Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Petal Hill during CMS and state inspections, most recent first.
A resident with dementia, severe cognitive impairment, wandering behavior, and a high elopement risk exited a secured unit without staff knowledge or supervision. Staff later learned the resident had gone through a secured door that had not been properly closed, and interviews showed the alarm was not heard and the hallway cameras were not functioning. The resident was found about one block away by police and facility staff.
Surveyors found that the primary therapy room was in active use while multiple ceiling vents and surrounding areas showed visible black, spotty mold growth, later identified in testing as penicillium, aspergillus, and another fungus, with heavy mold spore populations in the ductwork. Two cognitively intact male residents with significant neurologic and mobility impairments were observed receiving daily therapy directly beneath the contaminated vents, one using exercise equipment and another working at a table, both unaware of the condition above them. Therapy staff, the DON, ADON, Administrator, and regional maintenance leadership acknowledged prior concerns about a water leak, suspected mold, instructions not to use the central HVAC, and the need for remediation, yet the room continued to be used for therapy after a wall/window unit was installed for temperature control. The facility’s own mold report documented employee skin irritation and symptoms possibly related to mold exposure and recommended that the HVAC not be operated until ductwork was cleaned and remediated, while the facility’s homelike environment policy required a clean, sanitary, and orderly environment, which was not maintained in this therapy area.
The deficiency concerns a failure to timely report an allegation of resident-to-resident physical abuse to the state agency within the required two-hour window. A cognitively impaired resident seated in a dining area was struck in the face with a sneaker by another cognitively impaired resident who was walking by. Staff witnesses separated the residents, assessed the struck resident, and notified nursing, and the resident showed no redness, bruising, or distress on assessment and neurological checks. Multiple staff, including CNAs, an LVN, the SW, ADON, and DON, identified the administrator as the abuse coordinator and followed internal notification steps, but the DON delayed notifying the administrator and both the DON and administrator delayed reporting to the state, based on their belief that there was no willful intent and a misunderstanding of reporting timeframes. Facility policy, however, required that suspected abuse be reported immediately to the administrator and state authorities, defining "immediately" as within two hours of an allegation involving abuse, while the actual report to the state was not received until about five hours after the incident.
Resident council meetings were held in the dining room, where staff repeatedly entered despite residents asking them not to. Six confidential residents said they preferred a private meeting space because staff came through during meetings. The AD confirmed staff had often entered the room, and the DON and ADM identified other available areas, but the dining room continued to be used even though it also housed the staff breakroom, kitchen, and vending machines.
An LPN failed to use proper eye drop technique for two residents during med pass, including not creating a conjunctival pocket and, in one case, instilling drops directly onto the eyeball. The main med storage room contained expired medications, and two nurses signed controlled substance count sheets at the beginning of their shifts instead of at shift change. The DON acknowledged the eye drop technique and narcotic count practices were not followed as required.
A resident with documented major depressive disorder and schizoaffective disorder had two Level 1 PASRR screenings that incorrectly stated she did not have a mental illness diagnosis. The MDS Coordinator said both screenings were wrong and that the LA should have been notified so a new PASRR could be submitted; the DON stated the MDS Coordinator was responsible for the PASRR process and that accurate screenings were needed to ensure eligible residents received PASRR services.
A resident with intellectual disabilities and mental health diagnoses did not receive a timely request for specialized occupational therapy services due to the facility's failure to submit the required NFSS form after an IDT meeting. Documentation showed the need for OT services, but confusion over staff responsibilities and lack of awareness of submission timelines led to the omission.
Two residents were involved in a physical altercation when a resident with severe cognitive and behavioral issues assaulted another resident, causing a head injury and spinal fracture. Staff were unable to intervene in time, despite care plans addressing behavioral risks, and the injured resident required emergency medical care.
The facility failed to maintain a safe and sanitary environment, with deficiencies observed in 17 out of 25 rooms. Issues included black spots around air vents, holes in walls, missing baseboards, and mold in some rooms. Several rooms were improperly used for storage, contributing to an unsafe environment. Interviews revealed a lack of awareness and communication regarding the extent of the issues, despite some remediation efforts.
The facility failed to maintain a safe and homelike environment, with residents reporting mold, broken lights, and showers. Despite complaints, maintenance issues persisted, compromising resident safety and comfort.
The facility failed to secure narcotics in the DON's office, leaving the door and a cabinet containing discontinued narcotics unlocked. This oversight occurred when the DON was called away, and the ADON, who shared the office, did not lock the door upon returning. The facility's policy mandates double-lock storage for such medications.
A facility with over 120 beds failed to employ a qualified full-time social worker, as required. The personnel file inaccurately listed a social worker, and the current social worker's license had expired. The facility was sharing a social worker from a sister facility, and the administrator was unaware of the full-time requirement. The non-licensed social worker was in the process of reinstating his license.
The facility failed to maintain a safe and clean environment for two residents, with issues such as missing flooring panels, broken vanity drawers, and unsanitary bathroom conditions. Maintenance and housekeeping staff were unaware of these issues due to a lack of communication and documentation in the maintenance logbook, as required by facility policy.
