Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Richland Hills during CMS and state inspections, most recent first.
Two cognitively impaired, fall‑risk residents who required extensive assistance with ADLs were found without accessible call lights, despite care plans specifying that call lights must be kept within reach. One resident in a wheelchair had the call light placed on the bed with the cord trapped between beds, and another resident in bed had the call light on the floor and was unaware of its location. Staff, including a CNA, DON, and Administrator, acknowledged that call lights are essential for residents to request help and that staff are responsible for ensuring accessibility, yet there was no facility policy addressing call lights being kept within reach.
The facility failed to keep toxic products out of resident reach when a resident with dementia and severe cognitive impairment had a can of insect repellent on his bedside table, and an LVN twice left a container of germicidal wipes on top of an unattended cart in a resident care area. The DON acknowledged that germicidal wipes contain chemicals that can cause adverse effects and should be stored inside carts, and the SDS for the wipes identified them as eye irritants, flammable, and to be kept out of reach of children. The Administrator reported there was no policy governing resident possession of insect repellent or storage of germicidal/disinfectant wipes.
A resident with asthma and a respiratory disorder, care planned and ordered for continuous O2 via nasal cannula and BiPAP at bedtime and PRN for naps, was observed asleep in a wheelchair receiving O2 from a portable tank while the concentrator oxygen tubing lay unbagged on the floor and the BiPAP mask sat unbagged on the nightstand. An LVN, the DON, the ADON, and the Administrator all acknowledged that respiratory items were expected to be stored in bags when not in use to prevent infection and that nursing staff were responsible for ensuring this, but there was no facility policy in place for storing respiratory equipment when not in use.
Two residents with chronic pain conditions had topical pain-relief products (a spray and a roll-on) stored openly in their rooms rather than in locked medication storage, despite lacking physician orders, self-administration assessments, or care plan authorization for self-administration. One cognitively impaired resident kept a pain spray on a drawer visible from the hallway while out of the room, and another cognitively intact resident kept a pain roll-on on her overbed table and reported using it herself with staff awareness. An LVN and the DON acknowledged that such medications should not be stored in resident rooms and should be kept in medication carts for staff administration, contrary to the facility’s self-administration policy.
A resident with severe cognitive impairment, hemiparesis, and dependence on staff for mobility and self-care was found in bed with a nonfunctional wall-mounted call light and a separate bell placed on the bedside table instead. The resident reported that staff did not always respond and that the call light did not work. An LVN confirmed the call light failed to activate the hallway signal, and the Maintenance Director stated there was no prior work order and that he had only just been informed. A CNA reported the resident had been given a bell when the call light broke but did not know when it had stopped working. The DON and ADON were unaware of the malfunction, despite facility policy requiring the resident call system to remain functional at all times.
A CNA failed to perform hand hygiene before providing perineal care and cleaned a female resident from back to front instead of front to back, contrary to professional standards and facility policy. The resident had a history of urinary tract infections and was care planned for bowel incontinence. The CNA acknowledged knowledge of proper procedures but did not follow them during the observed care.
A deficiency was cited for not ensuring a safe, clean, comfortable, and homelike environment for residents, including the safe provision of treatment and daily living supports.
A ceiling leak with exposed wires and insulation, a hanging wall socket, and a partially covered bathroom light switch were observed in one hall and two rooms. Residents and family members reported these issues had persisted, and maintenance staff were aware but repairs were delayed pending corporate approval. Facility policy requires maintenance of a safe and hazard-free environment, but these deficiencies remained unaddressed.
The facility failed to store and prepare food according to professional standards, with observations of improperly stored items like cucumbers with fuzzy spots and unlabeled sandwiches. Additionally, pork loin was served at an unsafe temperature of 131°F, risking food-borne illness. The Dietary Supervisor confirmed these practices were against policy and could harm residents.
A facility failed to provide timely incontinent care for a resident with dementia and muscle weakness, who required total dependence on staff for toilet use. The resident was found soiled with urine, and her linens were wet, indicating a lack of timely care. The CNA responsible admitted to being too busy to change the resident throughout the shift, despite expectations to routinely check and provide care. The DON emphasized the importance of assisting residents with ADLs care to prevent skin breakdown and maintain dignity.
