Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At River Ridge during CMS and state inspections, most recent first.
The facility failed to implement an effective infection prevention and control program when EBP physician orders for two residents with wounds were written only for wound care rather than for all high-contact activities, despite care plans and facility policy requiring gown and glove use for broader high-contact care. In one observed case, an LVN performed wound care on a resident on EBP without donning a gown, did not have a trash bag in the room, placed contaminated dressings and gloves on a clean barrier with clean supplies, inadequately cleansed the wound, failed to perform hand hygiene between glove changes, washed hands for only a few seconds, and disposed of contaminated trash outside the room, all contrary to the facility’s EBP and hand hygiene policies and CDC PPE guidance.
Two residents were affected when staff failed to notify providers of significant clinical findings. For one resident with multiple comorbidities and pressure ulcers, a critical MRSA lab result was reported but not communicated to the physician, and no corresponding progress note documented provider notification. For another resident with an abdominal abscess and at risk for skin breakdown, a treatment nurse assessed a new dark lesion on the right great toe and only informed the charge nurse, without notifying the physician, NP, or on-call provider, despite the resident later reporting the issue directly to the NP. These actions were inconsistent with the residents’ care plans and the facility’s change in condition policy requiring prompt provider notification of critical results and new or worsening skin issues.
A resident admitted with an abdominal wall abscess and identified as at risk for pressure ulcers had an abdominal wound documented by an LVN on admission, including measurements, and a care plan noting actual skin impairment and the need for monitoring and treatment. However, the LVN did not obtain wound care orders to evaluate and treat the wound for several days after admission, despite facility policies requiring physician orders for wound care and notification for changes requiring altered treatment. The DON confirmed that wound care orders should have been obtained at the time of admission, and the report notes this failure could place residents at risk for wound care complications or not receiving necessary wound care.
The facility failed to maintain complete and accurate clinical records when wound care treatments were not documented on the TARs for two residents with significant skin conditions, including pressure ulcers and an abdominal abscess. One LVN reported completing ordered wound care for a cognitively impaired resident with multiple pressure ulcers but acknowledged forgetting to record the treatment. An RN reported performing wound care for another resident with an abdominal abscess over several days but did not document it due to unfamiliarity with the TAR documentation process. The DON confirmed that treatments should have been recorded in the medical record in accordance with facility policy requiring documentation of all treatments and services performed.
A resident with an unstageable sacral pressure ulcer and a Foley catheter did not receive wound care consistent with professional standards. The WCN performed wound care while the resident’s brief and old dressing were saturated with urine, failed to provide incontinence care before treatment, and did not follow hand hygiene or glove-change requirements when moving between contaminated and clean tasks or when re-entering clean supplies. The WCN also used incorrect wound cleansing technique, cleaning from the outside to the inside rather than from clean to dirty. The Foley catheter, ordered to aid wound healing, was reported by the WCN to be constantly leaking and leaving the brief wet, but this issue was not addressed or reported. The NP was not informed of significant changes in the wound’s size or condition, and the DON confirmed that these practices did not follow facility wound care and hand hygiene policies.
Surveyors found that the facility failed to maintain an effective infection prevention and control program, including proper implementation of Enhanced Barrier Precautions (EBP) and hand hygiene. Multiple rooms housing residents on EBP had PPE supplies but lacked required EBP signage on doors or walls outside the rooms, despite facility policy. During observed wound and incontinent care for a resident with a stage 3 sacral wound, sepsis, CHF, and an indwelling catheter, a nurse and a CNA did not perform hand hygiene or change gloves when moving from dirty to clean tasks, re-entered a clean wipes container with contaminated gloves, used improper wound-cleaning technique, and the CNA carried a wipes container accessed with dirty gloves out of the room. Staff interviews and policy review confirmed that these practices were inconsistent with the facility’s EBP, perineal care, hand hygiene, and glove-use policies and could result in cross-contamination and infection, as acknowledged by the DON, NP, and involved staff.
A resident receiving lisinopril had a BP medication pass where the MA prepared the dose without comparing the blister pack directions to the active order in PCC, despite differing hold parameters. In a separate event, an LVN used an expired Lantus pen from the nurse cart to give insulin to a resident with DM2 and severe cognitive impairment, and the cart was found to contain the expired pen. The DON stated staff were responsible for checking carts for expired meds, and the facility policy required checking the medication label and expiration date before administration.
Kitchen Food Storage and Sanitation Deficiencies: The facility failed to keep food items sealed, labeled, and dated in the refrigerator, freezer, and dry storage area, and multiple kitchen surfaces and tools were observed dirty or in poor condition. Surveyors found open food items exposed to air, rodent droppings in dry storage, buildup on the stove, oven, steam table wells, can opener, shelves, and walls, plus scratched utensils and a pan with damaged non-stick coating. Staff said cleaning was a team effort and that food should be sealed, but no cleaning logs were provided.
Pest control was ineffective, with rodent droppings observed in the kitchen dry storage area and repeated mouse and roach sightings documented in the dining room, halls, resident rooms, and kitchen. Staff, an RN, and a resident reported seeing mice or evidence of gnawing, while the DM and administrator acknowledged ongoing rodent issues and increased pest control visits, but pests remained present.
A resident with severe cognitive impairment and right-sided paralysis was left in bed with the call light out of reach for about 10 minutes after being transferred from a wheelchair. The care plan and facility policy required the call light to be accessible, but staff failed to ensure this, leaving the resident unable to call for assistance.
A CNA failed to follow the care plan for a resident with severe cognitive impairment and osteoporosis by providing one-person assistance during transfers and incontinent care instead of the required two-person assist. This resulted in the resident sustaining acute fractures to the left lower leg. The CNA was unaware of the updated assistance level and did not check the Kardex, while nursing staff did not verify that the correct assistance was being provided.
