Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Sherman during CMS and state inspections, most recent first.
A CNA failed to follow hand hygiene and glove-change protocols while providing incontinence care to a cognitively impaired male resident who required substantial assistance with toileting and personal hygiene. After cleaning the resident’s perineal area and removing a urine-soaked brief, the CNA applied a clean brief without changing gloves or performing hand hygiene, then assisted with dressing and wheelchair transfer. The CNA also removed gloves, immediately donned new gloves without hand hygiene, and made the resident’s bed and handled soiled linens before finally sanitizing hands upon exiting the room. Both the CNA and ADON acknowledged that this practice did not follow facility policy, which requires hand hygiene before and after resident contact, when moving from dirty to clean tasks, and immediately after glove removal.
Staff failed to follow the facility’s medication administration policy by prefilling routine and controlled medications for multiple residents and storing them in medication cart drawers instead of preparing them at the time of administration. One MA used prefilled cups labeled with residents’ names, later comparing the contents to blister packs and the eMAR, and even added a missed cranberry tablet to an already prefilled cup before giving it. The same MA also administered a prefilled cup containing several drugs, including controlled substances such as Ativan and hydrocodone/APAP, after a resident’s scheduled dose time had passed. Another MA pre-pulled tramadol and hydrocodone/APAP for three residents at once to save time, acknowledging that controlled meds should be pulled and signed out one resident at a time at the time of administration. Leadership confirmed that prefilling medications, including narcotics, was contrary to facility policy, which requires verification of the rights of medication administration at the time doses are given.
A resident with dementia, metabolic encephalopathy, and protein-calorie malnutrition was discharged to another LTC facility without a required discharge summary in the electronic medical record. Although an LVN documented the transfer and that belongings and meds were sent, no discharge summary recapping the stay and final status was completed. The Regional Nurse Consultant indicated such summaries were expected within 72 hours of discharge, while the social worker, who arranged transfer to a secured unit with responsible party agreement, reported not knowing who was responsible for the summary. The DON stated nursing was responsible for initiating the discharge summary and that a recent change in the electronic record system contributed to staff uncertainty. The administrator and facility policy both specified that a comprehensive discharge summary, including diagnoses, medical history, course of illness, test results, functional and nutritional status, ADL ability, and medication therapy, must be completed and provided to the resident and receiving facility.
A resident with multiple complex medical conditions experienced a change in mental status that was identified by a family member, leading to a hospital transfer. Facility staff did not notify the attending physician of this significant change or the transfer, as required by policy. Interviews and record reviews confirmed that the responsible nurse failed to follow the notification protocol.
A resident with multiple complex diagnoses and a positive PASRR Level II determination did not have the required NFSS form for specialized therapy services submitted within the mandated timeframe. The delay occurred during a transition from a second party provider to internal management of PASRR documentation, resulting in late submission of necessary paperwork, though therapy services continued without interruption.
The facility did not maintain clean and sanitary shower rooms, with visible residues and stains left unaddressed due to inconsistent cleaning practices and lack of proper supplies. Multiple residents reported frequent shortages of clean washcloths and towels, sometimes using pillowcases or large towels for bathing, and experienced delays in bed linen changes. Staff interviews confirmed ongoing linen shortages and inconsistent adherence to cleaning and linen change protocols, resulting in unsanitary conditions and increased risk of infection for residents.
Three residents' care plans did not reflect their specific needs and preferences, including requests for only female staff for personal care, an exception for one male CNA, and documentation of severe hearing, vision, and communication impairments. Staff awareness of these needs was inconsistent, and the omissions led to repeated misunderstandings and unmet preferences.
Surveyors found that the facility's medication error rate exceeded 5% after two residents did not receive their prescribed medications as ordered. One resident was given the wrong dosage of Vitamin B-12 and missed a dose of duloxetine, while another did not receive folic acid. In both cases, medication aides signed the records as if the medications had been administered, contrary to facility policy.
Several residents with complex medical needs reported that meals were frequently cold, bland, and unappetizing, with specific complaints about tough, dry fried chicken and overcooked vegetables. Surveyors observed that food delivered to rooms was often lukewarm and unpalatable, and group interviews confirmed ongoing dissatisfaction with food quality and temperature. Staff and records acknowledged repeated complaints, and the facility lacked a specific policy on food palatability.
Surveyors identified deficiencies in food storage and hand hygiene practices in the kitchen, including improperly sealed, unlabeled, and undated food items in the freezer, and a Dietary Aide handling food and drink items without proper handwashing or glove use after touching clothing and personal items. These actions were inconsistent with facility policy and professional standards.
Multiple lapses in infection control were observed, including a nurse failing to use required PPE during IV medication administration for a resident on Enhanced Barrier Precautions, improper disinfection of glucometers between residents, a medication aide not performing hand hygiene and mishandling medications after they were dropped, and a CNA not performing hand hygiene after resident contact. These actions did not follow established infection control protocols and placed residents at risk for infection and cross-contamination.