A facility failed to implement a comprehensive care plan for a resident, omitting details on the resident's PASRR Evaluation and smoking status. The resident, with multiple diagnoses, was observed smoking without a care plan addressing safety measures. Staff interviews confirmed the lack of assessment and documentation, contrary to facility policies.
A resident with a history of smoking was not assessed for safe smoking upon admission, and her care plan did not address her smoking status or safety needs. Despite being observed smoking safely in the designated area, staff interviews revealed that her smoking status and safety needs were not documented or communicated, contrary to the facility's policy.
The facility failed to maintain an effective pest control program, resulting in a persistent cockroach infestation. Despite monthly treatments and additional call-outs, the infestation persisted, with grievances from residents and observations of cockroaches in rooms and bathrooms. The Maintenance Director and the Pest Control Company confirmed ongoing issues and treatments, but the problem was not resolved effectively. Interviews with residents and staff revealed frequent sightings of cockroaches, and the facility's pest control policy was not adequately implemented to eradicate the pests.
A resident admitted for respite care did not receive his prescribed Ambien for three days due to the facility's failure to follow up with the family or pharmacy. The DON acknowledged the lack of a policy for insurance respite care and the absence of documentation regarding the missing medication.
The facility failed to ensure that a resident had CBC and CMP lab tests every six months as ordered, due to miscommunication with the lab and the resident's occasional refusal of lab draws.
A resident did not receive his prescribed health shake or double meat portion at lunch, despite his meal card indicating these items. Staff interviews revealed that it was the nurses' responsibility to check meal trays against meal tickets, but this protocol was not followed. The facility's policies emphasized the importance of providing nutritional supplements and individualized diets, but these were not adhered to for the resident.
The facility failed to ensure that a resident with dysphagia received honey thickened liquids as required, leading to instances where the resident was given incorrect liquid consistencies. Staff did not verify the correct thickness, and there was a lack of clarity on responsibility for ensuring proper fluid consistency.
The facility failed to ensure dietary staff wore hair restraints in the kitchen, as observed during a survey. Multiple staff members, including a dietary aide and the cook, were seen without hair nets, and the kitchen was out of hair nets. The Dietary Manager and Director of Nursing emphasized the importance of hair restraints for hygiene and preventing food contamination, while the Administrator noted the policy only required hair nets when handling or preparing food.
The facility failed to maintain a safe, sanitary, and comfortable environment, with issues such as a damaged dining room door and a resident's bathroom with fallen tiles, peeling wallpaper, and a warped baseboard. The Maintenance Director acknowledged the need for renovations but lacked systematic documentation and follow-up.
The facility, with a capacity of more than 120 beds, has failed to employ a qualified full-time social worker since November 2023. This has led to difficulties in addressing residents' social service needs, including transfer requests, and has required non-licensed staff to attempt to cover the social worker's duties.
Inadequate Supervision Allowed a High-Risk Resident to Elope from a Secured Unit
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions for a resident who lived on a secured unit and was assessed as high risk for elopement. The resident had diagnoses including dementia, psychotic disturbance, anxiety, hypertension, trigeminal neuralgia, hyperlipidemia, conversion disorder with seizures or convulsions, major depressive disorder, type 2 diabetes mellitus, TIA, dysphagia, cerebral infarction, COPD, and cognitive communication deficit. The resident’s BIMS score showed severe cognitive impairment on one assessment and moderate impairment on another, and the record also documented wandering behavior and a high elopement risk score. On the day of the incident, the resident was last observed on the secured unit and then exited the building without staff knowledge or supervision. The police report stated the resident was wandering in the neighborhood and entering a residential backyard, and facility staff were contacted to verify whether any residents were missing. The MDS RN reported the resident exited through a secured door that had not been properly closed, allowing the resident to leave unsupervised. A CNA statement documented that police contacted the facility about a white female with gray hair located about one block away, and staff then identified the individual as a resident. Facility documentation and staff interviews showed the resident was seen in the unit shortly before the elopement, but staff could not determine how the secured door was opened. Staff reported the hallway cameras were not functioning, and the alarm at the secured door was not heard. Interviews with nursing, CNA, activity, administration, and MDS staff reflected that the resident had been on a secured unit, that the door was supposed to remain secured, and that staff were unable to explain how the resident exited. The resident was found approximately one block from the facility on a sidewalk in a college district, and the incident was documented as an actual elopement without injury or emotional distress.