A resident with severe cognitive impairment and a history of falls experienced a fall resulting in a head injury. Due to an electronic system outage, the MDS nurse documented the incident and interventions on paper but did not transcribe this information into the electronic care plan accessible to staff. As a result, the electronic care plan did not reflect the fall or updated interventions, and staff relied on incomplete information for ongoing care.
A facility's kitchen inspection revealed multiple deficiencies in food storage and sanitation practices. Unlabeled and undated drinks and pureed bread were found in the refrigerator, with several food items left open to air in the freezer. Sanitation issues included gnats, personal items on prep tables, and dirty dishes on the clean rack. Eroded non-stick pans and a chipped spatula posed contamination risks, while improper grease disposal was noted. Staff interviews highlighted a lack of adherence to labeling, dating, and proper storage protocols.
A facility failed to follow its abuse reporting procedures when a CNA allegedly abused a resident with severe cognitive impairment. The LVN who witnessed the incident did not notify the resident's RP or physician immediately, as required by policy. The DON later discovered the RP had not been informed, highlighting a lapse in communication and adherence to protocol.
The facility failed to conduct accurate PASRR screenings for two residents, leading to deficiencies in their care. One resident with severe cognitive impairment and multiple mental health diagnoses was admitted without an accurate PASRR Level 1 screening, risking their access to necessary services. Another resident with moderate cognitive impairment and a history of schizoaffective disorder and bipolar disorder also lacked an accurate screening, potentially delaying appropriate care. Staff interviews revealed procedural oversights in ensuring accurate PASRR evaluations.
A resident with a history of stroke and dementia experienced significant changes in her condition, including the removal of a tracheostomy and changes in feeding methods, which were not reflected in her care plan. The facility failed to update the care plan to reflect these changes, leading to a deficiency in care management. Interviews with staff revealed a lack of awareness and communication regarding the resident's current condition.
A medication cart on the 200-hall was found unlocked and unattended, allowing access to medications. LVN D admitted to leaving the cart unsecured while assisting a resident, acknowledging the importance of keeping it locked. The DON confirmed the cart should not have been left unlocked, as it posed a safety risk. Facility guidelines require medication carts to be secured and within sight when not in use.
A facility failed to ensure proper infection control practices when an LVN did not wear the required PPE during wound care for a resident with significant wounds. Despite the presence of signs and available PPE, the LVN forgot to gown up, potentially compromising the resident's wound care. Interviews revealed that the oversight was due to forgetfulness and the absence of a PPE cart as a reminder.
A resident under hospice care experienced a fall, leading to a significant increase in pain and a delayed diagnosis of a displaced femur fracture. The facility failed to promptly notify the physician of the resident's condition change and critical x-ray findings, resulting in a delay of approximately 15 hours. This lack of timely communication potentially contributed to inadequate medical intervention.
A resident in a LTC facility experienced a significant increase in pain after a fall, but the facility failed to promptly notify the physician of critical x-ray findings showing a displaced femur fracture. The delay in communication and action potentially contributed to the resident's decline and eventual death.
A resident with dementia and under hospice care fell in the dining room, resulting in a displaced femur fracture. The facility delayed ordering an x-ray and failed to promptly notify the physician of the critical results, contrary to policy. Staff interviews revealed inconsistencies in handling and communicating diagnostic results, contributing to the deficiency.
A facility failed to maintain a comprehensive care plan for a resident, omitting critical information such as DNR status and allergy details. The resident, with multiple health issues including dementia and chronic kidney disease, experienced several falls that were not reflected in the care plan. Staff interviews revealed confusion and delays in updating the care plan, potentially impacting the resident's care.
A facility failed to develop a comprehensive care plan within the required timeframe for a resident with complex health needs, including dementia and chronic kidney disease. The care plan was not updated with necessary information after revisions, and staff interviews revealed confusion about responsibilities for updating care plans. This deficiency could impact the resident's individualized care.
Failure to Implement Enhanced Barrier Precautions and Proper Wound Care Infection Control
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program, including proper implementation of Enhanced Barrier Precautions (EBP) for residents with wounds. For one male resident with a disrupted external surgical wound, physician orders specified EBP only for wound care once daily and did not include a general EBP order or directions for use during all high-contact activities. His care plan indicated EBP for a midline IV access and a right leg wound, with instructions that staff must use gowns and gloves during high-contact resident care activities that could result in transfer of multidrug-resistant organisms (MDROs), but the physician orders did not align with this broader requirement. For a female resident with a non-pressure chronic ulcer of the back and a sacral surgical wound, physician orders also limited EBP use to once-daily wound care, while her care plan called for EBP for both a colostomy stoma and sacral wound, again specifying gown and glove use during high-contact activities. The Director of Nursing later acknowledged that EBP was intended for high-contact activities such as wound care, dressing, bathing, transferring, and changing linens, and that the EBP orders for both residents were written too narrowly, specifying only wound care instead of all high-contact activities as outlined in the facility’s EBP policy and CDC guidance. During an observed wound care procedure for the female resident on EBP, an LVN failed to don the required PPE gown before entering the resident’s room and did not bring a trash bag into the room, where no trash bag was available. The LVN removed the old dressing and dirty gloves and placed them on the clean barrier with clean wound care supplies, instead of disposing of them in a trash bag. She performed inadequate wound cleansing by dabbing the wound a few times with Dakins-soaked gauze and dry gauze rather than cleansing from the cleanest to dirtiest area, and she failed to perform hand hygiene between glove changes. After completing wound care, she washed her hands with soap for only 4–5 seconds, below the facility policy requirement of at least 20 seconds, and disposed of contaminated trash outside the resident’s room. These observed actions did not comply with the facility’s EBP policy, hand hygiene policy, or CDC recommendations for PPE availability and use.