A resident with diabetes, malnutrition, anemia, and lactose intolerance did not receive a therapeutic diet as ordered by her physician. The facility did not offer a diabetic diet and failed to clarify or communicate the physician's order, resulting in the resident receiving regular meals that did not meet her medical needs. Dietary and nursing staff were not properly notified, and the dietician did not assess the resident's dietary requirements in a timely manner.
Nursing staff did not consistently document or assess a resident’s vital signs, dialysis access site, or mental status after the resident returned from dialysis, despite facility policy requiring such monitoring. Pre-dialysis assessments were generally completed, but post-dialysis sections of communication records were left incomplete, and staff interviews revealed a lack of awareness about the requirement for post-dialysis assessment and documentation.
A resident with multiple psychiatric diagnoses, including PTSD and schizoaffective disorder, did not receive ongoing psychiatric services as required. Despite being prescribed several psychotropic medications and having a care plan that called for regular mental health follow-up, the resident missed scheduled psychiatric appointments for several months, and facility staff were unaware of the lapse. The lack of clear responsibility and follow-up led to the resident not receiving necessary behavioral health services.
A nurse failed to properly prime a Humalog insulin pen before administering insulin to a resident with Type 2 diabetes, resulting in the potential for inaccurate dosing. The nurse was unaware of the correct priming procedure, and the facility's medication administration policy did not address insulin pen use.
A resident with multiple medical conditions and limited hand function was found with an over-the-counter topical analgesic at her bedside, without a physician order or documentation of self-administration ability. Staff were aware of the medication's presence but did not ensure its removal or secure storage, contrary to facility policy requiring all medications to be stored by authorized personnel.
A resident who was dependent on staff for ADLs and had a history of heart attack, contractures, and hemiplegia was found with long, dirty fingernails. Staff interviews confirmed that nail care responsibilities were not met according to facility policy, resulting in inadequate grooming and personal hygiene for the resident.
A LVN failed to disinfect a blood pressure cuff between use on two residents with significant medical conditions, contrary to facility policy requiring cleaning of non-critical equipment between residents. The incident was observed during a medication pass and confirmed by both the LVN and DON.
The facility failed to maintain personal hygiene for two residents, leading to long and dirty fingernails. One resident, with multiple health issues including diabetes, had not received nail care for over a month, despite it being part of her care plan. Another resident, requiring extensive assistance, was found with discolored and dirty nails. Staff interviews revealed a lack of adherence to the facility's policy on regular nail care, posing potential infection risks.
The facility failed to properly store and date food items in its kitchen, with observations noting missing expiration dates on various food packages. Additionally, a staff member was observed with improperly restrained hair while handling utensils, violating the facility's sanitation policy. These deficiencies were confirmed by the Dietary Manager and a kitchen staff member, highlighting lapses in adherence to food safety standards.
The facility failed to label and monitor insulin pens for expiration dates on a medication cart, affecting two residents with diabetes. Observations revealed that the insulin pens had expired open dates, contrary to the facility's medication storage policy. Interviews with staff confirmed the oversight in checking expiration dates, which could lead to diminished medication effectiveness.
A resident with severe cognitive impairment received incontinence care from CNAs, during which one CNA failed to perform hand hygiene after removing dirty gloves and before donning clean ones. This action violated the facility's infection control policy, which mandates hand washing after glove removal to prevent infection spread.
The facility failed to provide timely incontinence care for four residents, leading to inadequate personal hygiene and potential health risks. Residents reported long wait times for call light responses and inconsistent care, with staff interviews revealing discrepancies in expected response times.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene practices during incontinence care for one resident. The resident was an older male with seizure disorder/epilepsy, hypertension, and depression, with a BIMS score of 07 indicating severely impaired cognition, and required substantial/maximal one-person physical assistance with toilet use and personal hygiene. During an observed episode of incontinence care, the CNA entered the bathroom in response to the call light, found the resident standing next to the toilet with pants and brief down, washed her hands, and donned clean gloves. She then cleaned the resident’s buttocks and the tip of his penis using wipes and removed a urine-soaked brief. After completing the cleaning of the resident’s perineal area, the CNA obtained and applied a clean brief without changing gloves or performing hand hygiene. She then assisted the resident in pulling up his pants, returning to the wheelchair, washing his hands, and exiting the bathroom. The CNA removed her gloves, exited the bathroom, immediately donned new gloves from a box near the exit door without performing hand hygiene, and proceeded to make the resident’s bed and handle dirty linens and trash before finally removing gloves and sanitizing her hands upon leaving the room. In interviews, the CNA acknowledged she was supposed to wash hands before and after care, and to change gloves and perform hand hygiene before applying a clean brief, stating she did not do so because she was nervous. The ADON confirmed that facility expectations and policy required hand hygiene and glove changes when moving from dirty to clean tasks, and record review of the hand hygiene policy specified hand hygiene before and after resident contact, before moving from a soiled to a clean body site on the same resident, and immediately after glove removal.
