Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At The Meadow during CMS and state inspections, most recent first.
Food remained on the floor in two residents’ shared room across repeated observations, including chicken strips and dried green peas under and between the beds. One resident had severe cognitive impairment and required setup/clean-up help with meals, while the other had severe cognitive impairment, CVA, and dysphagia. The Administrator said staff on all shifts should have noticed and cleaned the debris, and the Dietary Manager confirmed the prior dinner meal included the same foods observed on the floor.
Incomplete Person-Centered Care Plans Missing Key Diagnoses and Orders: The facility failed to ensure that care plans for 3 residents reflected their assessed needs and active conditions. One resident’s plan omitted a G-tube order, advance directives, and diagnoses; another resident’s plan omitted dementia, COPD, schizoaffective disorder, bipolar disorder, anxiety, diabetes, hypertension, and smoking status; and a third resident’s plan omitted dementia, ESRD, and dialysis. The MDS Nurse confirmed the plans had not been fully transferred and updated, and the DON stated she was unaware the plans were incomplete.
Two residents with indwelling catheters were observed with the catheters not secured with a stat lock or leg strap. One resident had a suprapubic catheter related to neurogenic bladder and MS, and the other had a Foley catheter with orders for leg strap monitoring. Staff interviews confirmed catheters should be secured to the inner thigh, and the facility policy required a leg strap to reduce friction and movement.
Expired, discontinued, and improperly labeled medications were found on medication carts, and nystatin powder was also found in two residents’ rooms instead of being stored with the nurse-administered medications. The issues involved expired nitroglycerin, morphine, Colace, oyster shell calcium, a discontinued triamcinolone cream, and an opened bottle of Keppra without a resident label. Staff stated medications should be labeled, within date, and not left in resident rooms.
Cold and Unpalatable Meal Service: A survey observation found 3 test trays for regular, mechanical soft, and puree diets served cold at lunch, with residents reporting meals were often cold or seldom hot when delivered. The Dietary Mgr confirmed the pureed mashed potatoes lacked flavor and stated kitchen staff were responsible for checking palatability and temperature before service, while also noting trays were not always delivered to residents in a timely manner.
Food storage and kitchen safety practices were not followed in the main kitchen. Surveyors observed expired food items, multiple unsealed packages and containers in the dry pantry, refrigerator, and freezer, and dented cans stored with other canned goods. The Dietary Manager and kitchen staff stated that food should be labeled, dated, sealed, and checked for expiration, but the observed items had been overlooked.
A resident’s MDS did not accurately code an indwelling Foley catheter or current pressure ulcer status. The record showed active Foley care and wound care orders, and the resident was observed with a coccyx wound and a Foley draining yellow urine. The MDS Coordinator acknowledged the catheter should have been coded, and the ADON and DON stated the care plan was pulled from the MDS.
Unsecured Mechanical Lifts Left in Hallways: Surveyors observed two unlocked and unsecured mechanical lifts on the 200 Hallway, including one in front of a resident room and another near the elevator by the Dining/Activity Room entrance. CNA I stated she left one lift there after use and did not lock it, while CNA A observed residents walking around the lift and did not move it because she was carrying a food tray. The DON and LVN stated mechanical lifts should be stored in the Utility Room/Utility Closet when not in use, and the facility policy required lifts to be stable and locked.
Nebulizer Mask Not Changed Per Policy: A resident with respiratory failure, HF, HTN, and severe cognitive impairment had a nebulizer mask found dated outside the weekly change schedule and stored in a plastic bag. Staff, including the assigned LVN, ADON, and DON, stated the mask and tubing were to be changed weekly and as needed, and the facility policy required weekly changes with documentation in the EHR.
Improper Storage of Controlled Medications: Two residents’ Tramadol 50 mg controlled meds were found on a nurses’ cart with broken blister seals that had been taped, while the pills remained inside. Staff stated broken narcotic seals should be wasted with two nurses witnessing and that narcotics should not be taped. The RN, LVNs, ADON, and DON all acknowledged the issue, and the facility policy required meds to remain in their received packaging and controlled substances to be securely stored.
Catheter Drainage Bag Placed on Floor: A resident with a suprapubic catheter, neurogenic bladder, and moderate cognitive impairment was observed with the drainage bag on the floor and not anchored to the bed. Staff, including the CNA, LVN, ADON, and DON, stated the bag should be kept off the floor and secured to the bed, and the facility policy also required the tubing and drainage bag to remain off the floor.
Failure to Make Anonymous Grievance Information Available: The facility did not notify residents or their representatives, either individually or through prominent postings, on how to file a grievance or complaint anonymously. A surveyor observed no grievance forms in common areas, and residents said they did not know where forms were located or how to file anonymously. Staff gave inconsistent responses about where forms were kept and how a resident could submit an anonymous grievance, despite the facility policy stating grievances may be filed anonymously.
Surveyors found portable space heaters plugged in on nightstands in two secure-unit rooms, including one heater that was turned on and unattended while the residents were not in the room, even though the central heat was functioning and the rooms were warm. A CNA reported not knowing how long the heaters had been present. The DON, Maintenance Director, and ADM all confirmed there was no facility policy on portable or space heaters, acknowledged these devices as safety hazards that could cause injury, and stated that space heaters had been placed on the unit during a recent heating issue despite an existing heat-loss policy that relied on clothing, blankets, hot beverages, and environmental measures rather than portable heaters.
A resident with dementia, severe cognitive impairment, and multiple psychotropic medications exhibited escalating behavioral episodes, including yelling, kicking, and knocking over furniture, for which PRN Xanax and Haldol were ordered and administered. Following one such episode, staff documentation noted a facial scratch, and a CNA later obtained photos from a confidential source showing scratches to the face and reddened areas on the forearm and hand. One CNA reported that another staff member feared reporting the incident and believed staff had been aggressive with the resident, while another CNA described seeing blood on the resident’s face, swelling around an eye, and bruising to the wrist and hand after the incident. The ADON viewed photos on a CNA’s phone but concluded the markings were related to the behavioral episode and redirection, instructed that the photos be shown to the involved LVN for documentation, and did not initiate an internal abuse or injury‑of‑unknown‑source investigation. The DON and corporate RN later stated they did not see the photos, did not identify injuries on assessment, and determined the situation did not meet criteria for mandatory reporting, resulting in the facility’s failure to immediately report the alleged abuse and suspicious injuries to the administrator and state authorities as required.