Failure to Notify Providers of Critical Lab Result and New Skin Lesion
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify physicians of significant clinical findings for two residents, contrary to professional standards, the residents’ care plans, and the facility’s own change in condition policy. For the first resident, an older female with multiple serious diagnoses including sepsis, severe sepsis without septic shock, stage 3 sacral pressure ulcer, unstageable coccyx wound, cognitive communication deficit, and other local skin infections, a critical laboratory result indicating Methicillin Resistant Staphylococcus aureus (MRSA) was reported on 02/16/2026 at 08:22 AM. Review of the resident’s progress notes for that date showed no documentation that the physician was notified of this critical MRSA result. The resident’s care plan required staff to observe, document, and report changes in skin integrity and to report improvements and declines to the physician, and the facility’s policy required physician notification for significant changes and discovery of injury or need to alter treatment. For the second resident, an older female admitted with a cutaneous abscess of the abdominal wall and requiring wound care, the facility failed to notify the physician or NP when a new skin irregularity was identified on the right great toe. The resident, who had moderate cognitive impairment and was at risk for pressure ulcers, reported a black area on her right great toe to the NP on 02/20/2026 and stated she had informed the wound care nurse approximately two days earlier. The treatment nurse confirmed in interview that on 02/18/2026 she had been made aware of the toe lesion, assessed it as a blood blister, and then informed the charge nurse but did not notify the physician, NP, or on-call provider. She stated that notifying the physician was not within her scope and that it was the charge nurse’s responsibility, despite her role including performing skin assessments and wound care. Additional interviews and record reviews further clarified the failures in notification. An LVN who worked on 02/16/2026 stated she was never made aware of the MRSA lab result for the first resident and that, during her shift, she reviewed the resident’s chart but did not see any critical lab results. The NP later discovered the critical MRSA result dated 02/16/2026 while reviewing labs on 02/18/2026 and reported that she had not been notified by the facility. The NP also reported that when she questioned the treatment nurse about the second resident’s toe lesion, the nurse acknowledged knowing about it since 02/18/2026 and had not sought orders. The facility’s change in condition policy required prompt notification of the attending physician or on-call physician when there was a significant change in condition or discovery of injury, but in both residents’ cases, the required physician notification did not occur as expected.
Failure to Obtain Wound Care Orders for Abdominal Abscess
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement wound care treatment orders for a resident’s abdominal wound in accordance with professional standards of practice and the resident’s person-centered care plan. The resident, an older female admitted with a cutaneous abscess of the abdominal wall and coded as being at risk for developing pressure ulcers, had a care plan initiated that identified an actual impairment to skin integrity of the abdomen related to the abscess. The care plan included monitoring and documenting the location, size, and treatment of the skin injury and reporting abnormalities or failure to heal to the physician. On admission, an LVN completed a head-to-toe assessment and documented the abdominal wound, including measurements, but did not obtain wound care orders to evaluate and treat the wound from the time of admission. Record review showed that the resident’s abdominal wound was present and measured on admission and again on a later skin assessment, with measurements indicating the wound was resolving and decreasing in size. However, there were no wound care orders in place for several days following admission, despite the facility’s wound care policy requiring verification of a physician’s order for wound care procedures and the change in condition policy requiring physician notification for discovery of injury of unknown source or significant changes requiring alteration of medical treatment. During interview, the LVN acknowledged forgetting to place wound care orders after identifying and documenting the abdominal wound on admission, and the DON confirmed that wound care orders should have been obtained at that time. The report states that this failure could place residents at risk for wound care complications or at risk of not receiving necessary wound care.
Failure to Accurately Document Wound Care Treatments on TARs
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for two residents receiving wound care, as required by professional standards and facility policy. For Resident #1, who had multiple complex medical conditions including severe sepsis, pressure ulcers (including a stage 3 sacral wound and unstageable coccyx ulcer), and significant functional and cognitive impairment, the Treatment Administration Record (TAR) for February 2026 showed no documentation of wound care on 02/16/2026. The resident’s care plan required observation and documentation of skin injury location, size, and treatment, as well as provision and documentation of wound treatments and weekly measurements. For Resident #2, who had a cutaneous abscess of the abdominal wall and was at risk for pressure ulcers, the TAR for February 2026 lacked documentation of wound care on 02/15/2026, 02/16/2026, and 02/17/2026. This resident’s care plan required monitoring and documentation of the abdominal skin abscess, including location, size, treatment, and reporting of abnormalities or signs of infection. Skin measurement assessments dated 02/12/2026 and 02/18/2026 showed decreasing wound size with no concerns noted, but there was no corresponding TAR documentation for the three specified dates. In interviews, LVN A stated she completed wound care for Resident #1 on 02/16/2026 after being notified by the treatment nurse that the care needed to be done, but acknowledged she likely forgot to document the completed treatment on the TAR or in a progress note. RN A stated she completed wound care for Resident #2 on 02/15/2026 through 02/17/2026 but did not document it because she was unfamiliar with how to chart on the TAR. The DON confirmed that both nurses should have documented the wound care in the TAR or progress notes and that the facility’s policy requires documentation of treatments or services performed in the resident medical record.