Prefilling of Routine and Controlled Medications in Violation of Medication Administration Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and to follow its own medication administration policy, including procedures to assure accurate administration of drugs and biologicals, for six residents observed during a medication pass. Medication Aide (MA) A was observed using prefilled medication cups stored in the top drawer of the medication cart, each labeled with a resident’s name and containing multiple pills that had been pulled before the scheduled administration time. For one resident, MA A retrieved a plastic cup already filled with several pills, then had to go to another medication cart to obtain the resident’s blister packs and compare the contents of the cup with the electronic medication administration record (eMAR) and the blister packs before administering the medications. In another instance, MA A was observed transporting two medication carts to a different hall to administer a second resident’s medications. The top drawer of one cart contained multiple prefilled medication cups labeled with different residents’ names. MA A selected the cup labeled for the second resident, then compared the pills in the cup with the blister packs and the eMAR and discovered that a cranberry tablet had been omitted. She then opened the cart, retrieved a cranberry tablet from a bottle, and added it to the prefilled cup containing other previously pulled medications such as amiodarone, Plavix, Eliquis, potassium chloride, vitamin C, and a multivitamin before administering them. Later, MA A pulled another prefilled cup labeled for a third resident whose medications were scheduled for 7 a.m. but had been delayed at the resident’s request. She compared the contents with the blister packs and eMAR, which showed that the cup already contained multiple medications, including controlled substances (Ativan and hydrocodone/acetaminophen), as well as other drugs such as carbidopa-levodopa, Wellbutrin XL, Lasix, primidone, and Flomax, and then administered them. During interview, MA A acknowledged knowing that she was not supposed to prefill medications and that she was required to follow the rights of medication administration (right resident, right medication, right dosage, right time, and right route). She stated she had been having difficulty completing medication passes within prescribed times because residents’ routine medications were scheduled at different times and she had to move between multiple carts and halls, so she took a shortcut by prefilling medications and consolidating them into one cart. She also stated she had requested that nurses correct administration times but that this had not been done due to staff changes, and she recognized that prefilling medications posed risks such as medications being spilled or the wrong resident’s medications being given. A separate deficiency was identified with MA B, who was observed at another medication cart with three prefilled medication cups in the top drawer, each labeled with a different resident’s name and containing controlled medications scheduled to be given with morning medications. MA B unlocked the narcotic lock box, pulled the blister packs, and compared them with the eMAR and the pills in the cups, confirming that the cups contained tramadol for two residents and hydrocodone/acetaminophen for a third resident. MA B stated she had pulled all of the narcotics at once around 8:45 a.m. for a 9:00 a.m. medication pass to save time, despite knowing that she was supposed to pull and sign out controlled medications one resident at a time at the time of administration. She acknowledged that prefilling and leaving medications in the cart could result in medications being mixed up, spilled, or given to the wrong resident. The Assistant Director of Nursing (ADON) stated that staff were not allowed to prefill medications for multiple residents and were required to prepare medications at the time of administration. The ADON explained that prefilling and storing multiple residents’ medications in the cart created the possibility that medications could be spilled, mixed up, or taken for the wrong resident, and that narcotics and controlled medications were to be signed out and administered at the same time. The Director of Nursing (DON) confirmed that prefilling medications was not consistent with facility policy, which required staff to compare medications with the eMAR at the time of administration to ensure the right dose, medication, resident, route, and time, and noted that some medications required parameters to be checked prior to administration that could be overlooked if medications were prefilled. The facility’s written policy on administering medications specified that medications are to be administered in a safe and timely manner as prescribed, that the individual administering medications must verify resident identity, and that the medication label must be checked three times to verify the right resident, medication, dosage, time, and route before administration.