A resident with severe cognitive impairment, vascular dementia, schizophrenia, schizoaffective disorder, insomnia, and multiple psychotropic medications did not have a comprehensive, person-centered care plan that addressed behaviors or psychotropic use. The current care plan omitted identified behaviors, high-risk psychotropic medications, and recent behavioral incidents that led to PRN administration of IM haloperidol and Xanax. Due to an ownership change and transition to a new electronic system, existing care plans did not transfer, and the MDS nurse, who was responsible for psychotropic-related care planning, had not yet rebuilt this resident’s individualized behavior-based care plan in accordance with facility policy requiring measurable objectives, timeframes, and ongoing revision.
A resident with dementia and severe cognitive impairment, receiving multiple psychotropic medications, was given PRN IM Haldol for resistance to care and reported combative behavior without clear documentation of behaviors or danger to self or others. The care plan did not reflect psychotropic use or recent behavioral incidents, and behavior monitoring logs showed no behaviors at the time PRN psychotropics were administered. Staff accounts of the resident’s behavior conflicted, with some describing effective de-escalation through calm redirection and others describing aggression and destructiveness. The facility’s antipsychotic policy required documented behavioral symptoms posing danger, prior behavioral interventions, and specific documented conditions for PRN psychotropic use, but these criteria and related documentation were not met, resulting in the use of an unnecessary antipsychotic medication.
Four residents with severe cognitive and mobility impairments were found to have their call lights out of reach, despite care plans and facility policy requiring accessibility. Staff interviews indicated that call lights were not always returned to accessible positions after care, and nursing staff acknowledged responsibility for ensuring accessibility. The facility's policy required accessible call systems, but this was not consistently followed.
A resident with COPD who required BPAP and continuous oxygen therapy was observed with a nasal canula dragging on the floor and a BPAP mask left unbagged on a nightstand. Nursing staff and administration confirmed that both items should have been bagged when not in use to prevent contamination, but this was not done, contrary to facility policy.
Two residents receiving oxygen therapy for COPD were not accurately documented in their MDS assessments, despite care plans, physician orders, and treatment records confirming ongoing oxygen use. Staff interviews confirmed the omission, and observations showed one resident actively receiving oxygen during the survey.
Two residents with COPD did not receive respiratory care in accordance with professional standards and physician orders. One resident's nasal cannula was visibly soiled and not replaced, while another's oxygen concentrator humidification bottle was not dated, making it unclear if required maintenance was performed. Staff interviews revealed inconsistent practices and lack of documentation regarding respiratory equipment changes.
Two residents with limited range of motion did not receive appropriate contracture management after therapy discharge. One resident, with severe cognitive impairment and hemiplegia, was observed without a splint despite having an order for contracture management. Another resident, with moderate cognitive impairment and a history of stroke, was also seen without a splint, indicating a lack of staff awareness and implementation of necessary interventions. This deficiency highlights a failure in communication and execution of therapy recommendations, risking further decline in residents' conditions.
The facility failed to ensure proper pharmaceutical services, including the counting and documentation of controlled drugs and the use of an expired insulin pen for a resident. Controlled drugs were not signed off at shift changes, risking drug diversion, and an expired insulin pen was used for a resident with diabetes, potentially compromising medication effectiveness.
Two residents in the facility did not receive necessary dental services, leading to potential risks such as mouth pain and difficulty eating. One resident reported tooth pain and discomfort, while another had difficulty eating due to dental issues. Despite these needs, the facility lacked a clear process for managing dental care, and staff were unaware of the residents' needs. The Social Worker, responsible for tracking ancillary services, was newly hired and developing a system to address these issues.
The facility's kitchen failed to meet food safety standards, with uncovered food items in the freezer and hot holding temperatures below 135°F during lunch service. A staff member initially served food at improper temperatures, later realizing the mistake after consulting with the Dietary Manager. The facility's policies and FDA guidelines require hot foods to be served at 135°F or greater to prevent foodborne illnesses.
The facility failed to maintain sanitary conditions in clean linen closets, where non-linen items were found, posing a risk of cross-contamination. Additionally, a CNA did not perform proper hand hygiene during incontinence care for a resident with severe cognitive impairment, increasing the risk of infection. The facility's policies require proper linen handling and hand hygiene, but these were not adhered to, as confirmed by staff interviews and observations.
The facility failed to maintain proper hygiene and grooming for two residents, resulting in long and unclean fingernails. One resident, cognitively intact, expressed discomfort due to nail length but did not report it, while another, cognitively impaired, had discolored and dirty nails. Staff were responsible for nail care, but oversight led to this deficiency, posing infection control risks.
A facility's secured unit had an unlocked shower room and cabinet containing personal care products and razors, posing risks to residents. Staff interviews revealed a lack of clear policy and training on securing these areas, with the DON and Administrator acknowledging the oversight.
A resident with severe cognitive impairment was recorded by an unauthorized visitor who signed in as a volunteer. The visitor posted the recording on social media, leading to a breach of privacy. The resident's family was upset upon discovering the video. The facility's DON acknowledged the violation of resident rights, as the facility's policy did not cover visitor conduct regarding recordings.
A resident in a memory care unit was verbally abused by an Activities Assistant, who referred to the resident as a 'pig' during an interaction. The incident was recorded and posted online by an unauthorized visitor, causing embarrassment and a loss of dignity for the resident. The facility lacked a specific policy on social media or recording by non-employees, contributing to the deficiency.
An LTC facility failed to report an incident where an Activities Assistant spoke rudely to a resident, making derogatory comments about her eating habits. The incident, captured in videos, was not reported to the state as required, despite the resident's family informing the facility. The resident, with a severely impaired BIMS score and multiple diagnoses, was at risk due to this reporting failure.
Food Left on Bedroom Floor in Memory Care Room
Penalty
Summary
The facility failed to maintain a sanitary, orderly, and comfortable bedroom environment for two residents when food from the prior dinner meal was left on the floor in their shared room. During observations on multiple occasions, chicken strips and dried green peas were seen on the floor underneath one resident’s bed and between the two beds. The food remained present across repeated observations later the same day. One resident had diagnoses including Parkinson’s disease, Alzheimer’s disease, dementia, encephalopathy, and anxiety. Her quarterly MDS reflected a BIMS score of 00, indicating severe cognitive impairment. Her care plan identified that she required setup/clean-up assistance for eating. The other resident had diagnoses including systolic CHF, dementia, Alzheimer’s disease, CKD stage 3, CVA, and oropharyngeal dysphagia. Her quarterly MDS reflected a BIMS score of 3, indicating severe cognitive impairment, and her care plan addressed nutritional concerns, dysphagia, and assistance with eating-related needs. During interviews, the Administrator stated he was unaware the food had been on the floor and said staff on all shifts in the Memory Care Unit should have noticed and cleaned it during rounds. The Maintenance Director stated the Memory Care Unit had one housekeeper assigned and that staff in the unit were responsible for cleaning debris and trash on the floor after housekeeping shifts. CNA staff stated they would have removed food from the floor immediately if they had seen it. The Dietary Manager confirmed the dinner meal served the prior evening included chicken strips and green peas, matching the food observed on the floor.
