initially believing it was acceptable because the peri care was not visible to the roommate, but later recognized that the open door and partially closed curtain allowed visibility of the peri care to anyone entering the room and that this compromised the resident’s right to privacy and dignity. The DON stated that staff were required to close doors, windows, and privacy curtains during nursing care, including incontinent care, and acknowledged that the door and curtain should have been fully closed before care, while also noting that resident rights, including privacy and dignity, were part of ongoing staff training and supported by the facility’s Resident Rights policy.
Improper Storage of Nebulizer Equipment for Residents on Respiratory Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards, residents’ care plans, and physician orders for two residents who required nebulizer treatments. One resident, an adult male with diagnoses including heart failure, dementia, acute and chronic respiratory failure, lung abscess without pneumonia, chronic kidney disease, obesity, and on oxygen therapy, had a care plan for altered respiratory status related to hypercapnic respiratory failure with interventions to administer ordered respiratory medications. His physician ordered Arformoterol Tartrate via nebulizer twice daily for COPD. Another adult male resident with COPD, heart failure, dementia, acute kidney failure, adult failure to thrive, and on oxygen therapy had a care plan for COPD with interventions to administer aerosol or bronchodilators as ordered, and a physician order specifying that plastic tubing must be kept in a plastic bag attached to the concentrator or nebulizer and checked every shift for infection control. During observation and interview, surveyors found that both residents’ nebulizer masks and tubing were lying openly on bedside tables rather than stored in clean protective bags as required. One resident’s mask and tubing were mixed among his personal belongings, and the other resident’s nebulizer mask was placed next to a urine bottle containing urine. The charge RN acknowledged on interview that the masks and tubing should have been stored in protective bags and that it was the nurses’ responsibility to ensure proper storage to prevent cross-contamination and microorganism colonization, which could lead to serious respiratory and other infections. The DON stated that nebulizer masks, tubing, and oxygen nasal cannulas should be cleaned and stored in clean protective bags after use, and that nurses were responsible for completing this process and monitoring during rounds. Record review showed there had been no in-services on safe handling of respiratory equipment and no facility policies on safe storage of nebulizer masks and tubing after medication administration.
Unsecured Computer Screen Exposed Resident Health Information
Penalty
Summary
Surveyors identified a failure to protect a resident’s personal health information when an RN left a charting computer on 300 Hall open and unattended with the resident’s clinical information visible on the screen. On 2/27/2026 at 10:12 a.m., observation showed the computer at the RN’s charting station was unlocked and displaying Resident #1’s personal clinical information, which could be seen by unauthorized individuals walking in the hallway, including visitors, other residents, or staff. Other nursing staff were observed walking near the charting station at the time, and the RN did not return to the computer until 10:15 a.m. During interviews, the RN stated she had received HIPAA in-service training five months earlier, which included instructions not to share private clinical information with unauthorized individuals and to lock the computer screen when stepping away. She acknowledged that everyone using charting computers was responsible for closing and locking them when not in attendance and admitted she was at fault for not locking the computer before answering a call light. The Administrator reported that he had received HIPAA training upon hire and again a few months prior, and that all staff received HIPAA in-services upon hire and annually, with the last one in September 2025. The DON stated the facility’s HIPAA policy required minimizing charting computer screens when stepping away and that staff working with private clinical information should lock the screen before walking away. Record review confirmed the RN had completed HIPAA in-service on 09/17/2026 and that facility policies on Privacy Notice and Resident Rights prohibited unauthorized release, access, or disclosure of resident information and required maintaining privacy of patient health information.