Failure to Complete Required Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to complete a required discharge summary, including a recapitulation of the resident’s stay and final status at discharge, for one resident who was permanently discharged. The resident was an elderly female with dementia, metabolic encephalopathy, and unspecified protein-calorie malnutrition who had been admitted and later discharged to another nursing home/LTC facility with a secured unit. The discharge MDS indicated a discharge with return not anticipated, and a nurse’s progress note documented that the resident was transferred to a new facility with personal belongings and medications sent. However, review of the electronic medical record showed that no discharge summary was present for this resident. Interviews revealed confusion and lack of clarity among staff regarding responsibility for completing the discharge summary. The Regional Nurse Consultant stated that a discharge summary with a recapitulation of the resident’s stay was expected within 72 hours of discharge and was part of the overall discharge process initiated at admission. The Social Worker reported arranging the transfer after being instructed by the Administrator and DON to find a secured placement due to exit-seeking behavior and confirmed agreement from the responsible party, but stated she did not know who was responsible for the discharge summary and had not been instructed on this. The DON stated that nursing was responsible for initiating the discharge summary in the electronic record, including medications sent, care received, and medical history, and acknowledged that the facility had recently changed electronic record systems and staff were still learning the process. The Administrator stated the discharge summary should be completed the day of or the day after discharge and be part of the electronic health record, and the facility’s policy required a discharge summary that included a description of the resident’s diagnoses, medical history, course of illness, test results, functional status, ADL ability, nutritional status, and medication therapy, with a copy provided to the resident and receiving facility and filed in the medical record.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's mental status, as required by facility policy. The resident, an elderly female with a complex medical history including acute kidney failure, chronic kidney disease, recent stroke, C-Diff infection, UTI, and metabolic encephalopathy, was admitted to the facility and experienced a change in mental status during her stay. Staff interviews and record reviews revealed that the resident was only at the facility for three days before being sent to the hospital at the request of her family, who noticed the change in her condition. On the day of the incident, the resident was observed by staff to be alert and oriented, but the change in mental status was not immediately recognized by the staff, many of whom had limited prior experience with the resident. The family member identified the change and requested hospital transfer. The nurse responsible for the resident at the time did not notify the attending physician of the change in condition or the transfer, as confirmed by interviews with facility leadership and the physician. The facility's policy required immediate notification of the physician in the event of a significant change in condition or hospital transfer, but this was not followed. Interviews with the resident's physicians and facility staff confirmed that the physician was not informed of the change in mental status or the hospital transfer. Both the Assistant Director of Nursing and the Administrator acknowledged that the nurse failed to follow the notification policy. The deficiency was identified through interviews, record reviews, and confirmation from the involved parties that the required physician notification did not occur.
Failure to Timely Submit PASRR NFSS Form for Specialized Therapy Services
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II determination and evaluation report for one resident who was reviewed for PASRR assessments. Specifically, the facility did not submit the Nursing Facility Specialized Services (NFSS) form request for therapy services by the required deadline. The resident in question was a female with multiple complex diagnoses, including cerebral palsy, speech and language deficits, muscle weakness, lack of coordination, chronic obstructive pulmonary disease, vision impairments, schizoaffective disorder, bipolar disorder, paraplegia, gout, and cerebrovascular disease. She was identified as PASRR positive for developmental disability and required specialized therapy services as indicated by the service coordinator. Record review showed that the resident's care plan and PASRR Comprehensive Service Plan documented the need for ongoing specialized occupational, physical, and speech therapy services. The facility had an interdisciplinary team meeting where these services were agreed upon, and the NFSS form was required to be submitted within 20 days of the meeting. However, due to a transition in facility ownership and a change from a second party provider to internal management of PASRR documentation, the NFSS form was not submitted within the required timeframe. The delay was attributed to the previous provider's failure to submit the documentation during the transition period. Interviews with facility staff confirmed that the missed deadline was not initially recognized by current staff and was only brought to their attention after notification from a PASRR representative. Despite the missed deadline, the resident continued to receive therapy services without interruption, and there was no documentation of services being declined or interrupted as a result of the deficiency. The facility's PASRR policy requires compliance with all federal and state regulations, including timely submission of required forms.
Failure to Maintain Clean Shower Rooms and Provide Adequate Linens
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents, specifically in the maintenance of shower rooms and the provision of clean linens. Observations revealed that two of five shower rooms had visible orange, pink, black, and brown residues along grout lines, walls, and floors, with one area appearing to have a stain resembling feces. Housekeeping staff acknowledged that showers were not cleaned to the expected standard, citing a lack of proper cleaning supplies such as scrubbers and inconsistent cleaning practices. The Housekeeping Supervisor admitted she had not noticed the extent of the residue until it was pointed out, and staff interviews revealed confusion over cleaning responsibilities, with some CNAs stating that aides, not housekeepers, typically cleaned the shower rooms. Multiple residents reported a lack of clean washcloths and towels for bathing, with some resorting to using pillowcases or large towels in place of washcloths. Interviews with residents and a confidential group of twelve residents confirmed ongoing issues with linen shortages, particularly washcloths, and inconsistent bed linen changes after showers. Staff interviews corroborated these shortages, with laundry and housekeeping staff noting that supplies would often run out and that orders for new linens were placed only every two weeks. Observations of linen carts and storage areas confirmed the lack of clean washcloths and towels available for resident use. One resident was observed to have a stained fitted sheet on her bed for at least two consecutive days, with staff acknowledging that sheets should be changed on shower days or when soiled. Interviews with CNAs, LVNs, and the DON revealed inconsistent practices regarding the frequency of linen changes and further confirmed periodic shortages of clean linens and towels. The facility's policy required a safe, clean, and homelike environment, but the policy was not provided upon request by surveyors. The failures in cleaning and linen provision placed residents at risk of exposure to infectious diseases and unsanitary conditions, as directly stated in the report.