Improper Wound Care and Hand Hygiene for Resident With Unstageable Sacral Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards for a female resident with an unstageable sacral pressure ulcer and an indwelling Foley catheter. The resident, who had diagnoses including sepsis, CHF, and wasting syndrome, was moderately cognitively impaired and dependent for toileting hygiene. Her care plan identified an actual impairment to skin integrity with a sacral wound initially documented as stage 3 and later as unstageable, with specific orders to cleanse the coccyx pressure ulcer with wound cleanser, dry with gauze, apply Thera Honey and calcium alginate, and cover with bordered silicone gauze daily and as needed. An order was also in place for a urinary catheter for 30 days to aid wound healing. During an observed wound care procedure, the WCN removed an old sacral dressing that was saturated with urine and did not ensure the resident had a clean brief prior to performing wound care. The WCN failed to perform proper hand hygiene and glove changes when moving between dirty and clean tasks. She did not sanitize or wash her hands and change gloves before re-entering a package of clean wipes after handling contaminated areas, and she touched a urine- and feces-soaked brief during wound care without subsequently cleaning her hands or changing gloves. The WCN also applied an inadequate amount of hand sanitizer and did not allow it to dry before donning gloves. The WCN did not use proper wound cleansing technique, cleaning the sacral wound from the outside to the inside and wiping from top to bottom instead of from the inside to the outside (clean to dirty) in a circular motion as described by the DON. The WCN acknowledged that the Foley catheter, ordered to assist with wound healing, constantly leaked and that the resident’s brief stayed wet, but she did not address this issue during care. She stated she should have ensured a clean brief before wound care and recognized that her wound cleansing technique and handling of contaminated items could have caused cross-contamination. The NP reported she had not seen the wound and had not been notified of significant changes in the wound’s size or condition, other than the request for a Foley catheter order, despite the wound measurements fluctuating and the development of slough. The DON confirmed that re-entering clean supplies with contaminated gloves, improper wound cleansing technique, and failure to report the leaking Foley catheter were inconsistent with facility policies on wound care and hand hygiene.
Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene During Wound and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program, including proper implementation of Enhanced Barrier Precautions (EBP) and hand hygiene practices. Surveyors identified that 12 residents were on EBP, yet multiple rooms on several halls, including the room of Resident #50, had PPE containers but no EBP signage posted on the doors or walls outside the rooms. The facility’s own EBP policy required signs to be posted on the door or wall outside the resident room indicating the type of precautions and PPE required. The DON stated she believed signs posted inside the rooms were sufficient and did not realize they also had to be posted outside the rooms. Resident #50 was a female resident with sepsis, congestive heart failure, and wasting syndrome, with an admission MDS showing moderately impaired cognition (BIMS score of 10), dependence in toileting hygiene, an indwelling catheter, and at least one unhealed pressure ulcer. Her care plan documented a stage 3 sacral wound and a Foley catheter related to skin breakdown. During an observation of wound and incontinent care for this resident, the WCN did not perform hand hygiene or change gloves when moving from dirty to clean tasks. Specifically, the WCN failed to sanitize hands and don clean gloves before re-entering a package of clean wipes, and did not perform hand hygiene or change gloves after touching a urine- and feces-soaked brief during wound care. The WCN also applied an inadequate amount of hand sanitizer and did not rub her hands long enough to allow the sanitizer to dry before putting on gloves, contrary to product directions. She cleansed the sacral wound from the outside to the inside, wiping from top to bottom, instead of working from the inside to the outside (clean to dirty) in a circular motion. After wound care, both the WCN and CNA-H re-entered the clean container of wipes with contaminated gloves while performing incontinent care. CNA-H continued incontinent care and placed a clean brief under the resident without changing gloves or performing hand hygiene until all care was completed, and then carried the container of wipes, which had been accessed with contaminated gloves, out of the resident’s room. In interviews, the WCN, DON, NP, and CNA-H acknowledged that these practices, including re-entering clean supplies with contaminated gloves and handling dirty briefs during wound care without hand hygiene, could cause cross-contamination and contribute to infection and wound worsening. Record review showed the facility had existing policies on EBP, perineal care, and hand hygiene, as well as an in-service on standard precautions and glove use, which required glove changes and hand hygiene between tasks and when moving from soiled to clean body sites. In addition, CNA-H reported not recalling being in-serviced on hand washing and glove changes between tasks on the same resident when going from dirty to clean. The NP stated that the observed failures in hand hygiene and wound care technique, including performing wound care while the resident remained in a urine-soaked brief with feces and touching the brief during wound care, could contribute to cross-contamination and wounds not healing or worsening. The DON confirmed that staff were not supposed to take items into the rooms of residents on precautions and then bring them back out, and that re-entering a package of clean wipes with gloves contaminated by urine and feces, as well as improper wound cleaning technique and failure to change gloves after touching a dirty brief, could cause cross-contamination and lead to infection and worsening of wounds. Record review of the facility’s policies showed that EBP required signs on the door or wall outside the resident room indicating the type of precautions and PPE required, that perineal care procedures required removal of heavily soiled items, glove removal, handwashing, and then new hand hygiene and gloves before proceeding, and that hand hygiene was required before touching a resident, before aseptic tasks, after contact with body fluids or contaminated surfaces, before moving from a soiled to a clean body site on the same resident, and immediately after glove removal. The in-service on standard precautions and glove use required clean gloves to be put on between tasks and procedures involving the same resident. The observed practices by the WCN and CNA-H, and the lack of required EBP signage outside resident rooms, were inconsistent with these written policies and contributed to the cited infection control deficiency. Interviews further clarified staff understanding and acknowledgment of the issues. The WCN stated she knew which residents were on EBP from the chart and a sign inside the room, but was unsure about the requirement for signage outside the room, though she agreed it would make sense so anyone entering would know the proper PPE to use. She also acknowledged she should have ensured the resident had a clean brief before wound care, should not have touched the dirty brief during wound care, and that her wound cleaning technique and re-entering clean wipes with contaminated gloves could have caused cross-contamination and infection. CNA-H acknowledged that reaching into a clean wipes container with contaminated gloves and touching clean linens or briefs with dirty gloves could cause cross-contamination. These observations and statements formed the basis of the surveyors’ finding that the facility failed to maintain an effective infection prevention and control program for all residents reviewed for infection control practices.