Failure to Follow EBP, Contact Precautions, and Hand Hygiene for Resident With MRSA Wound
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program for a resident with a history of a MRSA-infected wound on the right flank. The resident was an older male with multiple comorbidities, including traumatic brain injury, hemiplegia, chronic kidney disease, dysphagia, chronic pain, and a documented bacterial infection. His MDS showed mild to moderate cognitive impairment and total dependence on staff for ADLs, including transfers with a mechanical lift. The care plan identified an actual impairment to skin integrity related to cellulitis and infection of soft tissue in the right breast/axilla area, with interventions to monitor and document the wound and signs of infection. Physician orders documented contact precautions and later Enhanced Barrier Precautions (EBP) for a MRSA infection to a wound on the right flank, with orders specifying the use of gown and gloves during high-contact resident care activities. Video observations over several dates showed repeated failures by unidentified staff to follow contact precautions and EBP requirements when providing care to this resident. Staff were observed wiping a fungal area later diagnosed as MRSA and then using the same wipe on the rest of the resident’s body. Staff applied facial cream and checked the right-side wound while wearing only gloves and masks, without gowns. During incontinence care, staff used gloves but did not change them appropriately, applied patches without changing gloves, placed a trash can from the floor onto the resident’s sheets, and then used the same contaminated gloves to make the bed. Staff repeatedly failed to wear gowns during incontinence care, clothing changes, and wound care, and did not clean or disinfect surfaces and equipment such as bedside tables, wound care trays, markers, and mechanical lifts after use in the resident’s room. Additional observations showed that staff did not perform hand hygiene between glove changes or after glove removal, contrary to facility policy. One nurse used a marker stored in his pants on the resident’s wound bandage and returned it to his pants without cleaning it, did not change gloves, and left the room carrying trash and a tray without disinfecting them. Another nurse performed wound care on the bedside table without wiping it down afterward and touched the bed remote, bedside table, and drinking glass with contaminated gloves. On a later observation date, the resident’s door lacked an EBP sign despite active EBP orders, and a CNA provided peri-care without a gown and without handwashing or hand sanitizer between multiple glove changes while cleansing the peri-area and buttocks, applying skin barrier, and repositioning the resident. The same CNA also failed to disinfect the mechanical lift before removing it from the resident’s room. Interviews with the CNA, ADON, and ADM confirmed that staff had been trained on infection control, hand hygiene, and EBP, and that facility policies required hand hygiene before and after resident contact, between glove changes, and after glove removal, as well as appropriate use of gowns and gloves for residents on contact precautions.
Failure to Honor Resident’s Right to Communication in Primary Language and Respectful Treatment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with respect and dignity and informed of and supported in exercising her right to communication in her primary language. The resident was an older female with dementia, insomnia, anxiety disorder, hyperlipidemia, difficulty in walking, PTSD, cognitive communication deficit, bipolar disorder, and hypertensive heart disease, with a BIMS score of 15 indicating mild cognitive impairment. She required assistance with ADLs and transfers. During an observation and interview, the resident’s hands were trembling as she reported feeling labeled as “bipolar,” experiencing high anxiety throughout her body, frequent crying, and compulsive picking at the skin on her chin. She attributed her heightened anxiety in part to medication changes and confrontations between her responsible party and the facility. The resident reported that a medication aide spoke to her only in Spanish, even though her primary language was documented as English, and she felt obligated to speak Spanish to receive her medications and to show respect to the aide’s preferred language. She stated she did not know she had a right to be spoken to in her primary language and expressed that she did not want to upset anyone, so she would continue speaking Spanish to obtain her pain medications. She also stated she had previously spoken with the Administrator and DON about her concerns but could not recall when. The ADON confirmed that the resident frequently came to her to confide and had recently expressed feeling that nobody in the facility liked her. Facility staff, including the medication aide and ADON, acknowledged that residents have the right to be spoken to in their preferred language, and the facility’s written policy stated that residents must be informed of their rights and responsibilities in a language understandable to them, with accommodations for limited English proficiency and foreign languages commonly encountered in the community.