Incomplete Person-Centered Care Plans Missing Key Diagnoses and Orders
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 3 residents reviewed, because the plans did not include measurable objectives and time frames that reflected the residents’ identified clinical and psychosocial needs. For Resident #5, the care plan focused on cognitive stimulation and social engagement, but it did not include his G-tube order, advance directives, or active diagnoses. His record showed a full code status, a living will requesting life-sustaining treatment in terminal or irreversible conditions, and an active physician order for liquid protein via G-tube. Resident #21’s care plan did not include her active diagnoses of dementia, COPD, schizoaffective disorder, bipolar disorder, anxiety, hypertension, diabetes mellitus, or her smoking status. Her record showed moderate cognitive impairment on the MDS, and during observation and interview she stated that she had smoked cigarettes almost her entire life, had COPD, and used her walker several times a day to go across the street to smoke and buy items. The MDS Nurse stated that many care plans had not been updated and transferred from Matrix into PCC, and confirmed that Resident #21’s care plan was not updated and completed. Resident #35’s care plan did not include her active diagnoses of dementia, end-stage renal disease, or dialysis treatments. Her record showed a full code status, moderate cognitive impairment on the MDS, and diagnoses including diabetes mellitus, hyperlipidemia, dementia, end-stage renal disease, and dependence on renal dialysis. The DON stated she was unaware that the care plans for the 3 residents were not updated and completed with their diagnoses, advance directives, and smoking status where applicable. The facility policy stated that comprehensive person-centered care plans are to include measurable objectives and timeframes and be developed from the resident’s comprehensive assessment.
Unsecured Indwelling Catheters
Penalty
Summary
Appropriate care for residents with indwelling catheters was not provided for two residents when their catheters were observed unsecured. Resident #85 was a female with moderate cognitive impairment, neurogenic bladder, and multiple sclerosis who had a suprapubic catheter and active orders for catheter care every shift. During observation, her indwelling catheter was not secured with a stat lock or leg strap, despite the facility care plan and policy stating the catheter tubing should be secured to the resident’s inner thigh. Resident #9 was a female with moderate cognitive impairment and active orders for a Foley catheter, including an order to monitor leg strap placement every shift for wound healing. Her active care plan did not include a catheter-related problem, goal, or intervention. During observation, her indwelling catheter was also not secured with a stat lock or leg strap. The record showed orders for flushing the Foley as needed for obstruction or occlusion and for changing the catheter as needed for leakage, blockage, and sedimentation. During interviews, the assigned LVN stated indwelling catheters should always be secured with a stat lock or leg strap to the inner thigh and identified the risk as pulling or dislodgement. A CNA stated that if a stat lock came off, the nurse should be notified, and another CNA stated she did not know the Foley catheter was supposed to be secured with a device to prevent movement. The ADON and DON both stated nurses were responsible for ensuring indwelling catheters were secured during catheter care, and the facility policy required the catheter remain secured with a leg strap to reduce friction and movement at the insertion site.
Expired, Unlabeled, and Improperly Stored Medications Found on Medication Carts and in Resident Rooms
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with accepted professional principles on two medication carts. During observation, interview, and record review, expired and discontinued medications were found in the 100 hall and 200 hall medication carts, and some medications were not labeled with the resident’s name or were stored in resident rooms instead of the medication cart. On the 100 hall nurses’ medication cart, Resident #71’s expired nitroglycerin was present, Resident #42’s discontinued triamcinolone 0.1% cream was present, an expired bottle of Colace 100 mg was present, and an expired opened bottle of oyster shell calcium 500 mg was present. Resident #71’s record showed an active order for nitroglycerin for chest pain, while Resident #42’s record showed no active order for triamcinolone cream. The LVN who observed the cart stated expired and discontinued medications should be removed immediately and disposed of or given to the DON for destruction. On the 200 hall nurses’ medication cart, Resident #34’s expired morphine was present, and an opened bottle of Keppra 100 mg/ml was present without a patient label. Resident #34’s record showed active morphine orders for pain and shortness of breath. Staff stated it was the nurse’s responsibility to ensure medications had the patient label and were within date, and that missing labels or expired medications created medication error concerns. In addition, Resident #13’s nystatin powder was found in the resident’s room in a medication cup on the nightstand, and Resident #75’s nystatin powder was found in the resident’s room on the TV stand. Staff identified that medication should not be left in resident rooms and that Resident #75’s medication was to be administered by nurses only.
Cold and Unpalatable Meal Service
Penalty
Summary
The facility failed to provide foods that were palatable, attractive, and served at a safe and appetizing temperature during the lunch meal observation on 03/04/26. The State Survey Team observed 3 test trays for the regular, mechanical soft, and puree diets, each served with covered tops and containing roasted pork loin, baked sweet potato, seasoned cauliflower, and a dinner roll. All 3 test trays were cold when observed at 12:30 PM. Resident interviews reflected that food for all 3 daily meals was often cold, and in a confidential group interview residents stated their food was seldom hot when it arrived to their rooms. During an interview, the Dietary Manager stated her expectation was that meals served from the kitchen be warm and flavorful, and she confirmed the pureed mashed potatoes lacked flavor after tasting them. She stated kitchen staff were responsible for tasting food for palatability, flavor, and temperature before service, but she did not try the lunch meal served that day. The Dietary Manager also stated that food trays were taken from the kitchen to the floor and staff were not giving the food to residents in a timely manner, which could result in trays being cold when served. The Administrator stated his expectation was that food be served warm and not cold, and he had not tried the lunch meal served that day. The facility policy required residents to receive nourishing, palatable meals served at a safe and appetizing temperature, and required food service staff to inspect trays to ensure food appeared palatable and attractive and was served at the proper temperature.
Food Storage and Kitchen Safety Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen. During the initial kitchen tour, surveyors observed expired items in the dry pantry and freezer, including flavored soft drink mixes, baking soda, and shredded hash browns. Surveyors also observed multiple food items left unsealed and exposed to air in the dry pantry, refrigerator, and freezer, including pasta noodles, grain and wild rice, seasoned fish fry, creamy peanut butter, dried cranberries, lasagna, graham cracker crumbs, sugar, bread, pureed bread and dessert mix, chocolate chip cookies, and vanilla ice cream. The survey also identified dented cans in the dry pantry, including spaghetti sauce, sliced pears, Manwich sloppy joe, and black beans. In the refrigerator, a bag of bread was unsealed and exposed to air. The Dietary Manager stated that daily checks were performed but the items found by the surveyor had been overlooked by mistake. She stated that staff were responsible for ensuring food was labeled with the item name, storage date, and use-by date, that food should be sealed and closed, and that expired items should be discarded immediately. She also stated that dented cans were to be removed from the shelf and placed in the designated area marked for dented cans. Record review showed the facility’s Food Receiving and Storage policy required dry foods stored in bins to be labeled and dated, refrigerated and frozen foods to be covered, labeled, and dated, and frozen wrappers to remain intact until thawing. Staff interviews confirmed that kitchen staff were responsible for labeling, dating, sealing, and checking expiration dates on food items, and that unsealed or expired items should be discarded. The Dietary Manager and kitchen staff stated that food left unsealed or expired could lead to food-borne illness, stomach aches, vomiting, and diarrhea if consumed.