Medication Administration Errors Involving Order Verification and Expired Insulin
Penalty
Summary
The facility failed to ensure accurate medication administration for a resident receiving lisinopril for hypertension. The resident had a diagnosis of essential hypertension and a BIMS score of 4 indicating severe impairment. During a medication pass, the MA took the resident’s blood pressure at 105/57 mm/Hg and removed morning medications from the blister pack, including lisinopril 10 mg. The blister pack directions stated to hold the medication if SBP was less than 100 or DBP was less than 60, while the active order in PCC stated to hold only if SBP was less than 100. The MA did not compare the blister pack instructions with the physician’s order before preparing the medication for administration. The facility also failed to ensure the nurse cart for the 100-hall was free from expired insulin pens and failed to prevent expired insulin from being administered to another resident. That resident had type 2 diabetes and a BIMS score of 3 indicating severe impairment. The resident’s active order included Lantus insulin 5 units subcutaneously daily and 15 units at bedtime with a hold parameter for blood sugar less than 100. During observation of the nurse cart, a Lantus pen labeled for the resident was found with an open date of 12/25/25 in the cart, and the LVN stated the pen would have expired on 01/22/26. The LVN stated she was responsible for the cart and was not aware the expired insulin pen was present. She also stated she used the expired Lantus pen to administer the resident’s morning insulin dose. The DON stated nurses were responsible for checking their carts at the beginning of the shift to ensure no expired medications were present and that expired medications should not be stored in medication carts. The facility policy stated the medication label must be checked three times and the expiration or beyond-use date must be checked before administering medication.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen refrigerator, freezer, and dry storage room. During the initial kitchen observation, the refrigerator contained a squeezable bag of cilantro and a bag of shredded carrots that were not sealed and were exposed to air. The freezer contained a bag of chicken nuggets, a box of biscuits, a box of dinner roll dough, a bag of okra, and a bag of hashbrowns that were all open, undated, unlabeled, and exposed to air. In the dry storage area, two items of stuffing mix and a bag of pasta were undated, open, and exposed to air. The kitchen environment was also observed to be unclean. The dry storage room racks used for boxed items were dirty and the room had rodent droppings on the floor. The stove had a black, burnt, stuck-on substance at the bottom of the burners, and the oven had similar burnt buildup at the bottom. The outside of the stove had orange and yellow stuck-on staining on the side of the oven door. The steam table wells contained brownish fluid with substances floating around. Utensils for eating were scratched, old, and dirty, and a pan with the non-stick coating scratched off was found with other pots and pans being used. The can opener had brownish buildup on the opening side, the shelves where bakeware and cookware were stored had an oily film and food crumbs, and the walls behind the stove and food steamers had a yellowish sticky substance coating them. In interviews, kitchen staff stated that all staff were responsible for cleaning the kitchen and that food items should be sealed when stored, but they did not know who left the items open. Staff also stated the stove was cleaned once a week, the can opener was cleaned daily or after use, and the steam wells were cleaned at the end of each day or as needed, but no cleaning logs were provided to show the days and times the kitchen was cleaned. The dietary manager stated staff must have been in a hurry and did not seal the food items closed, and stated she would retrain staff and review cleaning schedules. The policy review showed requirements for safe food handling, storage, refrigerator and freezer sanitation, and expiration guidelines, but policies for the stove/oven, steam tables, and can opener were not provided.
Pest Control Program Failed to Keep Kitchen and Facility Free of Rodents
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the kitchen and the rest of the facility free of rodents and pests. During observation of the kitchen dry storage room, rodent droppings were seen on the floor, including numerous droppings in the right back corner of the storage room. The DM stated that rodents could carry diseases and make residents sick. Interviews and record review showed repeated pest sightings throughout the facility. Staff reported seeing a mouse by the ramp where residents are weighed, and a resident reported hearing noises from a trash can, seeing a mouse jump out and run across the floor, and finding crackers that appeared to have been gnawed on. The sighting log documented mice and roaches in the 300 hall, kitchen, dining room, 400 hallway, linen room, and resident rooms. Pest control records showed monthly service and emergency rodent services, and the facility policy stated it maintained an ongoing pest control program, but rodent activity was still present in the kitchen and other areas.
Call Light Placement Out of Reach for Resident with Hemiplegia
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, right-sided flaccid hemiplegia, aphasia, and dysphagia was found in bed with the call light placed out of reach. The resident's care plan specifically indicated a risk for falls and included an intervention to keep the call bell within reach. During observation, the call light was located under the bed remote on the left side of the bed, but the resident was unable to stretch far enough to access it, despite being able to use the bed remote with her left hand. Interviews with staff revealed that the nursing assistant who last attended to the resident did not realize the call light was out of reach and acknowledged that it should have been left accessible, especially considering the resident's right-sided paralysis. The facility's policy also required that call lights be placed within easy reach of residents. The resident was left without access to the call light for approximately 10 minutes after being transferred from her wheelchair to her bed.