A resident with severe cognitive impairment and mobility issues developed a pressure ulcer behind the left ear due to inadequate monitoring and assessment by nursing staff. The resident, who was using oxygen via nasal cannula, experienced skin breakdown from the tubing, which was not identified or treated promptly. The facility lacked a specific policy for addressing new wounds, contributing to the deficiency.
A resident with a history of falls and requiring maximum assistance was transferred without a gait belt by an LVN, contrary to facility policy. The LVN admitted to not using the gait belt due to being 'old school' and not having one available. The DON confirmed the policy requires gait belts to prevent falls and harm.
A resident with cognitive impairment and multiple health conditions received improper wound care when an LVN failed to change gloves and sanitize hands during a dressing change. The DON confirmed recent staff training on infection control, but the lapse in protocol could risk infection spread.
Two residents' personal health information was exposed due to staff leaving computers unlocked and unsupervised. An LVN left a laptop open during a medication pass, revealing a resident's medication orders, while another LVN left a computer unlocked at the Nurse's Station, exposing a resident's diagnoses. Both staff members acknowledged the importance of confidentiality but failed to secure the information.
A resident with severe cognitive impairment eloped twice from a secured unit due to inadequate supervision and monitoring. The first incident occurred when the resident exited through an exterior door, and the second when staff were not present on the secured unit. Both times, the resident was found by police and returned without injury.
A resident in hospice care experienced a significant decline and sustained a head injury, but the LTC facility failed to notify the designated emergency contact in a timely manner. Despite the resident's altered mental status and refusal to eat or drink, the facility staff did not inform the family member or document the incident properly, leading to a delay in the family being aware of the resident's condition.
A resident in hospice care with multiple medical conditions experienced neglect due to a lack of documentation and communication by facility staff. An LVN failed to document the assessment and treatment of the resident's injury and did not notify other staff or the resident's family, who was the emergency contact. The resident's family discovered unexplained bruises and was not informed of the resident's declining condition, leading to a police report. The facility's investigation found no evidence of abuse, but the deficiency was due to the lack of documentation and communication.
Failure to Keep Call Lights Within Reach for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring that call lights were accessible to two residents. For one male resident with a history of falls and rib fracture, the Quarterly MDS showed severe cognitive impairment (BIMS score 00) and a need for assistance with transfer, bed mobility, toileting hygiene, showering, dressing, and personal hygiene. His comprehensive care plan identified risk for falls and communication problems, with an intervention to ensure the call light was within reach. During observation, he was awake in his wheelchair, and his call light was found on top of his bed with the cord positioned between his and his roommate’s bed frames; when asked about the call light, he shook his head, indicating he did not know where it was. A female resident with epilepsy, muscle weakness, lack of coordination, repeated falls, and difficulty walking was also identified as having severe cognitive impairment (BIMS score 00) and needing assistance with transfer, bed mobility, toileting hygiene, showering, dressing, and personal hygiene. Her comprehensive care plan documented fall risk and included an intervention to keep the call light within reach. During observation, she was awake in bed, and her call light was found on the floor; when asked where her call light was, she shrugged her shoulders, indicating she did not know its location. Staff interviews confirmed expectations that call lights should always be within residents’ reach so they can call staff when they need something or need assistance. A CNA stated that call lights are for all residents, dependent or independent, and acknowledged responsibility for ensuring call lights are within reach for assigned residents, noting she should have verified the call light’s placement after making a bed. The DON stated that nurses and CNAs are responsible for ensuring call lights are within reach and acknowledged the importance of call lights for residents to call staff, but also commented that a resident might not need the call light while sleeping and that an alert, communicative resident might not have a problem if the call light was on the floor. The Administrator stated that call lights should be within reach at all times and monitored throughout the day, and also reported that the facility did not have a policy specifically addressing call lights being within reach.