Failure to Maintain a Safe and Sanitary Therapy Environment Due to Mold-Contaminated Vents
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, functional, sanitary, and comfortable environment in the primary therapy room, where black, spotty substance consistent with mold was observed on four air vents and the surrounding ceiling. During an observation, surveyors noted this substance in the primary therapy room, which was actively being used for resident therapy. The facility’s own mold report documented that the physical therapy room had visible mold growth around the vents on the ceiling and that ductwork testing showed heavy mold spore populations. The report also stated that employees working in that room had reported irritation to skin and other symptoms that may be caused by mold exposure. Two residents who regularly used the primary therapy room were observed receiving services directly underneath vents and ceiling areas with the black, spotty substance. One resident, a male with a history of spinal stenosis of the cervical region, weakness, unsteadiness on feet, gait abnormalities, and hemiplegia/hemiparesis following a cerebral infarction, had a BIMS score of 15 indicating normal cognition and received therapy services at least 15 minutes a day on one or more days in the last 7 days. He was observed using a SciFit machine directly under the affected vent and ceiling area and reported using the primary therapy room at least once a day, though he had not noticed the substance because he did not often look up. Another resident, a male with diagnoses including nontraumatic intracerebral hemorrhage, hemiplegia/hemiparesis affecting the right dominant side, muscle weakness, and unsteadiness on feet, had a BIMS score of 13 indicating normal cognition and also received therapy services at least 15 minutes a day on one or more days in the last 7 days. He was observed completing a puzzle at a table directly underneath a vent and ceiling area with the black substance and reported entering the primary therapy room daily, but stated he had never looked up to see it. Staff interviews and record review showed that facility leadership and therapy staff were aware of environmental issues in the primary therapy room but continued to allow resident use of the space. The Director of Rehab stated that someone had come to the facility months earlier, that they were instructed not to use the air conditioning or heat in that room, and that residents were to be brought to a separate therapy area when it was too hot or too cold. He reported that a wall unit was later installed to regulate temperature and believed it was safe because no air was going through the vents. The PT and PTA both reported being instructed around December not to use the main air system in the therapy room due to a water leak and inability to use the vented air system, and that a new window or wall unit had recently been installed; the PTA stated the vents had looked black, brown, and dusty since December and their appearance had not changed. The ADON was aware the air system was not working but unaware of further issues, while the DON acknowledged there had been talk of mold, that therapy had been moved to a separate area, and believed the vents were recently cleaned, though she was unsure if the substance was mold. The Administrator reported waiting on bids to repair the therapy area, planned to remove and replace the venting system, and knew the substance had been tested but could not provide who had deemed the room safe for resident use. The regional director of maintenance confirmed test results showing penicillin, aspergillus, and another fungus in the vents and ceiling and stated he would not want his family receiving therapy under those conditions. The facility’s own mold report recommended that the HVAC system not be operated until the ductwork was cleaned and remediated and described required containment and access restrictions for remediation, while the facility’s Homelike Environment policy required a clean, sanitary, and orderly environment. Despite this, the primary therapy room with visible mold growth on vents and ceiling remained in use for resident therapy. A review of facility records cross-referencing residents with pneumonia in the last six months and residents receiving therapy services showed no residents who had received therapy in the front therapy room had been diagnosed with pneumonia. Residents observed in the room did not have observable skin irritation or respiratory issues and denied experiencing such symptoms. However, the mold assessment report documented that the ductwork had heavy mold spore populations and that employees working in the room had reported irritation to skin and other symptoms that may be caused by mold exposure. The mold assessment consultant later stated that most typical mold spores in the area were low, with the air duct being the exception, and that the facility was obtaining quotes for remediation work. The facility’s continued use of the primary therapy room for resident services, despite visible mold growth on vents and ceilings, documented heavy mold spore populations in ductwork, and internal acknowledgment of suspected mold and the need for remediation, constituted the failure to maintain a safe, functional, sanitary, and comfortable environment as required by facility policy and regulatory standards.
Delayed Reporting of Resident-to-Resident Abuse Allegation to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of resident-to-resident physical abuse to the state agency within the required two-hour timeframe. A cognitively impaired female resident (Resident #1), with diagnoses including encephalopathy and dementia and a BIMS score of 3 indicating severe cognitive impairment, was seated in the dining area when another cognitively impaired female resident (Resident #2) walked by and hit her in the face with a sneaker she was carrying. Nursing documentation indicated that Resident #1 showed no signs of physical or emotional distress, had no redness, pinkness, bruising, or complaint of pain, and subsequent neurological checks throughout the evening showed she was alert, able to move all extremities, had equal and reactive pupils, and appropriate responses to pain. Social services documented that Resident #1 appeared without distress, was pleasant and calm, and was unable to recall the event. Resident #2, who also had dementia and a BIMS score of 3, was documented as having walked by Resident #1 and hit her in the face with a sneaker before sitting down and putting the shoe on. Staff witnesses, including two CNAs, reported that Resident #1 had her hand extended when Resident #2 passed by and struck her with the shoe, and both CNAs stated there was no redness observed on Resident #1. They reported that they separated the residents, ensured Resident #1 was okay, and notified the nurse. Nursing notes indicated Resident #2 was immediately placed on one-to-one supervision and separated from Resident #1. Social services documented that Resident #2 had referrals sent to behavioral health hospitals and that her family was informed of the incident. A psych NP later documented that Resident #2 reported she moved her