Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Town Creek during CMS and state inspections, most recent first.
Two male residents with significant cognitive impairments were involved in a resident-to-resident altercation when one resident was observed by an LVN striking another in the face with a closed fist. The LVN immediately separated the residents, notified the DON, NP, and responsible party, and completed a skin assessment that showed no injuries, while both residents were later observed clean, well groomed, and without bruising or skin tears. One resident had autism, severe intellectual disability, and behavioral symptoms such as yelling, while the other had dementia, a psychotic disorder, and severely impaired cognition but no prior documented aggression. Despite facility policies and staff training requiring immediate reporting of suspected abuse to authorities, the DON and ADM decided the incident was not reportable based on their belief that the aggressor’s limited cognition meant he could not willfully act, resulting in a failure to report the alleged abuse as required.
Surveyors found that food items in the kitchen refrigerator and freezer were not consistently labeled or dated, including premade waffles, chicken, fruit cups, ground beef, and ham. Staff interviews confirmed that food should be labeled and dated upon delivery or when opened, but this was not done according to facility policy and federal food codes.
The facility did not establish or maintain a required infection prevention and control program, as observed by surveyors during their review of facility practices.
A resident with a gastrostomy tube and intact cognition was left exposed to the hallway during tube care when the ADON did not pull the privacy curtain or close the door. Staff and the resident confirmed that this lack of privacy caused embarrassment, and facility policy required privacy to be maintained during care.
A resident with significant medical and cognitive needs was left in a room with a broken window frame that was detached from the wall, exposing screws and nails. Staff and department heads failed to notice or report the issue despite daily environmental rounds and established reporting procedures, resulting in the maintenance problem going unaddressed until discovered during a survey.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided according to regulatory standards.
A designated smoking area was found with a fire can containing a plastic liner, cigarette butts, and paper and plastic trash, contrary to facility policy. Staff interviews revealed confusion about responsibility for maintaining the smoking area, and the Maintenance Director was unaware of proper procedures. The facility's policy required metal containers for ash disposal, but this was not followed, resulting in an unsafe smoking environment.
A facility failed to ensure safe and sanitary storage of a resident's food items, as a personal refrigerator contained expired cheese. The resident, with cerebral palsy and mild intellectual disabilities, required assistance with eating. There was confusion among staff about who was responsible for checking food expiration, leading to non-compliance with the facility's policy and potential risk for foodborne illnesses.
A resident with diabetes and chronic ulcers developed facility-acquired wounds due to inadequate care. The facility failed to conduct regular skin assessments and did not provide a bed of appropriate size, leading to the resident's feet pressing against the footboard. Despite staff reporting the issue, the problem persisted, resulting in harm to the resident.
A resident in a facility was not provided with a bed of proper size, leading to discomfort and the development of diabetic ulcers. Despite being 80 inches tall, the resident's feet hung over the edge of the mattress, and the footboard was removed after ulcers developed. Staff acknowledged the bed was too small, but the facility initially failed to provide a suitable alternative, resulting in harm to the resident.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, on four days in June 2024. This occurred due to the departure of the DON and the unavailability of corporate travel nurses, with agency nurses calling in and no replacements provided. The facility's policy required RN services daily, which was not met during these days.
The facility's kitchen failed to maintain sanitary conditions, with the dish machine's sanitizer levels consistently above the manufacturer's guidelines. A scoop was improperly stored in a flour bin, and baking sheets had baked-on buildup. The Dietary Manager and Administrator were unaware of the correct sanitization levels, leading to these deficiencies.
The facility failed to submit complete RN staffing data to CMS for several dates in 2024 due to an oversight in capturing hours for the DON, traveling nurses, and agency nurses. The absence of RN coverage on specific dates was due to the departure of the DON and lack of available corporate RNs.
A resident was administered multiple psychotropic medications without obtaining informed consent, as required by facility policy. The resident, with complex medical conditions, received medications such as mirtazapine, risperidone, and others without documented consent. Facility staff acknowledged the oversight and began an audit to address the issue.
The facility failed to maintain proper infection control practices during care for two residents. A CNA did not change gloves or perform hand hygiene during incontinent care for a resident with hemiplegia, while an LVN used improperly cleaned scissors during ostomy care for another resident. Both staff members were aware of the correct procedures but did not follow them, posing a risk of infection.