Failure to Control Resident Access to Insect Repellent and Germicidal Wipes
Penalty
Summary
The facility failed to maintain a resident environment free of accident hazards by allowing access to toxic chemicals in resident care areas. One resident with dementia and severe cognitive impairment, who was otherwise independent in mobility and self-care but had documented communication problems and impaired ability to understand and make himself understood, had a can of insect repellent (Off) on his bedside table. The can was observed among several personal items while the resident was not in the room. The DON acknowledged that residents on the hall were generally alert and oriented and that residents or their families brought items into rooms, and stated that residents had the right to a home-like environment. The Administrator reported that staff had previously removed items brought by the resident’s family and stated there was no facility policy regarding a resident having insect repellent in the room. The facility also failed to control access to germicidal wipes containing hazardous chemicals. An LVN left a container of germicidal wipes on top of an unattended cart in a resident care area while she entered a room to change a colostomy bag and again when she left the room to obtain a gown. The LVN later stated she should have secured the wipes because residents might mistake them for ordinary wipes and use them on their bodies, and noted that anything labeled “Keep out of reach of children” should be considered harmful given the presence of confused residents. The DON stated that germicidal wipes should not be left on top of carts because the chemicals could cause adverse effects if consumed or if they contacted skin, eyes, or mouth, and that containers should be stored inside the carts. The Administrator stated she was not aware of the harm the wipes could cause and confirmed there was no policy regarding storage of germicidal/disinfectant wipes. A Safety Data Sheet for the specific germicidal wipes in use identified them as causing serious eye irritation, being flammable, and potentially causing drowsiness or dizziness, and directed that they be kept out of the reach of children.
Unbagged BiPAP Mask and Oxygen Tubing for Resident Requiring Respiratory Support
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards, the resident’s care plan, and physician orders for one resident who required BiPAP and continuous oxygen therapy. The resident was an older female with mild persistent asthma and a respiratory disorder, cognitively intact with a BIMS score of 15, and care plans and physician orders specifying continuous oxygen at 2–3 L via nasal cannula and noninvasive ventilation via BiPAP face mask at bedtime and as needed during naps. During an observation, the resident was asleep in her wheelchair receiving oxygen from a portable tank, while the oxygen tubing connected to her oxygen concentrator lay unbagged on the floor and the BiPAP mask was unbagged on the nightstand. Staff interviews confirmed that these respiratory items should have been stored in bags when not in use to prevent infection. An LVN acknowledged that the BiPAP mask and oxygen tubing should have been bagged, stated that the resident removed the BiPAP mask herself, and indicated that the tubing found on the floor would need to be discarded and replaced. The DON and ADON both stated that nurses were responsible for ensuring respiratory items were bagged when not in use, and that any staff member who observed unbagged respiratory items should notify a nurse. The Administrator stated that nurses or aides were responsible for bagging the items and reported that there was no existing facility policy regarding storage of respiratory items when not in use.
Improper In-Room Storage and Unapproved Self-Access to Topical Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to store drugs and biologicals in locked compartments under proper controls and to limit access to medications to authorized personnel, in accordance with state and federal requirements. For one male resident with chronic pain, gout, and depressive disorder, records showed severe cognitive impairment with a BIMS score of 00, chronic pain, and use of pain medication, but no care plan or clinical assessment authorizing or supporting self-administration of medications. Physician orders did not include a pain-relieving spray. During observation, the resident was not in his room, and a container of pain-relieving spray was found on top of his drawer, in plain view and visible from the hallway, a few steps from the door. The resident stated he used the spray for back pain and always kept it on top of his drawer, and he was unsure if nurses knew about it. For a female resident with osteoarthritis and a right hip fracture, records showed she was cognitively intact with frequent pain, and her care plan included administration of analgesia by staff, but there was no care plan for self-administration of medications and no clinical assessment documenting competence to manage her own medications. Physician orders did not include a pain-relieving roll-on. During observation, the resident was awake in bed with a pain-relieving roll-on on top of her overbed table at bedside. She reported that she sometimes used the pain reliever on her arthritic knees and that staff knew she had the pain reliever with her. Staff interviews confirmed that these pain-relief products were not being stored or controlled according to facility expectations and policy. An LVN stated that pain reliever sprays and roll-ons should not be inside residents’ rooms and should be kept in the nurses’ carts for administration by nurses, and that this was the first time she became aware of the products in these residents’ rooms. She acknowledged she had not noticed them during resident checks and described that residents might use them more than recommended or that confused residents might consume them. The DON stated that medications should not be stored in residents’ rooms because residents might use them inappropriately and that the pain relievers should be in the carts and administered by staff. The facility’s self-administration policy required an interdisciplinary determination, documentation in the medical record and care plan, and nursing administration of medications if residents could not safely self-administer, conditions that were not met for these two residents.