Failure to Accurately Reflect Resident Preferences and Needs in Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans accurately reflected the needs and preferences of three residents, as identified through observation, interviews, and record review. One resident, a cognitively intact female with multiple diagnoses including diabetes, malnutrition, depression, and metabolic encephalopathy, expressed a clear preference for only female staff to provide her personal and incontinent care. Despite communicating this preference to several staff members, her care plan did not document this need, and some staff were unaware of her wishes, resulting in her being pressured to accept care from male staff during a weekend. Another resident, a female with severe cognitive impairment and a diagnosis of dementia and depression, preferred only female aides except for one specific male CNA. Both the resident and her family had to repeatedly inform staff of this preference when male aides were assigned to her, as it was not reflected in her care plan. While some staff were aware of her wishes through verbal communication, others were not, and the care plan did not specify her preference or the exception for the one male CNA. A third resident, a male with severe hearing impairment, moderately impaired vision, and aphasia following a stroke, had no documentation in his care plan regarding his communication or sensory deficits. Staff interviews revealed inconsistent awareness of his needs, with some staff noting his hearing and vision issues and others unsure. The responsible party also confirmed the resident's significant impairments, but these were not addressed in the care plan, leaving staff without clear guidance on how to communicate with or care for him.
Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Omitted Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.89% based on three errors out of 38 observed opportunities. These errors involved two residents and two medication aides during medication administration. The errors included administering the incorrect dosage of a prescribed medication and omitting required medications during scheduled medication passes. One incident involved a cognitively intact female resident with a history of coronary artery disease, heart failure, depression, and muscle weakness. The medication aide administered 1000 mcg of Vitamin B-12 instead of the prescribed 100 mcg and failed to administer duloxetine 60 mg as ordered. The medication administration record was inaccurately signed to indicate that the medications were given as ordered, and a late administration note was entered, but the correct medications were not provided at the scheduled time. The aide later acknowledged misreading the dosage and missing the duloxetine during the medication pass. Another incident involved a cognitively intact female resident with heart failure and anemia. The medication aide failed to administer the resident's prescribed folic acid 1 mg during the morning medication pass, although the medication administration record was signed as if it had been given. The aide later confirmed the omission. Facility policy requires medications to be administered and documented as ordered by the physician, with verification of the medication and dosage prior to administration, but these procedures were not followed in the cited instances.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide palatable, attractive, and appropriately tempered food and drink for residents during a lunch meal, as observed and reported by both residents and surveyors. Multiple residents, including those with diabetes, malnutrition, anemia, heart failure, and kidney disease, reported that the food was often cold, bland, and unappetizing. Specific complaints included fried chicken that was too tough and dry to eat, mashed potatoes that were not edible, and vegetables that were overcooked or bland. Residents stated that they frequently had to supplement their meals with food brought in from outside due to dissatisfaction with the facility's offerings. Observations during meal service revealed that food trays delivered to residents' rooms were often lukewarm by the time they arrived, with the last tray being delivered significantly after dining room service had concluded. Surveyors who tested a tray found the fried chicken to be dry and difficult to chew, the broccoli bland and mushy, and the cheese sauce lacking flavor. Residents in the dining room finished eating well before those in their rooms received their meals, and group interviews confirmed that food temperature and palatability were ongoing issues despite previous attempts to address them. Interviews with staff and review of facility records indicated that complaints about food quality, temperature, and timeliness had been ongoing, with residents and staff both acknowledging the problems. The facility had attempted to address these concerns by purchasing warming trays and encouraging residents to request alternative meals, but residents continued to report dissatisfaction. The facility did not have a specific policy on food palatability, relying instead on general standards and recipes provided by an external source.
Deficient Food Storage and Hand Hygiene Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage and handling practices. During an inspection of the kitchen freezer, several food items, including corn dogs, biscuits, and dinner rolls, were found in open plastic bags that were not sealed, labeled, or dated. The Dietary Manager confirmed that these items should have been properly sealed and labeled, and acknowledged that the lack of labeling and sealing could lead to freezer burn and cross-contamination if the food was consumed. Additionally, during lunch service, a Dietary Aide was observed carrying trays of water and tea in a manner that allowed the cups to touch his clothing. The aide placed the trays on a serving table, wiped his hands on his shirt and pants, and then put on gloves without washing his hands. He subsequently handled food and drink items with gloved hands after touching his clothing and personal items, and disposed of dirty gloves on a food service table. The aide admitted he should have washed his hands before donning gloves and should not have touched his clothing or personal items while wearing gloves. Review of facility policies and the FDA Food Code confirmed that all food items removed from original packaging must be labeled and dated, and that proper hand hygiene, including washing hands before putting on gloves and after touching potentially contaminated surfaces, is required. The observed actions were inconsistent with these standards and policies, as confirmed by interviews with the Dietary Manager and the Dietary Aide.