Inaccurate MDS Coding for Foley Catheter and Coccyx Wound
Penalty
Summary
The facility failed to ensure Resident #9’s MDS accurately reflected the resident’s clinical status for an indwelling urinary catheter and pressure ulcers. The Quarterly MDS dated 02/09/26 coded the resident as not having an indwelling catheter in Section H0100 and not having a current pressure ulcer in Section M0300, even though the record showed active physician orders for Foley catheter care, Foley catheter flushing, catheter replacement for leakage/blockage/sedimentation, and wound care to the coccyx. The resident’s care plan, dated 12/12/2025 and revised 02/02/2026, documented impairment to skin integrity of the coccyx related to irritant contact dermatitis and a stage 3 pressure ulcer. Record review also showed the resident had an indwelling urinary catheter in place during the assessment period. During wound care observation on 3/5/2026, the resident was observed with a wound to the coccyx and an indwelling urinary catheter draining yellow urine to gravity. During interview, the MDS Coordinator acknowledged the resident had an indwelling urinary catheter during the assessment reference period and should have been coded accordingly on the MDS. The ADON and DON stated the MDS Coordinator was responsible for MDS coding and that the care plans were pulled from the MDS.
Unsecured Mechanical Lifts Left in Hallways
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible on the 200 Hallway. Survey observation on 03/04/26 at 10:15 AM found an unlocked and unsecured mechanical lift parked in front of a resident's room. A second observation on 03/04/26 at 12:11 AM also found an unlocked and unsecured mechanical lift parked in front of a resident's room on the 200 Hallway. An additional observation on 3/04/2025 at 12:11 PM revealed an unlocked mechanical lift on the 200 Hallway near the 2nd floor elevator in front of the entry to the Dining/Activity Room. Residents and staff were observed going around the mechanical lift as they entered and exited the Dining/Activity Room. During interview, CNA I stated she should not have left the mechanical lift by the elevator in front of the entry to the Dining/Activity Room, that she had used it for a resident, and that she did not store it in the Supply Room where the mechanical lifts are stored. She also stated she did not lock the mechanical lift when she placed it there. During interview, CNA A stated she observed residents going around the unlocked and unsecured mechanical lift near the elevator and confirmed residents were exiting and entering the Dining/Activity Room in that area. She stated she did not move it because she had a food tray in her hands. LVN E and the DON stated that mechanical lifts should not be stored in hallways and should be stored in the Utility Room/Utility Closet when not in use. The facility's policy stated that the environment should be kept as free from accident hazards as possible and that mechanical lifts should be stable and locked.
Nebulizer Mask Not Changed Per Weekly Schedule
Penalty
Summary
The facility failed to ensure that Resident #13 received respiratory care consistent with the facility’s policy and the resident’s care needs when the resident’s nebulizer mask was not changed weekly. Resident #13 was a [AGE]-year-old male admitted to the facility with diagnoses including respiratory failure, heart failure, and hypertension, and his quarterly MDS reflected severe cognitive impairment. His comprehensive care plan identified him as at risk for impaired gas exchange related to COPD and smoking, and his active physician order included Iprat-Albut nebulizer treatment as needed for shortness of breath. During observation, Resident #13’s nebulizer mask was found stored in a plastic bag and dated 2/16/2026. The resident was not showing signs of respiratory distress or infection at the time of observation, and he was uninterviewable. Staff interviews confirmed that the nebulizer mask and tubing were supposed to be changed weekly and as needed, with the assigned nurse expected to check that the equipment was within date and stored properly. The LVN assigned to the resident stated she was not aware the mask and tubing had not been changed, and the ADON and DON both stated the facility policy required weekly changes on Sunday night shift and documentation in the EHR.
Improper Storage of Controlled Medications
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 2 Tramadol 50 mg controlled medications reviewed on 1 of 3 medication carts. During observation of the 200 Hall nurses’ cart, Resident #38’s Tramadol 50 mg had 2 blister seals broken and taped, and Resident #35’s Tramadol 50 mg had 3 blister seals damaged, with the pills still inside and secured with tape. Both medications were present on the cart in this condition when the surveyor inspected the medication storage area. Resident #38 was a male admitted to the facility with a BIMs score of 08 and a diagnosis including Pain Disorder with related psychological factors. His care plan reflected pain medication therapy with Tramadol for generalized pain, and his physician order was for Tramadol HCl 50 mg by mouth every 8 hours as needed for pain. Resident #35 was a female with a BIMs score of 12 and diagnoses including pain, unspecified. Her physician order was for Tramadol HCl 50 mg by mouth every 6 hours as needed for pain. During interviews, RN F stated she was unaware the blister packs were broken and did not know how they became damaged. LVN B and LVN E stated that when a narcotic bubble seal is broken, the medication is to be disposed of and wasted with two nurses witnessing, and that narcotics should not be taped. The ADON and DON stated nurses were responsible for ensuring the medication cart was clean and narcotics were secured, and both stated that taped narcotics could create medication error and contamination concerns. The facility policy stated medications are to remain in the packaging containers or dispensing systems they are received in, and controlled substances are to be separately locked.
Catheter Drainage Bag Placed on Floor
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 1 of 5 residents reviewed for infection control when Resident #85's suprapubic catheter drainage bag was observed on the floor. Resident #85 was a female resident with moderate cognitive impairment, neurogenic bladder, and an indwelling catheter. Her care plan stated she required a suprapubic catheter related to neuromuscular dysfunction of the bladder associated with MS and identified that tubing or any part of the drainage system should not touch the floor. Her active orders included suprapubic catheter care every shift and as needed. During observation, Resident #85's catheter drainage bag was on the floor and the catheter was not anchored to a non-moveable part of the bed. In interviews, the resident stated the CNA had emptied the drainage bag at the end of the shift. The LVN, CNA, ADON, and DON all stated the drainage bag should be anchored to the bed and not placed on the floor, and that staff were responsible for ensuring this. The facility policy on catheter care also stated the catheter tubing and drainage bag should be kept off the floor.