Nonfunctional Call Light and Inadequate Access to Call System
Penalty
Summary
The facility failed to ensure that the resident call system remained functional and accessible for a resident who required staff assistance for mobility and self-care. The resident was an adult male with limitations of activities due to disability, hemiparesis, impaired mobility and balance, cognitive deficits, and severely impaired cognition with a BIMS score of 5. His comprehensive care plan identified risk for falls and included an intervention to ensure his call light was within reach and that he was encouraged to use it for assistance. During observation, the resident was found lying in bed with a call bell placed on the bedside table, while the wall-mounted call light was connected at the foot of the bed. The resident reported that staff did not always come when he rang the bell and that his call light did not work, though he was unsure how long it had been nonfunctional. When the LVN checked the call light, it did not activate the hallway indicator, confirming it was not working. The LVN stated she had been unaware of the malfunction. The Maintenance Director reported there was no work order for the call light and that he had only just been informed of the issue. A CNA stated she did not know when the call light had stopped working and that, when it broke, the resident had been given a separate call bell that staff recognized by sound. The DON and ADON both stated they were unaware that the resident’s call light was not working and acknowledged the importance of the call light for the resident to communicate needs. The Administrator stated they knew there was a problem and that the resident had a bell in his room. The facility’s policy required that the resident call system remain functional at all times, with audible or visual communication maintained at effective levels, which was not met in this situation.
Failure to Follow Infection Control and Perineal Care Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by a certified nursing assistant (CNA) not performing hand hygiene before providing perineal care to a resident. During an observation, the CNA entered the resident's room, donned clean gloves without first washing her hands, and proceeded to provide perineal care. The CNA cleaned the female resident's perineal area from back to front, contrary to professional standards and facility policy, which require cleaning from front to back. The CNA also touched the trash can with gloved hands and then handled a clean brief without changing gloves, only removing gloves and washing hands after completing care. The resident involved was a cognitively intact female with a history of arthritis, hypotension, urinary tract infections, anxiety, and asthma, and was care planned for bowel incontinence. Facility policy and the director of nursing (DON) both confirmed that staff are expected to perform hand hygiene before and after care, and to clean from front to back during perineal care. The CNA acknowledged awareness of these standards but stated she forgot to perform hand hygiene and had no reason for cleaning from back to front. The facility's policies on perineal care and infection control were reviewed and found to be consistent with professional standards.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that this includes, but is not limited to, receiving treatment and supports for daily living in a safe manner. Specific actions or inactions leading to this deficiency are not detailed in the provided excerpt, nor are there observations about the condition of the environment or the residents involved.
Failure to Maintain Safe and Homelike Environment Due to Unrepaired Maintenance Issues
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and homelike environment in one of its halls and two resident rooms. Observations included a ceiling leak in the 100 Hall, where a missing ceiling tile exposed wires and insulation, and a trashcan and bucket were placed on the hallway floor to catch water. The leak had been present for about two months and was awaiting corporate approval for repairs. In one resident room, a wall socket was found hanging from the wall, and both the resident and their family member confirmed it had been in that condition for some time. In another room, the bathroom light switch was only partially covered, with the cover frequently falling off, as reported by the resident. Interviews with the Maintenance Director revealed that the light switch cover had recently been replaced but had come off again, and he was unaware of its current state. The Maintenance Director also stated that the wall socket was only at risk of coming loose when the bed was moved. The Administrator confirmed that the roof leak had been reported to the regional office, which was still determining the scope of repairs. Facility policy requires maintenance to keep the building in good repair and free from hazards, but these issues persisted, affecting the living environment for residents.