Multiple Lapses in Infection Control Practices
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple observed lapses in infection control practices involving four residents. One incident involved a nurse administering intravenous antibiotics to a resident with a venous access device who was on Enhanced Barrier Precautions (EBP). The nurse performed hand hygiene and donned gloves but failed to wear a gown as required by EBP protocols, despite signage indicating the need for such precautions. The nurse later acknowledged confusion about the required personal protective equipment (PPE) for different situations, even though he had received training. Additional deficiencies were observed in the disinfection of glucometers used for fingerstick blood sugar testing on two residents. Nurses wiped the glucometers with germicidal wipes but did not allow the devices to air dry for the required contact time before returning them to the medication cart, potentially leading to cross-contamination. One nurse was unaware of the need to let the device air dry, and the facility did not have a specific policy for glucometer disinfection, relying instead on manufacturer instructions. Further lapses included a medication aide carrying eye drops and nasal spray into a resident's room, placing them on the bed and resident's chair, and failing to perform hand hygiene before administering the medications. The aide also failed to discard the medications after they were dropped on the floor, instead returning them to the medication cart. In another instance, a CNA did not perform hand hygiene after transferring a resident to a wheelchair and before leaving the room, contrary to facility policy. These actions were confirmed through staff interviews and record reviews, demonstrating a pattern of non-compliance with established infection control protocols.
Failure to Provide Physician-Ordered Therapeutic Diet for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including diabetes, malnutrition, anemia, and lactose intolerance, was not provided with a therapeutic diet as ordered by the physician. The physician's order specified a diabetic diet with a 1500ml fluid restriction and lactose intolerance, but the facility did not have a diabetic diet and instead offered a Low Concentrated Sweets (LCS) diet for diabetic residents. The resident's care plan and medical nutrition therapy assessment reflected the need for a diabetic diet, but her meal ticket listed a regular diet, and her lunch tray included items not consistent with a diabetic or lactose-intolerant diet, such as a dinner roll, fried chicken, pineapples in juice, and packets of sugar. Interviews revealed that the dietary and nursing staff were not properly notified or did not clarify the physician's order for a diabetic diet, as the facility did not offer this specific diet. The dietary manager was unaware of the resident's need for a diabetic diet until after the resident reported receiving inappropriate meals. The process for communicating new or changed diet orders involved nursing staff filling out a dietary form and handing it to the dietary manager, but this process failed in this instance, resulting in the resident not receiving the prescribed diet. Further, the dietician responsible for reviewing new admissions did not assess the resident's dietary needs within the expected timeframe, and the facility's policy required nursing to clarify any diet orders not matching the facility's available diets before forwarding them to dietary services. The lack of timely clarification and communication led to the resident receiving meals inconsistent with her medical needs and physician's orders.
Failure to Document and Assess Post-Dialysis Care
Penalty
Summary
Facility nursing staff failed to ensure that a resident requiring dialysis received care consistent with professional standards of practice. Specifically, on multiple occasions, staff did not document or assess the resident’s vital signs, dialysis access site, or mental status after the resident returned from dialysis treatments. This lack of post-dialysis assessment and documentation was noted on three separate dates, despite the facility’s policy requiring such monitoring. The resident involved was an older adult with diagnoses including anemia, kidney disease, heart failure, and diabetes, and was cognitively intact. She received dialysis twice weekly. While pre-dialysis assessments and documentation were generally completed, the post-dialysis sections of the communication records were left incomplete by facility nurses, even though the dialysis center staff completed their own sections. There were also no progress notes reflecting pre- or post-dialysis assessments by nursing staff during the relevant period. Interviews with staff revealed a lack of awareness regarding the requirement to complete post-dialysis assessments and documentation. The DON was unaware that these sections were not being completed, and one LVN stated she did not know she was supposed to check the resident’s vitals upon return from dialysis. The facility’s policy clearly outlined the need for monitoring blood pressure, pulse, and access site after dialysis, but these steps were not consistently followed.