Failure to Follow Care Plan for Resident Transfers and Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident with severe cognitive impairment, Alzheimer's disease, osteoporosis, and a history of fractures. The resident was care planned to require two-person physical assistance for transfers, bed mobility, and incontinent care. Despite this, the CNA performed a one-person transfer from wheelchair to bed and provided one-person assistance during incontinent care on multiple occasions. The CNA was unaware that the resident's assistance level had changed and had been providing one-person assistance since returning from leave, without checking the current care plan or Kardex. Following these transfers and care episodes, the resident began to complain of pain in her left leg, which was initially not accompanied by visible abnormalities. Over the course of the night and early morning, the resident's pain increased and discoloration developed on her left lower leg. Subsequent assessments and imaging revealed acute proximal and mid left lower leg fractures. The CNA stated she did not use a gait belt during the transfer and was not aware of the updated assistance requirements, citing issues with accessing the electronic care plan system. Nursing staff and the DON confirmed that the resident required two-person assistance and that the CNA did not follow the care plan as required. Interviews with nursing staff revealed a lack of clear communication and monitoring regarding changes in residents' assistance levels. The charge nurse and other staff assumed the CNA was aware of the resident's needs and did not verify that the correct level of assistance was being provided. The facility's policy and training documentation did not clearly specify the requirement to follow the care plan, and there was no written evidence of prior in-service training for the CNA on this topic. The failure to provide the appropriate level of assistance as outlined in the care plan resulted in the resident sustaining significant injuries.
Failure to Accurately Update Electronic Care Plan Following Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident. Specifically, after a resident experienced a fall that resulted in a head injury, the responsible MDS nurse documented the incident and related interventions on a paper care plan due to an electronic system outage. However, this information was not subsequently transcribed into the resident's electronic care plan, which was the version accessible to staff for ongoing care and reference. The resident involved was an elderly female with significant medical issues, including legal blindness, osteoporosis, repeated falls, and severe cognitive impairment as indicated by a low BIMS score. The fall in question was documented on paper, but the electronic care plan, which staff relied upon, did not reflect the incident or the interventions implemented. The care plan only included general fall risk factors and did not mention the specific fall event or the updated interventions following the incident. Interviews with the MDS nurse and the DON confirmed that the omission occurred because the system was down and the paper documentation was not uploaded into the electronic record. Both staff members acknowledged that falls and related interventions should be included in the care plan and that the facility's process required such updates. The facility's policy on care planning did not specify what should be included in the care plan, and there was no documentation available to confirm recent training for the MDS nurse on care plan development.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, and sanitation, as observed during a kitchen inspection. Unlabeled and undated prepared drinks and pureed bread were found in the service refrigerator, with the bread left open to air and containing a scoop. Additionally, several containers of spices and a large bag of cereal were left open to air, and various food items in the freezer were unsealed, including garlic bread sticks, sliced carrots, and hamburger patties. A bag of vegetable blend in the freezer was found to be discolored and covered in ice crystals, indicating improper storage. The kitchen was also found to have several sanitation issues, including the presence of gnats, personal items on prep tables, and dirty dishes on the clean rack. The ice machine had a removable brownish-red substance on the ice chute, and non-stick pans and a spatula were found to be eroded, flaking, and chipped, posing a risk of contamination. Six cases of frozen food were improperly stored on the floor of the walk-in freezer, and a large vat of used grease was found on the floor under the sink, indicating improper disposal practices. Interviews with kitchen staff revealed a lack of adherence to labeling and dating protocols, as well as improper handling and storage of food items. The cook acknowledged the potential risks of leaving spices and food items open to air and admitted to not discarding eroded pans and spatulas. The dietary aide identified mold or bacteria on the ice machine and noted improper storage of peanut butter and jelly. The dietary manager confirmed that staff should have been aware of proper food storage and sanitation practices, and expressed concern over the improper disposal of used grease, which could pose a risk to staff and the environment.
Failure to Implement Abuse Reporting Procedures
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case of a resident with severe cognitive impairment and major depressive disorder. An incident occurred where a CNA was alleged to have abused the resident by telling her to 'shut up' and covering her mouth. The LVN who witnessed the incident did not follow the facility's abuse policy, as she only reported the incident to the DON and did not notify the resident's responsible party (RP) or the physician immediately, as required by the facility's policy. The investigation revealed that the LVN was new to the facility and unsure of the reporting process, leading to a delay in notifying the RP. The DON instructed the LVN to call the RP, but this was not done, and the RP was only informed of the incident after being contacted by the surveyor. The facility's policy mandates immediate notification of the alleged victim's practitioner and family or RP, which was not adhered to in this case, potentially placing residents at risk of abuse and neglect.
Failure to Conduct Accurate PASRR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure that PASRR evaluations were completed for two residents, leading to deficiencies in their care. Resident #48, a male with severe cognitive impairment and multiple mental health diagnoses, was admitted without an accurate PASRR Level 1 screening. His medical records indicated a history of bipolar disorder, dementia, and anxiety, yet the PASRR screening incorrectly noted no evidence of mental illness. This oversight placed him at risk of not receiving necessary specialized therapy and equipment services. Similarly, Resident #25, a female with moderate cognitive impairment and a history of schizoaffective disorder and bipolar disorder, was also admitted without an accurate PASRR Level 1 screening. Her medical records showed active diagnoses of anxiety, epilepsy, and dementia, and she was on multiple psychotropic medications. However, her PASRR screening also failed to recognize her mental illness, potentially delaying her access to appropriate care and services. Interviews with facility staff revealed a lack of proper procedures in place to ensure accurate PASRR screenings. The MDS nurse acknowledged the oversight and mentioned being re-educated on PASRR requirements. The RDCR nurse confirmed the absence of necessary documentation for Resident #48 and recognized the need for a positive PL1 for Resident #25. The facility's policy on comprehensive assessments emphasized the importance of pre-admission screenings, yet these were not adequately conducted, leading to the deficiencies noted in the report.