Improper Food Storage and Preparation in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by improper storage and preparation of food in the kitchen. Observations revealed several instances of food being improperly stored, including cucumbers with fuzzy white spots, cut tomatoes and bacon exposed to air, and various vegetables with black spots or withered appearance. Additionally, there were issues with food items not being labeled or dated, such as individually wrapped sandwiches and pasta salad. The facility's refrigerator, freezer, and dry storage areas contained multiple items that were open and exposed to air, contrary to the facility's policies on food storage. Furthermore, the facility failed to ensure that food on the steam table reached the appropriate temperature before being served to residents. Specifically, pork loin was observed at a temperature of 131 degrees Fahrenheit, below the required 165 degrees Fahrenheit for safe consumption. Despite this, approximately 20 plates of pork loin were prepared and served to residents before the issue was identified and corrected. The Dietary Supervisor acknowledged the oversight and confirmed that the improper storage and undercooked pork loin could pose a risk of contamination and food-borne illnesses to residents.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide necessary services for a resident who was unable to carry out activities of daily living, specifically in providing incontinent care. The resident, a female with diagnoses including dementia and muscle weakness, required total dependence on staff for toilet use and was always incontinent of bladder. Her care plan indicated the need for monitoring incontinence and providing care to prevent complications such as UTIs. However, during an observation, the resident was found soiled with urine, and her linens were wet, indicating a lack of timely care. Interviews revealed that the CNA responsible for the resident's care admitted to being too busy to change the resident throughout the shift, despite being expected to routinely check and provide incontinent care. The resident confirmed she had not been changed since the night before, and the CNA acknowledged the oversight. The Director of Nursing stated the expectation for CNAs to assist residents with ADLs care and ensure timely completion to prevent skin breakdown and maintain dignity. The facility's policy emphasized providing care to maintain or improve residents' ability to carry out ADLs, which was not adhered to in this instance.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a pressure ulcer for a resident, identified as Resident #67, who was at risk due to impaired mobility, nutritional deficits, and incontinence. The resident, who had severe cognitive impairment and was dependent on assistance for most activities of daily living, developed a wound behind the left ear. This wound was not identified or treated in a timely manner, despite the resident's complaints of ear pain during wound care. The resident was using oxygen via nasal cannula, and the tubing was noted to be pulling on the ears, which contributed to the skin breakdown. The nursing staff, including an LVN and an RN, failed to assess the resident's ears for skin breakdown, even though the resident was supposed to have ear protectors to prevent such issues. The Director of Nursing (DON) was unaware of the wound, and the facility lacked a specific policy for addressing new wounds. The facility's failure to monitor and assess the resident's skin condition, particularly around the ears where the oxygen tubing was placed, led to the development of the pressure ulcer.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure that Resident #19 received the necessary assistive devices to prevent accidents during transfers. Resident #19, who has a history of falls and requires maximum assistance for transfers due to muscle weakness and mild cognitive impairment, was observed being repositioned in a wheelchair without the use of a gait belt. LVN A, who assisted in the transfer, did not use the gait belt as required by the facility's policy, citing that she was 'old school' and did not have a gait belt with her because she normally did not perform transfers. The Director of Nursing (DON) confirmed that the facility's policy mandates the use of gait belts during resident transfers to prevent falls and potential harm, such as fractures. The facility's policy on safe lifting and movement of residents, revised in July 2017, requires staff to be trained in using manual and mechanical lifting devices, including gait belts. The failure to use the gait belt as per policy could affect residents who require assistive devices during transfers, contributing to avoidable falls.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) during a wound dressing change for a resident. The resident, a female with cognitive impairment and multiple health conditions including dementia and muscle weakness, required assistance for personal care and was always incontinent of bladder. During the procedure, the LVN did not sanitize her hands or change gloves between the removal of the old dressing and the application of a new dressing on the resident's surgical wound, which involved amputated toes with sutures. This lapse in protocol could potentially place residents at risk for infection due to improper care practices. Interviews conducted with the LVN and the Director of Nursing (DON), who also serves as the infection preventionist, revealed that the LVN acknowledged forgetting to change gloves and perform hand hygiene during the wound care. The DON confirmed that staff had been in-serviced on hand washing and personal protective equipment (PPE) recently, and expressed an expectation for staff to adhere to infection control practices to prevent the spread of infection. The facility's policy on infection prevention and control, revised in October 2018, emphasizes the importance of following established guidelines, such as those from the Centers for Disease Control and Prevention (CDC), as part of their quality assurance and performance improvement program.