shoe to ward off Resident #1’s hand and that it was not an intentional provocation. Multiple staff interviews clarified the sequence of notifications and the facility’s interpretation of the event. The LVN, CNAs, SW, ADON, and DON all identified the administrator (ADM) as the abuse coordinator and indicated that staff were to report allegations of abuse to him. The ADON stated she was in the facility when the event occurred, went to the secured unit, and contacted the DON by phone. The DON reported she was notified by the ADON that Resident #2 hit Resident #1 with her shoe and that she contacted the ADM around 6:20 p.m., estimating a delay of about 1.5 to 2 hours between her learning of the incident and notifying the ADM. The ADM stated he was notified at 6:51 p.m. and that there was a delay in reporting to the state due to his need to arrive at the facility, obtain information, and issues with the TULIP reporting system. TULIP case details showed the state agency received the abuse allegation report at 9:16 p.m., approximately five hours after the incident. The DON and ADM both indicated they did not initially consider the event to be abuse due to their belief that Resident #2 lacked willful intent, and the DON stated she understood the reporting requirement to be within 24 hours if there was no bodily injury. This conflicted with the facility’s written policy, which defined that suspicions of abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the administrator and authorities, with “immediately” defined as within two hours of an allegation involving abuse. The facility’s own policies on Abuse, Neglect, Exploitation and Misappropriation, and on Reporting and Investigating, stated that residents have the right to be free from abuse, including physical abuse, and that the abuse prevention program includes protecting residents from abuse by other residents. The reporting policy required that suspected abuse be reported immediately to the administrator and to the state licensing/certification agency, with a specific definition of “immediately” as within two hours for allegations involving abuse. Despite this, the DON and ADM delayed reporting the allegation to the state agency beyond the two-hour requirement, based on their personal assessment of intent and misunderstanding of the reporting timeframe. Surveyors concluded that the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, or misappropriation of resident property were reported immediately, but not later than two hours after the allegation was made, when the event involved abuse, resulting in a late report of the allegation involving Resident #1 and Resident #2.
Resident Council Meetings Lacked Privacy
Penalty
Summary
The facility failed to provide a private space for resident group meetings for 6 of 6 confidential residents interviewed. The residents reported that resident group meetings were held in the dining room, but they preferred not to meet there because staff entered the room during the meetings. The residents stated that they had told staff not to enter while the meetings were in progress, but staff continued to do so. During interviews, the AD stated that staff had often entered the dining room during resident council meetings despite being asked not to, and that a sign had been placed on the door to notify staff not to enter while a resident group meeting was in process. The DON stated she was unaware of staff entering during the meetings, but acknowledged that residents could use an alternative meeting area that would be private. The ADM also stated that the dining room contained the staff breakroom, kitchen, and vending machines, and that alternative areas such as the conference room or therapy room were available. A facility policy titled Resident Council stated that staff, visitors, or other guests may attend meetings only if invited and that the resident council group is provided with space and privacy to conduct meetings.
Medication Administration, Storage, and Controlled Substance Count Deficiencies
Penalty
Summary
The facility failed to ensure proper administration of eye drops for two residents during medication pass observations. For one resident, an LVN administered eye drops without gently pulling down the lower eyelid to create a conjunctival pocket and without instructing the resident to look upward during instillation. For another resident, an LVN again did not gently pull down the lower eyelid to create a conjunctival sac and instead instilled the eye drops directly onto the eyeball. During interview, the LVN who administered eye drops to one resident stated she had been trained in the proper administration and care of eye drops and described the correct technique as maintaining aseptic technique and gently lowering the lower eyelid to create a conjunctival sac. The DON also stated that nursing staff were trained on the proper administration of eye drops, including the required procedural steps, and acknowledged that the observed administrations did not follow steps #7 and #8 of the facility procedure. The facility also had expired medications in the main medication storage room, including Magnesium oxide 400 mg expired 1/2026, Naprosyn 224 mg expired 1/2026, and CoQ10 100 mg expired 2/2026. In addition, during observation of two medication carts, RN A and LVN B were signing the controlled substance count sheets for the end of their shifts at the beginning of their shifts. Both nurses stated they knew they should not sign the narcotic count sheet for the off-going shift until they were leaving their shift, and the DON agreed that nurses were not to sign the sheet at the beginning and end of their shifts.
Incorrect PASRR Screening for Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to coordinate the assessment of 1 of 6 residents reviewed for the PASRR program and PASRR assessments and evaluations. Resident #6 was admitted with diagnoses that included major depressive disorder, and the record also showed schizoaffective disorder was added to the resident’s diagnoses on 09/21/2023. The resident’s MDS records listed depression on the admission MDS and later listed depression and schizophrenia on a quarterly MDS, and physician orders dated 03/04/2026 listed major depressive disorder and schizoaffective disorder. The resident’s care plan also addressed major depressive disorder and the potential risk of hallucinations, delusions, and behaviors related to schizoaffective disorder. Despite these documented mental health diagnoses, Resident #6’s Level 1 PASRR screening dated 03/14/2023 indicated she did not have a mental illness diagnosis, and a second Level 1 PASRR screening dated 04/01/2024 also indicated she did not have a mental illness diagnosis. During interview, the MDS Coordinator stated both screenings were incorrect and said the LA should have been notified so a new Level 1 PASRR could be submitted. She stated a corrected Level 1 PASRR would have led to a PASRR evaluation to determine whether the resident qualified for PASRR care and services. The DON stated the MDS Coordinator was responsible for the PASRR process and that accurate Level 1 PASRR screenings were important to ensure eligible residents received PASRR services.