Failure to Update Resident Care Plan After Significant Changes
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for a resident. The resident, who had a history of nontraumatic stroke, anoxic brain damage, vascular dementia, tracheostomy, and gastrostomy, experienced several significant changes in her condition that were not reflected in her care plan. These changes included the self-removal of her tracheostomy tube, the removal of tracheostomy sutures, the discontinuation of pleasure feeding, and a change to a pureed diet, as well as the discontinuation of enteral feedings. The resident's care plan, dated and revised shortly after her admission, did not include updates for gastrostomy care, dietary changes, or tracheostomy management. Despite the resident's significant changes in condition, such as the removal of her tracheostomy and the transition to oral feeding, the care plan remained outdated. The Director of Nursing (DON) acknowledged that care plans should be updated to reflect changes in resident conditions and that there was no real monitoring in place to ensure this was done. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's current condition and care needs. The Activities Director (AD) was unaware that the resident could speak after the removal of her tracheostomy, indicating a disconnect between the resident's care plan and her actual condition. The facility's policy required care plans to be updated with significant changes in conditions, but this was not adhered to, leading to a deficiency in the resident's care management.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an unlocked and unattended medication cart on the 200-hall. During an observation, the surveyor found the medication cart unlocked, with multiple blister packs and bottles of medication accessible. LVN D, who was responsible for the cart, admitted to leaving it unlocked while assisting a resident, acknowledging the importance of keeping the cart secured to prevent unauthorized access by residents, visitors, or staff. The Director of Nursing (DON) confirmed that the medication cart should not have been left unlocked, as it posed a safety risk. The DON noted that in-services on keeping medication carts locked are conducted quarterly, with the last one held in July 2024. LVN D received one-on-one training following the incident, and all staff were reminded of the importance of securing medication carts. The facility's guidelines emphasize that medication carts should be kept closed, secured, and within the line of sight when not in use.
Failure to Use PPE During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the area of hand hygiene and the use of personal protective equipment (PPE). During an observation, LVN E did not wear the required PPE, such as a gown, while performing wound care on a resident who required enhanced barrier precautions due to an arterial ulcer and other medical conditions. This oversight was noted despite the presence of a sign indicating the need for enhanced barrier precautions and the availability of PPE on a cart in the hallway. Interviews with the Director of Nursing (DON) and LVN E revealed that the failure to wear PPE was due to forgetfulness and the absence of a visible PPE cart, which usually served as a reminder. The DON emphasized the importance of following doctor's orders and wearing appropriate PPE to prevent infection. The facility's infection prevention and control policy outlined the necessity of enhanced barrier precautions for residents with significant wounds, yet this protocol was not followed in this instance.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's condition. The resident, who had a history of dementia and was under hospice care, experienced a fall in the facility's dining room, landing on her left side. Despite the fall, the resident initially denied pain, and no immediate x-rays were conducted. However, two days later, the resident reported a substantial increase in pain in her left leg and shoulder, which was not communicated to the physician. The resident's condition worsened, and an x-ray conducted three days after the fall revealed a displaced fracture of the left femur neck. The facility received the x-ray results via email, but the physician was not notified until the following morning, resulting in a delay of approximately 15 hours. Interviews with facility staff revealed a lack of clear communication and documentation regarding the notification of significant findings to the physician. The delay in notifying the physician of the resident's increased pain and the significant x-ray findings potentially contributed to a lack of timely medical intervention. The facility's policies did not specify a timeframe for notifying physicians of critical results, which may have contributed to the oversight. The resident was eventually sent to the emergency room, but no treatment for the fracture was provided, and the resident was discharged home, where she later passed away.
Delayed Notification of Critical X-ray Results
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The deficiency involved a resident who experienced a substantial increase in pain following a fall in the facility's dining room. Despite the resident's significant pain and a subsequent x-ray revealing a displaced fracture of the left femur neck, the facility did not immediately notify the resident's physician of these critical findings. The resident, who had severe cognitive impairment and was under hospice care, fell on her left side in the dining room. Initially, the resident denied pain, and no immediate x-rays were conducted. However, the resident later exhibited signs of pain, and an x-ray was ordered three days after the fall. The x-ray results, which indicated a significant fracture, were not communicated to the physician until the following day, resulting in a delay in addressing the resident's condition. Interviews with facility staff revealed a lack of clear communication and documentation regarding the notification of critical x-ray results. The DON admitted to receiving an email about the significant findings but did not open it, and there was no immediate follow-up to ensure the physician was informed. This delay in communication and action potentially contributed to the resident's decline and eventual death, as noted by the medical examiner.
Delayed Notification of Critical X-ray Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of critical x-ray results for a resident who had a displaced fracture of the left femur neck. The resident, who had a history of dementia and was under hospice care, fell in the facility's dining room. Despite the fall occurring on November 25, 2023, the x-ray was not ordered until November 28, 2023, and the results were not communicated to the physician until the following morning, November 29, 2023. This delay in notification was contrary to the facility's policy, which required immediate notification of significant findings. Interviews with staff revealed a lack of clarity and consistency in the process for handling and communicating critical diagnostic results. The Director of Nursing (DON) admitted to receiving an email with the x-ray results but did not open it, and there was no documentation of a call to the facility to report the significant findings. The facility's contracted radiology company had attempted to fax the results, but the fax failed, and there was no follow-up call to ensure the results were received. Additionally, there was no specific policy in place detailing the timeframe for notifying the physician of critical results, leading to a significant delay in the resident receiving appropriate care. The resident's family member reported that the resident was in pain following the fall, but the facility did not conduct an x-ray until three days later. The facility's staff, including the DON and other nurses, were unclear about the procedures for notifying physicians of critical results, and there was a lack of documentation regarding the notification process. The delay in notifying the physician and the lack of a clear protocol for handling critical diagnostic results contributed to the deficiency identified by the surveyors.