Confidentiality Breach of Resident Information
Penalty
Summary
The facility failed to protect the confidentiality of personal health care information for two residents. During a medication pass, LVN F left a laptop unlocked and unsupervised, exposing Resident #6's personal information, including medication orders, to staff, residents, and visitors. Similarly, LVN A left a computer unlocked at the Nurse's Station while attending to another resident, exposing Resident #65's personal information, including some diagnoses, to unauthorized individuals. Interviews with LVN F and LVN A revealed that both were aware of the importance of maintaining privacy and confidentiality, having been in-serviced on these protocols. However, they could not provide a valid reason for leaving the computers unlocked. The Director of Nursing confirmed that staff are expected to ensure resident information is not visible to unauthorized individuals, highlighting the risk of exposure when computers are left unlocked.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for a resident with severe cognitive impairment, leading to two elopement incidents. The resident, who had diagnoses including Alzheimer's disease, anxiety disorder, and depression, first eloped from the facility and was subsequently placed on a secured unit. Despite this measure, the resident managed to elope a second time, indicating a lack of effective supervision and monitoring. The first elopement occurred when the resident pushed on an exterior egress door, which released after 15 seconds, allowing her to exit the facility. She was found by the police at a nearby retirement community and returned without injury. The facility's investigation confirmed that the door and its magnetic lock were functioning properly, but the resident had removed her WanderGuard device and refused to have it replaced. The care plan was updated, and staff were in-serviced on the facility's elopement policy. The second elopement happened when the resident exited through the door of the secured unit. At the time, the assigned staff members were not present on the secured unit; one was documenting outside the unit, and the other was attending to residents in the general population area. The alarm sounded, but the staff did not immediately identify the resident as missing. A head count revealed her absence, and she was later found by the police and returned to the facility. The facility's staffing assignments and lack of continuous supervision on the secured unit contributed to the resident's ability to elope.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to immediately notify the designated emergency contact of a resident when there was a significant change in the resident's condition. The resident, who was receiving hospice care, developed an altered mental status and sustained a head injury while nearly falling out of bed. Despite the resident's family member being listed as an emergency contact, the facility did not inform them of the resident's decline or the head injury in a timely manner. This lack of communication led to the family member being unaware of the resident's condition until they were informed by the hospice social worker. The resident had a history of multiple medical conditions, including anemia, orthostatic hypotension, cirrhosis, anxiety, depression, and chronic obstructive pulmonary disease. The resident was in pain, required substantial assistance with activities of daily living, and had a history of falls. On the day of the incident, the resident exhibited signs of decline, such as refusing to eat or drink, generalized weakness, and gasping for air. Despite these significant changes, the facility staff failed to notify the family member or document the incident properly. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition and the head injury. The nurse responsible for the resident admitted to not notifying the family member or documenting the incident, assuming the hospice nurse would handle it. The Director of Nursing and Administrator were also unaware of the injury until the family member raised concerns. The facility's failure to notify the family member and document the incident properly resulted in a delay in the family being informed of the resident's condition and potential injuries.
Neglect and Lack of Documentation in Resident Care
Penalty
Summary
The facility failed to ensure that a resident was free from neglect, as evidenced by the lack of documentation and communication regarding the resident's injuries and condition. A Licensed Vocational Nurse (LVN) did not document the assessment and treatment of the resident's injury, nor did she notify other staff members or the resident's family about the injury. This oversight placed the resident at risk of pain, diminished quality of life, delayed diagnosis, treatment, and serious physical harm. The resident, who was receiving hospice care, had a history of multiple medical conditions, including anemia, orthostatic hypotension, cirrhosis, anxiety, depression, and chronic obstructive pulmonary disease. The resident was in pain, had moderately impaired cognition, and required substantial assistance for transfers. Despite these needs, the facility did not have care plans related to the resident's hospice care, and there was a lack of communication with the resident's family, who was listed as the emergency contact. The situation escalated when the resident's family member discovered unexplained bruises on the resident's head and was not informed of the resident's declining condition. The family member reported the incident to the police, who documented the injuries. Interviews with staff revealed that the LVN had failed to report the incident and did not document the injury, which was a significant oversight in the resident's care. The facility's investigation did not find evidence of abuse, but the lack of documentation and communication contributed to the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Richland Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Richland Hills Rehabilitation And Healthcare Cente | 0.5 mi | ★★★★★ | 13 | 0 |
| Glenview Wellness & Rehabilitation | 1.3 mi | ★★★★★ | 18 | 0 |
| Life Care Center Of Haltom | 2.5 mi | ★★★★★ | 15 | 0 |
| Avir At North Richland Hills | 2.8 mi | ★★★★★ | 5 | 0 |
| Hurst Plaza Nursing & Rehab | 3.8 mi | ★★★★★ | 6 | 0 |
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