Failure to Submit Timely PASRR NFSS Request for Specialized Services
Penalty
Summary
The facility failed to submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC Online Portal for one resident who required a PASRR assessment. Specifically, the required NFSS form for occupational therapy (OT) assessment and services was not submitted within 20 business days following the interdisciplinary team (IDT) meeting, as mandated. This omission resulted in the resident not receiving the Medicaid service for OT as identified in the PASRR Comprehensive Service Plan. Record reviews indicated that the resident had multiple diagnoses, including unspecified intellectual disabilities, anxiety disorder, and major depressive disorder. The resident's care plan did not include OT services, despite the PASRR Comprehensive Service Plan identifying a need for specialized OT assessment and services. Documentation also showed that the resident was receiving other IDD habilitative specialized services, such as habilitation coordination and independent living skills, but the required NFSS request for OT was not completed or submitted in a timely manner. Interviews with facility staff revealed confusion and lack of clarity regarding roles and responsibilities for PASRR processes. The MDS Coordinator, who was new to the position, was unaware of the timelines for submitting the NFSS form and did not have the necessary documentation for the resident's OT services. The Social Worker, who started after the relevant events, had not previously completed or submitted an NFSS form and believed it was the MDS Coordinator's responsibility. The DON confirmed that PASRR responsibilities were split between the Social Worker and MDS Coordinator, which contributed to the failure to submit the required documentation.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Serious Injury
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in a serious incident involving two residents on the secured memory care unit. One resident, with a history of cerebral palsy, paranoid schizophrenia, mood disorder, major depressive disorder, and traumatic brain injury, exhibited severe cognitive impairment and behavioral issues. Despite care plan interventions aimed at managing aggression and ineffective coping, the resident was able to leave her room, walk down the hallway, and physically assault another resident by grabbing her arms and throwing her into a wall. This action caused the second resident, who had dementia and moderate cognitive impairment, to sustain a closed head injury, a scalp laceration, and a fractured lumbar vertebra. Staff present at the time were engaged in other duties, with one LPN at the medication cart and two CNAs occupied with other residents or outside the unit. The LPN attempted to verbally redirect the aggressive resident but was unable to prevent the assault. Witness statements confirm that staff did not anticipate the aggressive behavior, and the resident's prior history of physical aggression was not recent. The incident occurred rapidly, and staff were unable to intervene in time to prevent harm. The assaulted resident required emergency medical attention, including EMS transport, wound care, and subsequent hospitalization for her injuries. The facility's documentation and staff interviews indicate that the aggressive resident had previously displayed behavioral symptoms, including delusions and agitation, particularly when denied requests such as going outside to smoke. The care plan included specific interventions for managing these behaviors, but on the day of the incident, the escalation was not effectively prevented. The staff's inability to anticipate or immediately intervene in the resident-to-resident altercation directly led to the physical abuse and resulting injuries.
Environmental Deficiencies and Mold Concerns in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by numerous deficiencies observed in 17 out of 25 rooms reviewed for environmental concerns. These deficiencies included black spots around air vents, holes in walls, missing baseboards, non-working lights, and showers not functioning properly. Additionally, mold was identified in some rooms, and several rooms were improperly used for storage, contributing to an unsafe and unsanitary environment. During observations and interviews, it was noted that rooms A1 through A10 had significant issues such as black spots around air vents, holes in walls, and missing baseboards. Room A1, for instance, was used as a storage room and had a bathroom with peeling paint and unflushed toilets. Rooms B10 and B11 were also problematic, with mold identified in B10 and B11 being used for storage. Rooms C12 through C22 exhibited similar issues, with black buildup in showers, missing tiles, and holes in walls. Interviews with the facility's administrator and staff revealed a lack of awareness and communication regarding the extent of the issues. The administrator, who had only been at the facility for a short time, was not fully informed about the previous conditions or the current state of the rooms. The RDO, who had temporarily overseen the facility, acknowledged some remediation efforts but was unaware of the full scope of the problems. Despite some remediation efforts in specific rooms, the facility's overall environment remained compromised, with ongoing concerns about mold and maintenance issues.