Unlicensed Staff Administered Medication Patch
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) applied a lidocaine pain relief patch to a resident, despite facility policy and state regulations requiring that only licensed personnel administer medications. The incident was discovered after the resident's family reported seeing a video of the CNA applying the patch. The resident involved had multiple diagnoses, including Type 2 Diabetes Mellitus, idiopathic epilepsy, major depressive disorder, and anxiety disorder, and was assessed as having severe cognitive impairment. The medication administration record showed an active order for the lidocaine patch. Interviews with facility leadership confirmed that the CNA was not authorized to administer medications and that the facility's policy restricts medication administration to licensed staff, such as nurses and medication aides. The CNA admitted to applying the patch and stated she was later informed that this was outside her scope of practice. The incident was corroborated by video evidence and staff interviews. The facility's policy on medication administration emphasizes adherence to legal requirements and proper orientation for staff involved in medication distribution.
Failure to Provide Shower Upon Resident Request, Resulting in Loss of Dignity
Penalty
Summary
A male resident with multiple complex medical conditions, including a history of cerebral hemorrhage, COPD, heart failure, atrial fibrillation, dementia, and moderate cognitive impairment, was dependent on staff for all activities of daily living, including showers and incontinence care. On the day of the survey, the resident was observed sitting in his wheelchair with a strong urine odor present near him and his bed. He reported to surveyors that he had not been given a shower that day despite requesting one, and that he had urine on his bed and clothing. The resident stated that staff told him it was not his scheduled shower day and that he should have taken a shower on his assigned day. He expressed feeling dirty, neglected, and unable to go to the dining room due to his condition. Record review showed the resident was scheduled for showers three times per week, and had received showers on the previous three scheduled days. However, facility policy and the Director of Nursing confirmed that residents requesting showers outside of their scheduled days should have their requests accommodated. The Director of Nursing acknowledged that the resident should have been provided a shower when requested, especially given the presence of odor, and that it was unacceptable for the resident to be left in dirty clothing. The facility's policy emphasized the right of residents to be treated with respect and dignity, which was not upheld in this instance.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not ensuring that enhanced barrier precautions (EBP) were implemented during care for a resident with a colostomy. The resident, an 85-year-old female with multiple diagnoses including dementia, hemiplegia, diabetes, and colostomy status, required EBP as indicated in her care plan. Observations revealed that while EBP signage and personal protective equipment (PPE) were present, staff did not consistently follow the required protocols. Specifically, two CNAs provided peri care and emptied the resident's colostomy bag while wearing gloves but failed to don gowns as required by EBP guidelines. Interviews with these CNAs indicated a lack of understanding and inconsistent application of EBP, with one CNA admitting to not always wearing a gown and being unable to explain the precautions, and the other stating she did not notice the EBP sign and sometimes omitted the gown. In contrast, a CMA was observed following proper EBP protocol by wearing both gown and gloves during resident care. Further interviews with facility leadership, including the DON, ADON, and Administrator, confirmed expectations that staff should wear gowns and gloves for residents on EBP, particularly during high-contact care activities. However, the ADON was unable to provide recent signed in-service documentation for EBP training, and there was acknowledgment that staff education on EBP had been reviewed but not consistently documented. The facility's policy outlined the requirements for EBP, including targeted gown and glove use during high-contact care, but these were not consistently followed in practice.
Failure to Maintain Medication Cart Integrity and Remove Expired Medications
Penalty
Summary
Surveyors observed that the facility failed to provide adequate pharmaceutical services, specifically in the management of medication carts and the storage of medications. During observations, a total of 29 loose pills were found across three medication carts, and three expired medications were identified. Staff interviews revealed that medication aides were unaware of the presence of loose pills and expired medications in their carts, despite being trained and required to check for such issues daily or weekly. The medication storage policy reviewed did not address the storage of non-refrigerated medications, and no records of recent cart audits or in-services on medication administration were available. One resident involved had multiple diagnoses, including dementia, diabetes mellitus, and a history of falls, and was prescribed nystatin powder for a fungal infection. Expired bottles of this medication were found in the medication cart assigned to this resident. The resident's care plan included monitoring for skin breaks and infection, but the presence of expired medication in the cart indicated a lapse in following these interventions as ordered. Interviews with the ADON, DON, and administrator confirmed that staff were expected to check medication carts for loose and expired medications at least daily and at every shift. However, the lack of documentation for cart audits and in-services, as well as the presence of loose and expired medications, demonstrated that these procedures were not consistently followed. Staff also indicated that they believed there was little risk to residents due to the availability of backup medications, but this does not address the failure to maintain proper pharmaceutical services as required.