Failure to Make Anonymous Grievance Information Available
Penalty
Summary
The facility failed to notify residents or their representatives, either individually or through prominent postings throughout the facility, on how to file a grievance or complaint in an anonymous manner. During observation on 03/04/26 at 2:45 PM, the State Surveyor found no grievance forms available in any common areas and no indications of where grievance forms were normally kept. Interviews with six confidential residents showed they were unaware of where grievance forms were located and stated they did not know how to anonymously file a grievance; they also expressed wanting the option to file anonymously. Staff interviews showed inconsistent knowledge about where grievance forms were kept and how residents could access them. A CNA stated grievance forms were kept at the nurse's stations and given to residents if they asked, while the ADON stated she was not sure where blank grievance forms were kept and was unsure how a guest or resident would obtain a form to file anonymously. The DON stated residents could get grievance forms from the Social Worker or after hours at the reception desk and could submit anonymous grievances by sliding them under the Social Worker's door. The facility policy stated grievances may be submitted orally or in writing and may be filed anonymously, and the Resident's Rights subsection stated the facility must make information on how to file a grievance or complaint available to residents.
Use of Portable Space Heaters in Resident Rooms Without Policy or Controls
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate environmental safety on the secure unit when portable space heaters were found in resident rooms despite the central heat functioning. During observation with a CNA, one resident room contained a portable space heater plugged into the wall and turned on, sitting on a nightstand with a digital temperature display reading 85 degrees Fahrenheit, while neither the resident nor the roommate were present in the room. Another resident room contained a portable space heater plugged into the wall on the nightstand; this heater was not turned on, and the resident was in bed without a roommate. The CNA reported not knowing how long the heaters had been in the rooms and confirmed that the heat was working and both rooms were warm. Interviews with the DON, Maintenance Director, and Administrator revealed that the facility did not have a policy on portable or space heaters in resident rooms, and each acknowledged that such heaters were considered a safety hazard and could result in injury. The Maintenance Director stated that space heaters had been placed on the secure unit on a specific date when reports were received that heaters were not functioning properly, and that an HVAC company had been contacted and repairs to a valve were completed within a couple of hours that same day, after which the heat was working. Despite this, space heaters remained in at least two resident rooms on the secure unit. Review of the facility’s Loss of Central Services Policy for heat loss showed procedures focusing on clothing, blankets, hot beverages, activities, and environmental measures such as closing windows and drawing curtains, with no mention of using portable or space heaters.
Failure to Report and Investigate Alleged Abuse and Suspicious Injuries
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported and investigated in accordance with state and federal requirements. The resident was an elderly male with metabolic encephalopathy, vascular dementia, diabetes, insomnia, and severe cognitive impairment (BIMS score of 6), who required moderate assistance with ADLs, used a walker, and was frequently incontinent. He was receiving multiple psychotropic and high‑risk medications, including Seroquel, Depakote, Trazodone, Remeron, and later PRN Xanax and Haldol for agitation and behavioral issues. Nursing notes documented escalating outbursts and aggressive behavior on multiple dates, including yelling, kicking, hitting, scratching staff, and knocking down tables and chairs, with new PRN psychotropic orders obtained. A late entry note on 12/30/25 documented a scratch to the right side of the resident’s face. Staff interviews revealed conflicting accounts of the behavioral incident(s) and the resident’s injuries. One CNA reported that on the morning of 12/24/25 the resident resisted ADL care, was taken to the dining room, began knocking on the table and making noise, and was then removed to his room; she stated she did not observe bruises or injuries afterward. Another CNA (CNA D) reported that around 12/30/25 a staff member contacted her, expressing fear about reporting what occurred and believing staff on the secured unit had been aggressive with the resident and harmed him. CNA D stated she had photos showing scratches and reddened areas on the resident’s face, forearm, and hand, and that she showed these photos to the ADON. She reported that the ADON told her she already knew about the incident, stated the resident had struck the nurse’s nose, and instructed her to show the photos to the same nurse (LVN A) so the nurse could document any injuries. CNA D believed no formal abuse or injury‑of‑unknown‑source investigation was initiated, that the incident was not reported to the state, and that alleged involved staff were not removed from the resident’s care. Additional interviews further demonstrated that an allegation of possible abuse and suspicious injuries was not treated as a reportable incident. LVN A acknowledged a behavioral episode in the dining room, stated the resident hit her nose, and later described the resident as wild and flailing, asserting that a facial scratch was self‑inflicted. The ADON stated she was present shortly after the behavioral escalation, saw the resident in his room, and later viewed photos on a CNA’s phone showing redness/scratches, but she did not believe the photos indicated abuse and did not initiate an internal abuse investigation, concluding any markings were related to the behavioral episode and redirection. The DON and corporate nurse reported they became aware of concerns only when state surveyors arrived, did not personally see the photos, and did not identify injuries on subsequent assessments; they stated the situation did not meet criteria for mandatory reporting to HHSC and no staff were suspended. Another CNA (CNA E) described hearing loud commotion, observing staff using loud, commanding voices, and later seeing blood running down the resident’s face, swelling around the eye, and bruising to the wrist and hand; she expressed fear of retaliation and concern that internal reporting mechanisms were not safe. Despite these staff concerns, photographic evidence of injuries, and the state’s definition requiring reporting of suspected abuse and suspicious injuries of unknown source, the facility did not immediately report the allegation or initiate a formal abuse or injury‑of‑unknown‑source investigation as required.
Failure to Develop and Implement Comprehensive Psychotropic and Behavior Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple psychiatric and medical diagnoses who was receiving psychotropic medications. Record review showed that the resident, an older male with metabolic encephalopathy, vascular dementia, diabetes, schizophrenia, schizoaffective disorder, and insomnia, had a quarterly MDS indicating severe cognitive impairment, use of high-risk medications (including antipsychotics and antidepressants), and functional limitations requiring assistance with ADLs. Despite these identified needs and conditions, the current care plan initiated in late December did not identify any behaviors, did not address the use of psychotropic medications, and did not include individualized behavior-based interventions. The record further showed that the resident had active orders for multiple psychotropic and related medications, including IM haloperidol as a one-time dose for restlessness and agitation, PRN Xanax for restlessness and agitation, mirtazapine for insomnia, Seroquel for vascular dementia, trazodone for depression, and Depakote for vascular dementia. The MAR documented administration of PRN Xanax and PRN IM Haldol during the review period. However, the resident’s current care plan did not address these medications, their indications, or associated behavioral symptoms, and did not incorporate the acute behavioral incidents that led to the PRN antipsychotic and anxiolytic use. Interview with the MDS nurse revealed that a change of ownership and transition to a new online system resulted in existing care plans not transferring, requiring all residents’ care plans to be rebuilt. The MDS nurse stated she was responsible for care planning residents on psychotropic medications and acknowledged that, during this transition, she had not yet updated this resident’s care plan, even though the resident was on her list. She was uncertain whether other licensed nurses could update care plans for acute or new issues. The facility’s own policy on comprehensive person-centered care plans required measurable objectives, timeframes, and ongoing revision of care plans as residents’ conditions changed, including addressing underlying sources of problem areas, but these requirements were not met for this resident’s behavioral and psychotropic medication needs.