Environmental Deficiencies and Maintenance Neglect in LTC Facility
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for several residents, as evidenced by multiple environmental concerns observed and reported. Residents and their families reported the presence of a black substance suspected to be mold in the rooms of two residents. One resident's family, who had experience in carpentry, identified the substance as black mold, leading to the resident's relocation to another facility. The facility's administrative staff locked the affected room, but there was no clear follow-up on the mold testing results. In addition to mold concerns, several rooms had maintenance issues that were not addressed, including broken lights, holes in walls, and broken showers. One resident was moved from a room due to remodeling, but the family reported ongoing mold issues in the new room as well. Observations revealed missing tiles, exposed pipes, and black substances in various rooms, indicating a lack of timely maintenance and repair. Residents expressed concerns about the inability to use showers due to broken fixtures, leading to inadequate personal hygiene. Interviews with staff and residents highlighted a lack of communication and action regarding maintenance requests. Maintenance issues, such as non-functional lights and missing tiles, created safety hazards and discomfort for residents. Despite repeated complaints from residents and their families, the facility did not adequately address these environmental deficiencies, compromising the residents' right to a safe and comfortable living environment.
Failure to Secure Narcotics in DON's Office
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by State and Federal laws. Specifically, the Director of Nursing's (DON) office, which was used for storing drugs and biologicals, was found unlocked and slightly ajar. Inside the office, a metal filing cabinet containing discontinued narcotics was also found unlocked. This situation was observed during a surveyor's visit, and it was noted that the office was unattended at the time, allowing potential access to unauthorized personnel. During interviews, the DON acknowledged that the office door was left open and the narcotics cabinet was not secured. The DON explained that the medications were awaiting destruction and admitted to being called away to the front desk, which led to the oversight. The Assistant Director of Nursing (ADON), who shared the office and had access to the office keys, also failed to lock the door upon returning. The facility's policy requires that narcotics and controlled substances be stored under double lock and key, and that discontinued medications be promptly secured until destruction.
Failure to Employ Qualified Social Worker in Facility with Over 120 Beds
Penalty
Summary
The facility, with a capacity of more than 120 beds, failed to employ a qualified full-time social worker, which is a requirement for facilities of this size. The facility had not had a qualified social worker since a specified date, and the personnel file inaccurately listed a social worker who was not currently employed. The Texas State Board of Social Worker Examiners did not list the current social worker as licensed, indicating a lapse in compliance with state regulations. Interviews with facility staff revealed that the licensed social worker's last day was on a specific date, and the newly hired social worker's license had expired, with reinstatement pending. The facility was temporarily sharing a social worker from a sister facility. The administrator, who was new to the position, was unaware of the requirement for a full-time social worker and believed sharing with a sister facility was permissible. The non-licensed social worker confirmed his license had expired and was in the process of reinstatement, having completed the necessary continuing education units.
Failure to Maintain Safe and Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for two residents, leading to deficiencies in their living conditions. In the case of Resident #13, the facility did not replace missing and damaged laminate flooring panels in his room. Observations revealed that several flooring panels were missing or loose, posing a potential hazard. The maintenance staff was unaware of the issue due to a lack of communication from the care staff, who failed to report the needed repairs in the maintenance logbook as per facility policy. For Resident #54, the facility did not replace missing baseboards in her bedroom and bathroom, repair a broken vanity drawer, or maintain cleanliness in the bathroom. Observations showed that the toilet was dirty, with brown water stains and particles resembling fecal matter, and a pile of trash was found behind a piece of sheetrock left in the bathroom. The maintenance and housekeeping supervisors were unaware of these issues, as the staff did not document them in the maintenance logbook, contrary to the facility's policy. The facility's policy requires all maintenance requests to be documented in the maintenance logbook, but this procedure was not followed, leading to unaddressed maintenance and housekeeping issues. The lack of communication and documentation resulted in an unsanitary and potentially unsafe environment for the residents, which could affect their quality of life.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not reflect the resident's positive PASRR Evaluation and the recommended specialized mental illness services, nor did it address the resident's smoking status. The resident, who had diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, mood disorder, anxiety, and depression, was observed smoking in the designated area without a care plan that included safety measures or supervision requirements. Interviews with facility staff revealed that the resident's smoking status was known, but the care plan did not include necessary interventions to prevent injury, such as the use of a smoking apron or supervision details. The facility's policies required that all safe smoking measures be documented in the care plan and communicated to staff, visitors, and volunteers. However, the resident had not been assessed for safe smoking, and the care plan did not address the specialized services recommended by the PASRR Evaluation, leading to a deficiency in providing a safe and healthy environment for the resident.
Failure to Assess Resident for Safe Smoking
Penalty
Summary
The facility failed to ensure adequate supervision and preventative measures to prevent injuries for a resident reviewed for accident hazards. Specifically, the facility did not follow its policy to assess the resident for safety when smoking. The resident, who had a history of smoking, was not assessed for safe smoking upon admission, and her care plan did not address her smoking status or identify any safety needs to prevent injury. This oversight was identified during observations and interviews, where it was noted that the resident was smoking in the designated area without a documented assessment or care plan interventions related to smoking safety. The resident, a female with diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure, mood disorder, anxiety, and depression, was observed smoking safely in the designated area with staff present. However, interviews with staff revealed that the resident's smoking status and safety needs were not communicated or documented, as required by the facility's policy. The facility's policy mandates that residents who smoke be assessed for safe smoking and that all safe smoking measures be documented on the resident's care plan. The failure to assess the resident for safe smoking and update her care plan accordingly could place residents at risk for accidents and injuries.