Failure to Provide Accurate PASRR Screening for Mental Illness
Penalty
Summary
The facility failed to provide an accurate Preadmission Screening and Resident Review (PASRR) Level 1 screening for a resident who had a documented diagnosis of Major Depressive Disorder. Upon admission, the resident's PASRR Level 1 screening, conducted by an acute care hospital, was marked negative for mental illness, intellectual disability, and developmental disability, despite the presence of a mental health diagnosis. The resident's medical record and care plan confirmed the diagnosis of Major Depressive Disorder and the use of antidepressant medication. Multiple staff interviews, including those with two MDS coordinators, the DON, and the administrator, confirmed that the resident's diagnosis should have resulted in a positive Level 1 PASRR screening, which would have triggered a Level 2 evaluation. The facility's PASRR policy requires that if a Level 1 screening is found to be incorrect, the MDS coordinator or designee must contact the hospital or responsible case worker to correct the form, or submit a new screening if necessary. In this case, the failure to identify and correct the inaccurate PASRR Level 1 screening resulted in the resident not being properly identified as having a mental illness, which could have affected the provision of specialized services. The deficiency was identified through record review and staff interviews, all of which acknowledged the oversight and its potential impact on the resident's care.
Failure to Update Care Plan for Gastrostomy Tube Dislodgement
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a history of intractable epilepsy, malnutrition, aphasia, dysphasia, intellectual disability, and anoxic brain damage, who was dependent on a gastrostomy tube for nutrition. The care plan did not include instructions or interventions for managing situations when the resident’s gastrointestinal tube became dislodged, despite multiple documented incidents of tube dislodgement that required medical intervention or hospitalization. The care plan only referenced checking tube placement and gastric contents, omitting guidance for tube removal or replacement. Record reviews revealed that the resident’s PEG tube had become dislodged on several occasions, leading to physician visits and hospital transfers for tube replacement. Staff interviews confirmed that there was no specific training or education provided to CNAs regarding the handling of PEG tubes during care, nor were there updates to the care plan following these incidents. The CNA involved in one incident reported not receiving additional training after the event, and both the CNA and LVN stated that having clear care plan instructions would have been beneficial for staff unfamiliar with the resident’s needs. Administrative staff, including the DON and ADM, acknowledged that care plans should be updated to reflect significant changes or incidents, such as hospitalization due to device dislodgement. However, the care plan was not revised to address the management of the resident’s PEG tube dislodgement, and the facility’s care plan policy was not provided upon request. This lack of comprehensive care planning placed the resident at risk for complications related to indwelling devices.