Failure to Ensure Ongoing Psychiatric Services for Resident with Mental Health Diagnoses
Penalty
Summary
A resident with a history of multiple psychiatric diagnoses, including anxiety, depression, schizoaffective disorder, and post-traumatic stress disorder, did not receive ongoing psychiatric services as required. The resident had previously attended psychiatric appointments outside the facility, with the last documented visit occurring several months prior to the survey. Despite being scheduled for regular follow-up every two months, there was no documentation or explanation for the missed appointments, and the resident confirmed he had not attended psychiatric services for an extended period and was unsure of the reason. Medical records indicated the resident was prescribed several psychotropic medications, including Latuda, Trazadone, Prozac, and buspirone, and his care plan identified him as being at risk for behavioral symptoms related to past trauma. The care plan included interventions such as allowing the resident to discuss emotions in a safe environment and consulting mental health services as needed. However, there was no evidence that the facility ensured the resident continued to receive psychiatric evaluations or medication management as outlined in his care plan and physician's notes. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's missed psychiatric appointments. The DON was unaware that the resident had not been seen by psychiatric services, and the social worker was unfamiliar with the resident's outside psychiatric care. The process for tracking and scheduling follow-up appointments was unclear, and responsibility for ensuring ongoing psychiatric care was not consistently assigned or monitored, resulting in the resident not receiving necessary behavioral health services.
Failure to Follow Insulin Pen Priming Procedure
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow the manufacturer's instructions for priming a Humalog insulin pen prior to administering insulin to a resident with Type 2 diabetes. The LVN did not prime the pen with 2 units as required, but instead dialed in an extra unit and pushed out 1 unit before administering the prescribed dose. The LVN was unaware of the correct priming procedure, which is necessary to ensure the accurate delivery of insulin. The resident involved was a female with a diagnosis of Type 2 diabetes, who was prescribed Humalog insulin per a sliding scale. Observation confirmed that the LVN did not prime the pen according to manufacturer instructions, and interviews revealed a lack of knowledge regarding the correct procedure. Additionally, the facility's medication administration policy did not include specific procedures for the use of insulin pens.
Improper Storage of Over-the-Counter Medication at Bedside
Penalty
Summary
A deficiency occurred when a resident was found to have a tube of BioFreeze, an over-the-counter topical analgesic, at her bedside table, accessible without staff supervision. The resident, an elderly female with diagnoses including hypertension, dementia, and cervical disc myelopathy, had a BIMS score indicating intact cognition but also had hand contractures that limited her ability to self-administer medication. There was no documentation in her care plan regarding her ability to self-administer medications, and no physician order was present for the BioFreeze. Multiple staff members, including CNAs and nursing leadership, were aware or became aware of the medication's presence but did not ensure its removal or proper storage according to facility policy. Interviews revealed that staff assumed nursing was aware of the medication, and the ADON had previously instructed a CNA to remove it but did not verify its removal. The DON confirmed that all medications, including over-the-counter products, require a physician order and must be stored securely in the medication cart. Facility policy states that only authorized personnel may administer medications and that self-administration must be specifically authorized by a physician. Despite these policies, the medication remained accessible at the resident's bedside, contrary to established procedures.
Failure to Provide Nail Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. Specifically, on 04/16/2025, a male resident with a history of myocardial infarction, contractures of the left hand and shoulder, and hemiplegia/hemiparesis was observed to have fingernails approximately 0.5 inches in length with a dark substance underneath. The resident, who was cognitively intact but dependent on staff for showering, bathing, and toileting hygiene, stated that his nails were too long and that he did not like it. Interviews with staff revealed that certified nursing assistants (CNAs) and nurses were responsible for nail care, with the exception that only nurses could provide nail care for residents with diabetes. Staff acknowledged that the resident's nails were long, dirty, and needed to be trimmed and cleaned, and recognized the risk of infection associated with this deficiency. Review of the facility's policy confirmed that nail care procedures were in place, but these were not followed for this resident.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices when a licensed vocational nurse (LVN) did not disinfect a blood pressure cuff between use on two residents. During a morning medication pass, the LVN checked the blood pressure of one resident and then immediately used the same cuff on another resident without sanitizing it before or after each use. This was observed directly by surveyors and confirmed in interviews with the LVN, who acknowledged that reusable medical equipment should be sanitized between residents to prevent cross contamination, but stated she forgot due to being new to the facility. Both residents involved had significant medical histories, including coronary artery disease, hypertension, diabetes, stroke, heart failure, and dementia, with varying levels of cognitive impairment as indicated by their BIMS scores. The facility's own infection control policy required that non-critical resident-care items, such as blood pressure cuffs, be cleaned and disinfected between residents. The Director of Nursing confirmed awareness of the incident and reiterated the expectation that all medical equipment be sanitized between uses.
Failure to Maintain Residents' Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #13, a female with multiple diagnoses including diabetes and moderate cognitive impairment, was observed with long and dirty fingernails. Despite her care plan indicating that nail care should be performed on bath days and as needed, interviews revealed that her nails had not been trimmed for over a month. Both CNAs and LVNs were responsible for nail care, but due to her diabetes, only nurses were allowed to perform this task. The LVN admitted to not offering nail care recently, acknowledging the risk of infection from inadequate nail care. Similarly, Resident #40, a male with moderate cognitive impairment and requiring extensive assistance, was found with discolored and dirty fingernails. His care plan also emphasized the importance of maintaining personal hygiene. Interviews with staff indicated that CNAs were responsible for nail care unless the resident had diabetes. The DON confirmed that nail care should be provided regularly, especially during shower times, and acknowledged the potential infection control issues arising from neglecting this aspect of care. The facility's policy on activities of daily living was not adhered to, resulting in these deficiencies.