Persistent Cockroach Infestation Due to Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a persistent cockroach infestation. Record reviews indicated multiple instances of cockroach sightings and treatments in various resident rooms and common areas from August 2023 to April 2024. Despite monthly treatments and additional call-outs, the infestation persisted, with grievances from residents and observations of cockroaches in rooms and bathrooms. The Maintenance Director and the Pest Control Company confirmed ongoing issues and treatments, but the problem was not resolved effectively. Interviews with residents and staff revealed frequent sightings of cockroaches, and the facility's pest control policy was not adequately implemented to eradicate the pests. During an observation on April 16, 2024, large cockroaches were seen in a resident's bathroom, and multiple residents reported seeing roaches in their rooms. The Maintenance Director admitted to using household chemicals for immediate treatment and logging complaints in the pest control book. The DON and Administrator acknowledged the issue but relied on monthly pest control services and the Maintenance Director for interim treatments. The facility's pest control program policy, dated January 2024, stated the need for an effective program to eradicate common household pests, but this was not achieved, leading to ongoing resident complaints and health risks.
Failure to Administer Prescribed Medication to Resident
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of Resident #2, who was admitted for respite care. Resident #2, with diagnoses including insomnia, did not receive his prescribed Ambien for three days. The physician orders indicated that Ambien 12.5mg was to be administered at bedtime starting from the day after admission, but the medication was not provided on multiple days as recorded in the Medication Administration Record (MAR). The family of Resident #2 reported that they had to administer the resident's medications themselves on the day of admission due to the facility's failure to do so. The Director of Nursing (DON) acknowledged that the facility did not have Ambien for Resident #2 and did not follow up with the family or insurance regarding the medication. The DON also mentioned that this was the first time the facility had a resident under insurance respite care, and there was no policy in place for such cases. The facility's pharmacy delivered other medications for Resident #2, but not Ambien. The DON admitted that there was no documentation of the admitting nurse contacting the family or physician about the missing Ambien. Interviews with nursing staff revealed that the admitting nurse was responsible for ordering new residents' medications from the pharmacy. If a medication did not arrive, it should be pulled from the emergency dispensing system if available. The DON expected nurses to reach out to the family or pharmacy if a medication was not provided. However, this protocol was not followed, resulting in Resident #2 not receiving his prescribed Ambien during his stay. The facility's Medication Reordering policy emphasized the importance of providing routine and emergency medications in a timely manner, which was not adhered to in this case.
Failure to Ensure Timely Laboratory Services
Penalty
Summary
The facility failed to ensure that laboratory services were obtained to meet the needs of a resident. Specifically, the facility did not ensure that a resident had a CBC and CMP lab tests every six months as ordered. The resident, who had diagnoses including vitamin deficiency, protein-calorie malnutrition, adult failure to thrive, and anemia, only had these tests drawn once in the reviewed period. The physician orders indicated that these tests were to be conducted in March and September starting from a specified date, but this was not adhered to. Interviews with the DON and an LVN revealed that the resident sometimes refused lab draws, and there was a miscommunication with the lab regarding the orders. The lab had requested a lab orders audit from the previous DON, which was never received, leading to the labs not being drawn. The facility's policy stated that they must provide or obtain laboratory services when ordered by a physician, but this was not followed, resulting in the deficiency.
Failure to Provide Prescribed Nutritional Supplements and Portions
Penalty
Summary
The facility failed to provide Resident #3 with a nourishing, well-balanced diet that met his daily nutritional and special dietary needs. On 4/16/24, Resident #3 did not receive his health shake or double meat portion at lunch, despite his meal card indicating these items. Resident #3, who has diagnoses including dysphagia, diabetes, hypertension, and pneumonia, expressed that he liked the health shakes and extra meat but did not always receive them. The resident's care plan and meal ticket specified a mechanical soft diet with honey thickened liquids, fortified foods, health shakes with all meals, and double portions of meat. Interviews with staff, including RN E, CNA F, CNA G, LVN H, the DON, and the Administrator, revealed that it was the nurses' responsibility to check meal trays against meal tickets to ensure residents received the correct diet, texture, portions, and supplements. However, this protocol was not followed for Resident #3 on the specified date. The staff acknowledged the importance of providing the correct diet and portions to prevent choking and ensure residents' nutritional needs were met. The facility's policies on Nutritional and Dietary Supplements and Liberalized Diets emphasized the importance of providing nutritional supplements and individualized diets based on residents' assessed needs and preferences. Despite these policies, the facility did not adhere to the prescribed dietary requirements for Resident #3, leading to a deficiency in meeting his nutritional needs.