Failure to Ensure CNA Competency in Bed Bath Care for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in providing care for a resident with a PEG tube, specifically during bed baths. One nurse aide, while providing a bed bath and dressing the resident, accidentally dislodged the resident's PEG tube. The resident, who was completely dependent on caregivers for bathing and had multiple complex medical conditions including intractable epilepsy, aphasia, dysphasia, and required gastronomy feeding, was subsequently transferred to the hospital for tube replacement. The care plan for the resident did not include instructions for providing bed baths in the presence of a PEG tube. Interviews with staff revealed that the nurse aide involved had only received general bed bath training during CNA school and had not received any specific training or competency assessment on caring for residents with PEG tubes at the facility. Other CNAs also reported not being checked off on providing bed baths and relied on common sense or asking nurses if they had questions. There was no documentation of in-services or competency assessments related to bed baths or PEG tube care in the staff files or facility records. Supervisory staff, including the LVN and DON, confirmed that there was no formalized training or assessment for CNAs regarding PEG tube care during bed baths. The DON was unaware of the incident and stated that any change of condition requiring hospitalization should have triggered reeducation, but this did not occur. The administrator acknowledged that while reeducation was provided after the event, CNAs were not assessed for competency in providing bed baths for residents with PEG tubes, and there was no documentation of initial check-offs for the involved CNA.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA), identified as CNA A. The incident involved a male resident with a history of dementia, traumatic brain injury, and other medical conditions, who was completely dependent on staff for toileting hygiene. During an interaction captured on video, CNA A was observed verbally threatening the resident while assisting him with dressing. The resident, who exhibited moderately impaired cognition, expressed discomfort and resistance during the interaction, which escalated to CNA A making threatening remarks. The facility's administration was not initially aware of the incident, as the family member of the resident did not trust the facility to intervene and did not provide the video evidence until later. The family member believed CNA A had been removed from the facility, but later observed her still working there, raising concerns about the resident's safety. The facility's Administrator and Director of Nursing were unaware of the specific incident until it was brought to their attention during the survey, despite having previously addressed a separate issue of poor customer service involving CNA A. The facility's policy on abuse prevention was not effectively implemented in this case, as the incident was not reported or addressed in a timely manner. The Administrator, who was responsible for the abuse prevention program, acknowledged the potential negative outcomes of such behavior, including the resident not feeling safe. The Director of Nursing emphasized the importance of staff training and routine monitoring to prevent abuse, but the failure to identify and address the incident promptly highlighted a gap in the facility's abuse prevention efforts.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident who was diagnosed with an L1 transverse process fracture. The resident, a male with severe cognitive impairment due to traumatic brain injury and dementia, was admitted to the facility with multiple diagnoses including unspecified dementia, hemiplegia, generalized anxiety disorder, and morbid obesity. The resident's hospital discharge paperwork indicated he was admitted for low back pain and knee pain, during which the fracture was discovered. Despite this, the facility did not report the injury to the State Survey agency as required. During an interview, the Director of Nursing (DON) stated that the fracture was not considered a reportable incident because the timing and cause of the injury were unknown, and there had been no recent falls at the facility. The Administrator mentioned that if she had known the fracture was confirmed, she would have reported it to the Health and Human Services Commission (HHSC). The facility's policy on abuse investigation and reporting, revised in July 2017, mandates that all reports of resident abuse, neglect, and injuries of unknown source be promptly reported to local, state, and federal agencies and thoroughly investigated by facility management.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, the facility did not ensure that the call lights for five residents were within reach, which is crucial for residents to call for assistance or in case of an emergency. This deficiency was observed in multiple instances, where call lights were found on the floor or out of reach, despite care plans indicating the necessity for call lights to be accessible to residents. Resident #69, who is severely cognitively impaired and totally dependent on staff for transfers, toileting, and bed mobility, was found with his call light on the floor. Despite his care plan emphasizing the importance of keeping the call light within reach, staff interviews revealed a lack of consistent adherence to this requirement. Similarly, Resident #9, who has no cognitive impairment but requires maximal assistance, was observed with her call light wrapped around a bed rail, out of her reach, forcing her to use a stick or wheel herself to the hallway for help. Other residents, including Resident #71, who is moderately cognitively impaired and dependent on staff for transfers, and Resident #352, who has intact cognitive status but is dependent for repositioning and transfers, also had their call lights out of reach. Staff interviews consistently highlighted a policy that call lights should be within reach, yet observations and interviews indicated a failure to consistently implement this policy, leaving residents unable to call for assistance when needed.