Deficiencies in Food Storage and Hair Restraint Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specifically, food items in the refrigerator, freezer, and dry storage were not properly covered and dated. Observations revealed that a packet of hot dogs in the refrigerator, a packet of tortillas in the dry storage, and a packet of bread in the freezer lacked expiration dates. Additionally, a packet of cornflakes was left open without a use-by date. These lapses in food storage practices were confirmed through interviews with the Dietary Manager and a kitchen staff member, who acknowledged the importance of dating and covering food items to prevent food-borne illnesses. Furthermore, the facility did not ensure that kitchen staff used appropriate hair restraints. During a lunch meal service observation, a staff member was seen with improperly restrained hair while handling washed utensils in the kitchen prep area. The Dietary Manager confirmed that all kitchen staff are required to wear hair restraints as part of their uniform to prevent hair from contaminating food. The staff member admitted to having long, frizzy hair that was not fully secured, acknowledging the risk of hair contaminating food and the potential for food-borne illness. The facility's policies on food storage and employee sanitation, as well as the FDA Food Code, were not followed, contributing to these deficiencies.
Expired Insulin Pens Found on Medication Cart
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles, specifically regarding the expiration dates of insulin pens on the 200 hall nurses' medication cart. During an observation, it was found that insulin pens for two residents had expired open dates. One insulin pen for a female resident with type 2 diabetes mellitus and hyperlipidemia was opened beyond the 28-day discard period. Similarly, another insulin pen for a male resident with type 2 diabetes mellitus, elevated blood pressure, and hyperlipidemia was also found to be expired. Interviews with the LVN and the DON revealed that the insulin pens were not checked for expiration dates, and the purpose of open dates was acknowledged as being for expiration purposes. The facility's policy on medication storage requires that outdated medications be immediately removed and disposed of, which was not adhered to in this instance. The failure to monitor and discard expired insulin pens could result in diminished effectiveness of the medication for the residents involved.
Infection Control Lapse During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of CNA D during incontinence care for a resident. The resident, a female with severe cognitive impairment due to dementia, required extensive assistance with personal hygiene. During the care, CNA D did not perform hand hygiene after removing dirty gloves and before donning clean gloves, which is a critical step in preventing the spread of infection. This lapse occurred despite the facility's policy requiring hand washing after glove removal. The incident was observed during a care session where CNA D and another CNA were attending to the resident. After cleaning the resident's front pubic area and discarding the dirty gloves, CNA D failed to wash her hands before putting on new gloves to continue the care. This oversight was acknowledged by CNA D, who attributed it to nervousness, and was confirmed by the Director of Nursing, who reiterated the importance of hand hygiene in infection prevention. The facility's policy clearly states that hand washing is essential after glove removal, highlighting the deficiency in adherence to established infection control protocols.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene. Specifically, the facility did not provide timely incontinence care every two hours or as needed for four out of five residents reviewed. This failure was observed through record reviews, interviews, and direct observations, indicating a pattern of neglect in providing essential care to residents who are incontinent and at risk for skin breakdown and other complications. Resident #1, a cognitively intact female with multiple diagnoses including blindness, ankylosing spondylitis, and chronic kidney disease, reported being left wet overnight and not receiving timely incontinence care. Her care records showed significant gaps in incontinence care, with long intervals between changes. Similar issues were reported by Resident #3, who also noted that her roommate did not receive timely care. Resident #4, who has Alzheimer's disease and other chronic conditions, reported that staff often did not respond to call lights, forcing her to change herself. Resident #5, who is on diuretic therapy, expressed concerns about long wait times for call light responses, especially during mealtimes. Interviews with staff members, including CNAs and RNs, revealed inconsistencies in the expected response times for call lights and incontinence care. While some staff stated that call lights should be answered within 5-10 minutes, others were unsure of specific timeframes. The facility's call light procedures emphasized the importance of prompt responses, yet the observed practices did not align with these guidelines. This discrepancy between policy and practice contributed to the inadequate care provided to the residents, as documented in their care records and personal accounts.
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 102 citations issued within 25 miles in the last 12 months — including the 4 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 Sherman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Texoma Healthcare Center | 0.6 mi | ★★★★★ | 16 | 0 |
| Focused Care At Sherman | 3.5 mi | ★★★★★ | 3 | 0 |
| Beacon Hill | 3.7 mi | ★★★★★ | 10 | 0 |
| Woodlands Place Rehabilitation Suites | 5.6 mi | ★★★★★ | 14 | 0 |
| Denison Nursing And Rehab | 5.8 mi | ★★★★★ | 3 | 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.