Unnecessary PRN IM Antipsychotic Use Without Adequate Indications or Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s drug regimen was free from unnecessary psychotropic medication, specifically PRN intramuscular (IM) Haldol, and to ensure adequate indications and documentation for its use. The resident was an elderly male with metabolic encephalopathy, vascular dementia, diabetes, insomnia, and previously documented but later unsubstantiated diagnoses of schizophrenia and schizoaffective disorder. A quarterly MDS showed severe cognitive impairment with no documented delirium, negative mood, or verbal/physical behaviors toward others. The resident required moderate assistance with ADLs, used a walker, and was frequently incontinent. His care plan initiated in late December did not identify behaviors or psychotropic medication use and did not address acute behavioral incidents that occurred later in the month or the new PRN psychotropic orders. The resident’s psychotropic regimen included Seroquel for agitation, Depakote sprinkles for mood disorder, Trazodone for agitation and dementia, and Remeron for insomnia. A psychiatric NP evaluation shortly before the incidents documented the resident as calm, with dementia and insomnia, and noted no supporting evidence for schizophrenia or schizoaffective disorder, recommending removal of those diagnoses. Subsequent physician orders included a one-time IM Haldol dose for restlessness and agitation, and PRN Xanax for restlessness and agitation. The MAR showed administration of PRN Xanax and PRN IM Haldol, but the behavior monitoring section did not document any behaviors at the time of PRN administration. Nursing notes described the resident as having outbursts, yelling “mama, mama,” and attempting to kick staff, with reports of aggressive behavior and knocking down tables and chairs, but these behaviors were not reflected in the behavior monitoring logs or care plan. On one occasion, staff reported the resident resisted incontinent care, was taken to the dining room, and began yelling and interacting with furniture, after which he was returned to his room and later given PRN Xanax. On another morning, the nurse described the resident as destructive and combative in bed, kicking at staff, and decided to administer IM Haldol based on an existing order, stating that oral Xanax had been ineffective because the resident spit it out. Other staff interviews provided differing accounts, with one CNA stating the resident was not normally aggressive, that she did not see him flip tables or chairs, and that he could be calmed with soft redirection, while describing other staff using loud, commanding voices. The facility’s own antipsychotic policy required that antipsychotics for dementia be used only after other causes of behavior were addressed, that behaviors present a danger to the resident or others, that behavioral interventions be attempted, and that PRN psychotropics only be used for specific documented conditions. A clinical leader acknowledged errors including lack of psychotropic medications on the care plan, lack of documented behaviors, and behavior monitoring logs showing zeros despite PRN psychotropic use, and stated that IM antipsychotics should not be used to compel residents to comply with care. The administrator stated IM antipsychotics should only be used when a resident posed a threat to self or others and that resisting care alone would not justify IM antipsychotic use, while affirming residents’ right to refuse care. An observation of the resident after these events found him in a wheelchair at lunch with a full plate of food, eyes closed, slightly slumped, and only slowly beginning to eat after being roused, remaining non-responsive to questions and keeping his eyes closed. No visible injuries were noted. The facility’s antipsychotic policy also specified that antipsychotics should not be used when the only symptoms were restlessness or uncooperativeness and that residents should not receive PRN psychotropics unless necessary to treat a specific documented condition. Despite this, the resident received PRN IM Haldol in the context of resistance to care and combative behavior without clear documentation of danger to self or others, without adequate behavior documentation on the MAR or behavior logs, and without corresponding updates to the care plan, leading surveyors to determine that the resident’s drug regimen was not maintained free from unnecessary drugs.
Failure to Ensure Resident Call Lights Were Accessible
Penalty
Summary
The facility failed to ensure that the resident call light system was accessible to residents in their rooms, as required by facility policy. During observations, four residents with significant mobility limitations and severe cognitive impairments were found to have their call lights out of reach. In each case, the call light was either on the floor, under the bed, or otherwise not accessible to the resident, despite care plans specifying that call lights should be within reach due to their high risk for falls and need for assistance with activities of daily living (ADLs). Staff interviews revealed that the call lights were not returned to accessible positions after care activities such as bathing. In one instance, a restorative aide admitted to forgetting to place the call light within reach after bathing a resident. Other staff members, including CNAs and an LVN, were either unaware of why the call lights were not accessible or acknowledged that it was the responsibility of nursing staff to ensure call lights were within reach. The Director of Nursing confirmed that all staff should be checking to ensure call lights are accessible to residents. Record reviews for the affected residents showed that each had care plans and assessments indicating severe cognitive and physical impairments, requiring substantial or total assistance for ADLs. The facility's own policy required that residents be provided with a means to call staff for assistance from their beds, bathrooms, and bathing areas, but this was not consistently implemented, as evidenced by the observations and staff interviews.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with COPD who required both BPAP and continuous oxygen therapy. On the morning of the survey, the resident was observed sitting in a wheelchair with his nasal canula attached to an oxygen tank, but the canula was dragging on the floor. Additionally, the resident's BPAP mask was found unbagged on top of his nightstand, despite not having been used since early that morning. Both items were not stored in a manner consistent with infection control practices as outlined in the facility's own policy and professional standards. Interviews with nursing staff and administration confirmed that the nasal canula and BPAP mask should have been bagged when not in use to prevent contamination and infection. The RN present was unaware of why the items were not properly stored, and both the DON and ADON acknowledged that it was the nurse's responsibility to ensure proper storage. The facility's policy on oxygen administration also emphasized the need for safe handling and storage of respiratory equipment, which was not followed in this instance.
Failure to Accurately Document Oxygen Therapy in MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents who were receiving oxygen therapy. For both residents, the MDS assessments did not document their ongoing oxygen use, despite evidence from care plans, physician orders, and treatment administration records indicating that oxygen therapy was being provided. The omission was identified through observations, interviews, and record reviews conducted by surveyors. One resident, a female with a diagnosis of chronic obstructive pulmonary disease (COPD), had a care plan and physician orders specifying oxygen therapy via nasal cannula at 2 liters per minute as needed. Her care plan included detailed interventions for monitoring respiratory status and safety precautions related to her smoking history. However, her comprehensive MDS assessment did not indicate that she was receiving oxygen therapy during the look-back period, even though her care plan and other records confirmed its use. Another resident, a male also diagnosed with COPD, had physician orders for continuous oxygen via nasal cannula, with instructions to titrate the flow rate and monitor oxygen saturation. His care plan and treatment administration records documented regular maintenance and monitoring of his oxygen equipment. Despite this, his MDS assessment left the section for special treatments, including oxygen therapy, blank. Interviews with facility staff, including the DON and MDS coordinator, confirmed that the MDS assessments were completed without reflecting the residents' actual oxygen use.