Failure to Provide Correct Liquid Consistency for Resident
Penalty
Summary
The facility failed to ensure that honey thickened liquids were prepared in a form designed to meet the individual needs of Resident #3, who had a diagnosis of dysphagia and required a mechanically altered diet with honey thickened liquids. On two separate occasions, Resident #3 did not receive the appropriate consistency of liquids with his lunch meal. Specifically, on 4/16/24, Resident #3 was given nectar thickened liquid instead of honey thickened liquid, and on 4/17/24, he was initially given thin liquids before being provided with the correct honey thickened water. The deficiency was observed through multiple instances where staff failed to verify and provide the correct liquid consistency for Resident #3. CNA B did not know the specific thickness of the liquid she obtained for Resident #3 and relied on the nurse, who also did not verify the correct consistency. Similarly, Cook D did not check the resident's meal ticket before providing a beverage, resulting in Resident #3 receiving thin liquids initially. These actions were contrary to the facility's policy, which required nursing staff to notify dietary staff of the need for thickened liquids and ensure the correct consistency was provided. Interviews with various staff members, including LVNs, CNAs, the DON, and the Administrator, revealed a lack of clarity and responsibility regarding who was accountable for ensuring residents received the correct fluid consistency. The staff consistently stated that it was the nurse's responsibility to check meal trays and fluid consistency, yet this was not effectively carried out, leading to the deficiency. The facility's policy on thickened liquids emphasized the importance of providing the correct consistency to prevent aspiration, but this was not adhered to in the case of Resident #3.
Failure to Ensure Dietary Staff Wore Hair Restraints
Penalty
Summary
The facility failed to store, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. During an observation, it was noted that multiple dietary staff members, including a dietary aide and the cook, were not wearing hair restraints while in the kitchen. The dietary aide admitted to not having put on a hair net because the kitchen was out of them. The Dietary Manager (DM) confirmed that the kitchen was out of hair nets and acknowledged the importance of wearing hair nets to prevent hair from contaminating the food. The Director of Nursing (DON) also emphasized the importance of hair restraints for hygiene and to keep hair out of the food, stating that anyone entering the kitchen should have their hair secured by a hair net, cap, or bonnet. The facility's policy, as reviewed, indicated that hair restraints should be worn when preparing or handling food to prevent the spread of bacteria that may cause foodborne illness. However, the Administrator mentioned that the policy only required hair nets when handling or preparing food and not when merely walking through the kitchen. Despite this, the Administrator expressed a preference for anyone in the kitchen to wear a hair net for hygiene purposes. The lack of hair restraints among dietary staff could place residents at risk of cross-contamination and foodborne illness.
Failure to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed that the door to the dining room was damaged with thick plastic peeling off. Additionally, the bathroom in a resident's room had tiles that had fallen off the wall, wallpaper peeling off, a warped baseboard, and a vanity drawer with the face peeling off. The resident in the room mentioned that they did not look at the issues. The Maintenance Director acknowledged awareness of the need for renovations but had not seen the specific bathroom in question. The Director also mentioned that maintenance logs were discarded after tasks were completed, and there was no documentation of contacting corporate about renovations. Interviews with the Maintenance Director and the Administrator highlighted a lack of systematic documentation and follow-up on maintenance issues. The Maintenance Director stated that they performed daily walkthroughs and inspected 5-6 rooms per day but did not keep a log of tasks or repairs performed. The Administrator expected the Maintenance Director to make daily rounds and inspect every bathroom monthly. The facility's policy indicated the importance of maintaining a safe, clean, and comfortable environment, but the observed conditions and lack of proper documentation and follow-up suggest a failure to adhere to this policy.
Failure to Employ Full-Time Social Worker
Penalty
Summary
The facility, with a capacity of more than 120 beds, failed to employ a qualified full-time social worker since 11/6/2023. This deficiency was identified through record reviews and multiple interviews with staff and residents. The HR director confirmed that the last full-time social worker left in November 2023, and since then, the facility has only had a PRN social worker who works a few hours in the evening. The Director of Nursing (DON) and the Administrator have been attempting to cover the social worker's duties, but neither is a licensed social worker. The facility's policy mandates that a facility with more than 120 beds must employ a full-time qualified social worker, which they have failed to do since November 2023. A resident expressed frustration over not being able to speak to a social worker regarding her request to transfer to a different facility. The Ombudsman also noted that several residents had requested transfers, but the absence of a full-time social worker has made the process slow and difficult. The Regional Director of Operations and the Administrator both acknowledged the lack of a full-time social worker and mentioned ongoing efforts to hire one. Despite these efforts, the facility has not yet succeeded in filling the position, thereby failing to meet the regulatory requirement and potentially impacting the psychosocial well-being of the residents.
What surveyors are citing around you — mapped
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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 186 citations issued within 25 miles in the last 12 months — including the 9 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 Tyler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Rose Trail | 0 mi | ★★★★★ | 23 | 3 |
| Park Place Nursing & Rehabilitation Center | 1 mi | ★★★★★ | 11 | 0 |
| Briarcliff Health Center | 2.7 mi | ★★★★★ | 0 | 0 |
| Avir At Azalea Heights | 2.7 mi | ★★★★★ | 11 | 1 |
| The Waterton Healthcare & Rehabilitation | 3.3 mi | ★★★★★ | 5 | 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.