Failure to Ensure Valid Advance Directives for Residents
Penalty
Summary
The facility failed to ensure the residents' right to formulate an advance directive for three residents. Resident #52's Medical Power of Attorney (MPOA) was incomplete, lacking signatures, dates, and witness or notary confirmation, rendering it invalid. This resident had a history of encephalopathy, unspecified dementia, and major depressive disorder, with increased cognitive impairment noted in a neuropsychological report. Despite the care plan indicating the need to follow advance directives, the MPOA was not properly executed. Resident #62's Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) form was missing critical information, including the physician's license number, date of signature, and printed name in the physician's statement section, making the document invalid. This resident had severe cognitive impairment, as indicated by a BIMS score of 1, and a care plan that reflected a DNR status. However, the necessary documentation to support this status was incomplete. Resident #99's OOH-DNR form was also incomplete, lacking required physician signatures, printed names, and license numbers. This resident had multiple diagnoses, including acute respiratory failure and schizoaffective disorder, and was admitted to hospice care. Despite choosing a DNR status, the form was not properly executed. Interviews with facility staff, including RN B, LVN A, and the DON, revealed a lack of proper verification and execution of advance directives, with responsibilities not clearly followed, leading to these deficiencies.
Deficiency in Shower Room Privacy and Maintenance Reporting
Penalty
Summary
The facility failed to maintain a clean, sanitary, comfortable, and homelike environment in two shower rooms used by residents, specifically in the 100-200 Hall and 300-400 Hall. Observations revealed that the shower curtains in these areas were missing hooks and did not close completely, compromising residents' privacy during showers. A confidential interview confirmed that a resident did not have privacy during showers due to the incomplete closure of the curtains. Interviews with staff, including the Maintenance Director and CNAs, highlighted a lack of awareness and training on how to report maintenance issues using the facility's computer application. The Maintenance Director admitted to not noticing the curtain issues during his rounds and was only informed of the problem on the day of the survey. The facility's administration expected regular checks of the shower rooms to ensure functionality, but the checklist used for daily care rounds did not include shower curtains, indicating a gap in the facility's procedures for maintaining resident privacy and dignity.
Failure to Ensure Proper Use of Mechanical Lift
Penalty
Summary
The facility failed to ensure the environment remained free of accident hazards and that residents received adequate supervision and assistance devices to prevent accidents. Specifically, the legs of a mechanical lift were not widened during a transfer, resulting in the lift falling on a resident. This incident involved a resident with multiple diagnoses, including unspecified dementia, hemiplegia, and chronic pain syndrome, who was dependent on mechanical lift transfers. The resident was assessed for injuries following the incident, and no injuries were found. The incident was captured on video footage, which showed that the legs of the mechanical lift were not widened during the transfer, causing the lift to fall. Interviews with staff revealed inconsistent knowledge and practices regarding the proper use of mechanical lifts. Some staff members were aware that the legs should be widened, while others were unsure or had not received recent training on the procedure. The facility's policy on safe lifting and movement of residents indicated that the legs of the mechanical lift should be opened wide to prevent tipping. The Director of Nursing (DON) confirmed that two people should be present during a mechanical lift transfer and that the legs of the lift should be widened to prevent accidents. The DON acknowledged that failing to widen the legs could result in the resident being dropped or the lift tipping over. The facility's policy and staff interviews highlighted the importance of proper mechanical lift use to ensure resident safety, but the incident demonstrated a lapse in adherence to these guidelines.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 344 citations issued within 25 miles in the last 12 months — including the 21 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gracy Woods Nursing Center | 0.4 mi | — | 21 | 1 |
| Gracy Woods Ii Living Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Windsor Nursing And Rehabilitation Center Of Duval | 2.5 mi | ★★★★★ | 1 | 0 |
| Legend Oaks Healthcare And Rehabilitation - North | 3.4 mi | ★★★★★ | 11 | 2 |
| Sage Park Austin | 4.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.