Failure to Provide Safe and Consistent Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to residents requiring such care, as evidenced by observations, interviews, and record reviews. One resident with a history of chronic obstructive pulmonary disease (COPD) and a smoking habit was found with a nasal cannula (NC) that had visible discoloration in various shades of brown, which had not been replaced despite being dirty. The resident reported that the NC tubing was never changed and the oxygen concentrator was not cleaned. Physician orders and the care plan specified that oxygen tubing and humidifier bottles should be changed weekly and as needed, but these instructions were not followed. Another resident, also diagnosed with COPD, was observed with an oxygen concentrator humidification bottle that was not dated. Although the resident stated that the nurse checked the tubing and bottle during rounds, he could not recall when the water bottle was last changed. Physician orders required the humidification bottle to be checked for adequate distilled water every shift and the tubing to be changed weekly, but the lack of dating on the bottle made it unclear whether these procedures were being followed as ordered. Interviews with nursing staff and facility leadership revealed inconsistencies in the implementation of respiratory care protocols. Staff acknowledged that tubing was supposed to be changed weekly and as needed, but there was no system in place to date the NC or humidification bottles, and responsibilities for cleaning equipment were not clearly defined. The facility's policy required weekly documentation of tubing changes, but observations and staff statements indicated that these procedures were not consistently carried out, resulting in deficiencies in respiratory care for the residents involved.
Failure in Contracture Management for Residents
Penalty
Summary
The facility failed to ensure that residents with limited range of motion received appropriate treatment and services to prevent further decline in their condition. Specifically, two residents, identified as Resident #3 and Resident #12, did not receive adequate contracture management after being discharged from therapy services. Resident #3, a severely cognitively impaired female with a history of cerebral infarction and hemiplegia, was observed without a splint on her contracted hand, despite having an order for contracture management. Interviews with staff revealed a lack of awareness and implementation of the necessary interventions to manage her condition. Resident #12, a male with moderate cognitive impairment and a history of cerebrovascular accident, was also observed without a splint on his contracted left hand. Despite having a care plan and physician orders for contracture management, staff interviews indicated a lack of knowledge about the resident's therapy history and the presence of a splint. The resident was seen grimacing and unable to open his left hand, suggesting discomfort and potential worsening of his condition. The deficiency was further highlighted by the facility's failure to communicate and implement therapy recommendations effectively. Interviews with the Director of Rehabilitation and other staff members revealed that the responsibility for continuing splint orders post-therapy discharge was not clearly understood or executed. This lack of coordination and follow-through placed the residents at risk for further decline in their range of motion and increased dependency on assistance for activities of daily living.
Pharmaceutical Service Deficiencies in Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by two main deficiencies observed during the survey. Firstly, the facility did not ensure that controlled drugs were counted and documented at every shift change for Med Aid cart 2 west front. Specifically, there were missing signatures for narcotic counts on two separate dates, indicating that the required procedure of counting and signing off on narcotics was not followed. LVN P admitted to counting the narcotics but forgetting to sign the narcotic sheet, which could potentially lead to drug diversion. The Director of Nursing (DON) confirmed the importance of signing the narcotic count sheet to prevent drug diversion and stated that random checks were supposed to be conducted by the DON and Assistant DON. Secondly, the Nurses cart 2 Central contained an insulin pen for a resident with an expired opened date. The resident, a female with severe cognitive impairment and a history of type 2 diabetes mellitus, was administered insulin from this expired pen. LVN K acknowledged using the expired insulin pen and admitted to forgetting to check the open date, which is crucial as insulin loses effectiveness after 28 days. The DON reiterated the necessity of dating insulin pens upon opening to ensure they are used within their effective period. The facility's policy on medication expiration dates was not adhered to, as evidenced by the expired insulin pen being used for the resident.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure that two residents, Resident #8 and Resident #23, received necessary dental services, including routine dental care. Resident #8, a moderately cognitively impaired female, reported experiencing pain and discomfort in two teeth and had requested dental services multiple times over the past year without any action taken by the facility. Despite her complaints, the nursing staff, including RN D and the Social Worker, were unaware of her need for dental care, and no referral had been made for her to see a dentist. Resident #23, also moderately cognitively impaired, expressed difficulty eating due to a lack of teeth and food getting stuck in her teeth. However, she had not communicated these issues to the nursing staff, including CNA H, RN D, and LVN I, who were unaware of her dental needs. The Social Worker confirmed that Resident #23 had not been referred to a dentist in the past year, and her care plan did not address her dental needs. The facility lacked a clear policy or process for managing ancillary services like dental care. The Social Worker, who was responsible for tracking these services, had only recently been hired and was in the process of developing a system to monitor residents' needs. The Director of Nursing and the Administrator were unsure of the frequency with which residents should receive dental care, and the facility did not have a policy in place for routine dental services. This lack of coordination and communication among staff contributed to the failure to provide necessary dental care to the residents.
Deficiency in Food Safety Standards in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its kitchen, as observed during a survey. Specifically, food items such as cut zucchini, cut carrots, cinnamon rolls, and cooked sausages were found uncovered in the walk-in freezer, which could lead to food contamination. Additionally, during a lunch service, the hot holding temperatures for menu items like turnip greens, mashed potatoes, and pureed vegetables were below the required 135°F. The staff member responsible for measuring these temperatures, [NAME] A, initially believed it was acceptable to serve food below 135°F as long as it was in a steaming water bath, but later acknowledged the mistake after consulting with the Dietary Manager. The Dietary Manager confirmed that all foods in the freezer should be covered and that hot foods should be held at temperatures above 135°F to prevent foodborne illnesses. The manager also stated that the cook should have taken corrective actions to ensure the food was at the proper temperature before serving. The facility's policy and the FDA Food Code require that hot foods be served at 135°F or greater, and the failure to comply with these standards could lead to foodborne illness among residents. The Administrator emphasized the importance of following state and federal food safety regulations to prevent such risks.