Removal Plan
- Resident #21 was assessed and being monitored by the nurses prior to being sent to the hospital. Per hospital report, resident did not receive any treatment for fracture and was discharged home with family.
- Director of Nursing/Assistant Director of Nursing conducted an audit of all residents to identify any abnormal x-rays to ensure the MD and family representatives have been notified and appropriate interventions are in place and prescribers orders have been carried out as ordered.
- The Regional Nurse (DCO) conducted an in-service to the Director of Nursing/Assistant Director of Nursing regarding the process for ensuring that abnormal x-ray have been identified, x-ray portals are being checked during shift to identify pending results, and the results are reported to the medical provider, orders provided should be implemented as ordered and nursing should document in the electronic health record the notification of abnormal x-ray results to the MD/NP/PA as well as any prescribed orders.
- Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses regarding: a. The process for ensuring that abnormal x-rays have been identified, x-ray portals are being checked once in first half of shift and once in second half of shift to identify pending results, and the results are reported to the medical provider upon receipt of abnormal x-ray findings, orders provided should be implemented as ordered and nursing should document in the electronic health record the notification of abnormal x-ray results to the MD/NP/PA as well as any prescribed orders.
- If the x-ray company is unable to reach the nursing staff on duty, they will place a call to the Director of Nursing/Administrator or Regional Nurse DCO (contact information provided) so that timely notification to the MD/NP/PA. This has been communicated to the X-ray company and confirmed by them via email and telephone call.
- Charge Nurses will report abnormal x-ray findings to DNS/ADNS via in person or telephonic communication.
- Nurses will communicate during change of shift nursing report any pending x-rays results or changes in condition such as increased pain needs and ensure proper interventions are in place and notifications to the MD/NP/PA have been completed.
- Charge Nurses educated to follow HHSC guidance that indicates that the nurse should conduct a post fall assessment following the fall event. The nurse will continue ongoing monitoring of the resident following a fall event and should conduct follow up assessments upon any changes in condition identified. The nurse should then notify the medical provider upon identifying the change in condition or abnormal findings.
- DNS/ADNS (Director of Nursing / Assistant Director of Nursing) will review during the clinical meeting abnormal x-ray results, both pending and resulted in order to validate appropriate interventions are in place, proper follow up and notifications to MD/NP/PA has been made in order to ensure patient care needs are met, and documentation is noted within the medical record.
- Administrator and Director of Nursing conducted an Ad Hoc QAPI meeting with the Medical Director to review plan of removal / immediate corrective action plan implemented.
- The facility will conduct a monthly QAPI meeting to review the status and compliance notification to MD/NP/PA abnormal x-ray results, ensuring appropriate intervention and orders are implemented as ordered and appropriate documentation is in noted within the E.H.R. Findings of audits and status of compliance will be reviewed to the Administrator and the QAPI committee during the monthly meetings.
Failure to Maintain Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, which included not retaining the resident's Do Not Resuscitate (DNR) status in the care plan when the resident was transferred to the hospital. Additionally, the DNR status was not included in the care plan when it was signed by the physician, and the care plan was not updated to reflect multiple falls experienced by the resident. Furthermore, the resident's latex allergy was not retained in the care plan upon transfer to the hospital. The resident involved was an elderly female admitted to the facility with a primary diagnosis of palliative care, alongside other significant health issues such as congestive heart failure, dementia, and chronic kidney disease. The resident had a history of breast and colon cancer, but recent scans showed no cancer. The resident's family member indicated that the resident's kidney disease was stable, and the admission to the facility was due to the progression of dementia. Interviews with facility staff revealed a lack of clarity and responsibility regarding the updating and maintenance of the resident's care plan. The Director of Nursing (DON) and other staff members were unsure why the DNR status was marked as resolved and reverted to full code, and there was no set schedule for DNR audits. The Social Worker (SW) and other staff members acknowledged delays in updating the care plan, which could lead to potential issues with the resident's plan of care.
Failure to Timely Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment for a resident, which is a requirement to ensure individualized care. The resident, an elderly female, was admitted with a primary diagnosis of palliative care and other significant health issues, including congestive heart failure, dementia, and chronic kidney disease. Despite these complex needs, the comprehensive care plan was not completed within the required timeframe, potentially impacting the resident's care. The report highlights that the initial care plan was created upon admission and revised multiple times, but it lacked necessary updates and information. The Director of Nursing (DON) revised the care plan after the resident's hospital visit, but crucial information was either not retained or added. Interviews with staff revealed a lack of clarity and responsibility regarding who should update the care plan, leading to inconsistencies and omissions in the resident's care documentation. Interviews with various staff members, including the DON, Social Worker (SW), and Nursing Assistant Coordinator (NAC), revealed systemic issues in the care planning process. The SW was on leave during the resident's admission, which contributed to delays in updating the care plan. The NAC admitted to not knowing when or how the comprehensive assessment should be completed, indicating a lack of training or communication within the team. These deficiencies in the care planning process could lead to inadequate care for residents, as their needs and preferences may not be accurately reflected in their care plans.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 149 citations issued within 25 miles in the last 12 months — including the 2 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 Corpus Christi
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windsor Calallen | 1.8 mi | ★★★★★ | 3 | 0 |
| Robstown Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 6 | 0 |
| Avir At Corpus Christi | 14.1 mi | ★★★★★ | 6 | 0 |
| Windsor Nursing And Rehabilitation Center Of Morga | 16.2 mi | ★★★★★ | 4 | 0 |
| Windsor Nursing And Rehabilitation Center Of Corpu | 16.6 mi | ★★★★★ | 10 | 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.