Infection Control Deficiencies in Linen Storage and Resident Care
Penalty
Summary
The facility failed to maintain a sanitary environment in its clean linen closets, which were observed to contain items that posed a risk of cross-contamination. During an inspection, a cart with a broken bottom shelf was found in the clean linen closet of the secured unit, containing bagged clothes without identification, personal hygiene items, and clean linens. Additionally, a black vest was hanging on the clean linen cart. Staff interviews revealed uncertainty about the cart's presence and acknowledged that non-linen items in the closet could lead to infections. A similar issue was observed in another unit, where a cardboard box with personal items was found near the clean linen cart. The facility also failed to ensure proper hand hygiene during incontinence care for a resident with severe cognitive impairment and total urinary incontinence. During care, a CNA did not perform hand hygiene between glove changes while cleaning the resident, which could lead to cross-contamination. The CNA acknowledged the mistake and stated she was trained to sanitize hands between glove changes. The DON confirmed that staff are expected to sanitize hands when transitioning from dirty to clean tasks to prevent infection spread. The facility's policies on infection control and hand washing were reviewed, indicating that linens should be properly stored and handled to minimize contamination, and that staff must wash hands before and after resident care and after removing gloves. The DON and ADON were identified as responsible for ensuring safe practices to control infection spread, but the observed deficiencies indicate lapses in adherence to these policies.
Failure to Maintain Resident Hygiene and Grooming
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. Two residents, identified as Resident #30 and Resident #48, were observed with long and unclean fingernails. Resident #48, a cognitively intact male with a history of cerebral infarction and muscle weakness, required moderate assistance with personal hygiene. Despite his care plan indicating the need for assistance with ADLs and keeping fingernails cut, his nails were found to be 0.4 cm long, and he expressed discomfort due to their length. He did not report this to staff as he perceived them to be busy. Resident #30, a cognitively moderately impaired male with cerebral infarction and hemiplegia, was dependent on staff for personal hygiene. His care plan required regular checking and trimming of nails. However, his nails were observed to be 0.4 cm long, discolored, and dirty. Staff interviews revealed that both CNAs and nurses were responsible for nail care, but the oversight led to the deficiency. The Director of Nursing acknowledged that nail care should be completed as needed and observed daily, highlighting the risk of infection control issues due to long and dirty nails.
Unsecured Shower Room and Cabinet in Secured Unit
Penalty
Summary
The facility failed to maintain a secure environment in the secured unit's shower room, which was observed to be unlocked on multiple occasions. Inside the unlocked shower room, a cabinet was also found unlocked, containing various personal care products and an opened razor box. These unsecured items posed potential risks to residents, particularly those who might wander into the room and accidentally ingest or misuse the products, leading to possible injuries or falls. Interviews with staff, including a CNA, an LVN, the DON, and the Administrator, revealed a lack of clarity and enforcement regarding the locking of the shower room and cabinet. The CNA and LVN acknowledged the importance of keeping the room locked to prevent accidents, but there was uncertainty about who held the keys to the cabinet. The DON admitted there was no specific policy on accident prevention in the secured unit and could not recall when staff were last trained on safety practices. The Administrator also recognized the risk posed by unlocked doors but confirmed the absence of a formal policy addressing these hazards.
Breach of Resident Privacy Due to Unauthorized Recording
Penalty
Summary
The facility failed to ensure the personal privacy of a resident, leading to a breach of confidentiality. A visitor, who was not an approved volunteer, was allowed to sign in as a volunteer and subsequently recorded a resident during their visit. The visitor then posted the recording on social media, which was discovered by the resident's family. The resident, a female with a severe cognitive impairment as indicated by a BIMS score of 05, was recorded in the dining hall of the memory care unit during interactions with the Activities Assistant and the visitor. The resident's family expressed their anger and concern over the incident, noting that the resident did not remember the event but recalled eating cupcakes. The Director of Nursing (DON) acknowledged the breach of privacy and stated that the facility's policy only covered staff and electronic monitoring, not visitors. The facility's policy on resident rights, dated 2018, affirms the right to privacy, including during visits and personal needs. The DON and the Administrator both agreed that residents should not be recorded without their permission, as it violates their rights. The facility was still investigating how the visitor gained access and why the recording was made.
Resident Verbal Abuse and Unauthorized Recording
Penalty
Summary
The facility failed to protect a resident from verbal abuse and unauthorized recording, which led to a deficiency in ensuring residents' rights to be free from abuse and neglect. A resident, who was severely impaired with a BIMS score of 05, was referred to in a derogatory manner by an Activities Assistant. The assistant called the resident a 'pig' during an interaction that was recorded and posted online by a visitor who was not an approved volunteer. The incident occurred in the dining hall of the memory care unit, where the resident was interacting with a visitor. The Activities Assistant made inappropriate comments about the resident's eating habits and instructed the resident to clean up after herself in a manner that was deemed disrespectful. The visitor, who was allowed to sign in as a volunteer without proper approval, recorded the interaction and shared it on social media, causing embarrassment and a loss of dignity for the resident. The resident's family was upset upon discovering the video online and expressed their concerns to the facility's Director of Nursing (DON) and Administrator. The facility's policy on abuse and resident rights emphasizes the importance of treating residents with dignity and respect, and the incident highlighted a failure to adhere to these standards. The facility did not have a specific policy regarding social media or recording by non-employees, which contributed to the deficiency.
Failure to Report Verbal Mistreatment Incident
Penalty
Summary
The facility failed to report an incident involving verbal mistreatment of a resident by an Activities Assistant within the required timeframe. The incident occurred on Thanksgiving Day when the Activities Assistant spoke rudely to a resident, calling her names and making derogatory comments about her eating habits. This interaction was captured in two videos posted online, which showed the Activities Assistant making inappropriate remarks to the resident in the presence of a visitor. The facility's Director of Nursing (DON) and Administrator were made aware of the incident by the resident's family during the Thanksgiving weekend. The resident involved was an elderly female with a diagnosis of Mood Disorder, Insomnia, Essential Hypertension, and Restlessness and Agitation, and had a severely impaired BIMS score. Despite the facility's policy requiring immediate reporting of such incidents, the Administrator admitted that the incident was not reported to the state, and no reason was provided for this failure. The Activities Assistant was placed on investigatory suspension following the incident, but the lack of timely reporting could place residents at risk of continued abuse or mistreatment.
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Illustrative
What surveyors actually found near you
We read the 1,341 citations issued within 25 miles in the last 12 months — including the 39 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Walnut Place | 0.3 mi | — | 0 | 0 |
| The Legacy Midtown Park | 0.7 mi | ★★★★★ | 4 | 0 |
| Pure Health Transitional Care At Texas Health Pres | 0.8 mi | ★★★★★ | 0 | 0 |
| Presbyterian Village North Special Care Ctr | 1.5 mi | ★★★★★ | 0 | 0 |
| The Highlands Guest Care Center | 1.7 mi | ★★★★★ | 20 | 0 |
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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 August 2026) and official state health department websites.