The facility failed to implement comprehensive care plans for four residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. This included not providing necessary meal assistance, missing fortified foods, and failing to perform required weekly weight checks.
The facility failed to maintain acceptable nutritional status for 15 residents, including inadequate communication with dietary staff, insufficient monitoring of weight changes, and failure to provide therapeutic meals and necessary assistance during meals. These deficiencies placed residents at risk of severe weight loss, delayed interventions, and worsening health conditions.
A resident with a history of dysphagia choked on every bite of food during breakfast, but the facility failed to notify the physician and responsible party. The resident's diet was downgraded without proper notification, and the resident was observed eating alone and without assistance. Staff interviews revealed that the facility's policy for notifying significant changes was not followed.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed expired and improperly labeled food items in the dry storage area and refrigerator. The Dietary Manager confirmed the oversight, citing staff shortages as a contributing factor. The Administrator emphasized the importance of discarding expired food to prevent foodborne illnesses, in line with the facility's food storage policy.
The facility failed to ensure that licensed nurses had the necessary competencies to care for a resident with dysphagia. After a choking incident, the resident's diet was changed without proper assessment or physician notification. The resident, who required assistance during meals, was observed eating alone and quickly, leading to coughing and potential aspiration risks. Staff interviews revealed that facility policies were not followed, and the necessary evaluations were delayed.
The facility failed to ensure RN coverage for at least eight consecutive hours a day, seven days a week, as required. Specifically, RN coverage was missing on one day in December 2023. The ADON, new to her role, was still learning her responsibilities, which contributed to the oversight. The DON and ADON typically provide coverage themselves if no other RN is available, but this did not occur on the specified day.
The facility failed to ensure proper labeling of an insulin vial for a resident with multiple diagnoses, including dementia and type 2 diabetes. The insulin was found opened and undated, posing a risk of reduced effectiveness in controlling blood sugar levels. The nurse responsible was unaware of the opening date, and the ADON confirmed the labeling should have been done upon first use.
Failure to Timely Report Resident-to-Resident Physical Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged resident-to-resident physical abuse incident to the appropriate authorities as required. On the date in question at approximately 3:38 p.m., an LVN (LVN A) heard someone call out for the nurse, exited a resident’s room, and observed one resident (Resident #2) make contact with another resident (Resident #1) on the cheek with what appeared to be a closed fist. LVN A separated the residents, notified the DON, NP, and responsible party, and completed a skin assessment on Resident #1, which revealed no injuries or alterations in skin integrity. The incident was documented as physical aggression on an incident report. Resident #1 was a male with autistic disorder, muscle wasting and atrophy, diabetes mellitus, and severe intellectual disability. A recent MDS indicated he was rarely or never understood, and he required varying levels of assistance with toileting hygiene, dressing, personal hygiene, eating, oral hygiene, and footwear. His care plan, dated 2/4/26, documented behavioral symptoms related to severe intellectual disability, including self-biting and yelling out when agitated, with interventions such as maintaining a calm environment, using calming techniques and words, and removing him from the area if his behavior interfered with others. Following the incident, Resident #1 was assessed as nonverbal and not appearing emotionally distressed, and later observation showed him clean, well groomed, and without suspicious marks, skin tears, or bruising. Resident #2 was a male with unspecified dementia and a psychotic disorder with delusions due to a known physiological condition. His admission MDS showed severely impaired cognition with a BIMS score of 4 and indicated he required supervision or assistance with eating, oral hygiene, dressing, personal hygiene, toileting hygiene, showering/bathing, and footwear, with no documented physical or behavioral symptoms directed toward others. His care plan, dated 2/4/26, identified risk for impaired social interactions related to mood and psychotic disorders, with interventions including administering medications as ordered and monitoring for side effects and effectiveness. The DON and ADM acknowledged being notified of the altercation and stated they determined it was not reportable to the state because, in their view, Resident #2’s limited cognition meant he could not willfully act. This decision was made despite facility policies stating that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the administrator and other officials according to state law and HHSC reporting guidelines, and despite staff training on abuse and reporting requirements.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen inspection, multiple food items in both the refrigerator and freezer were found to be undated and unlabeled, including premade waffles, precooked and uncooked chicken, breaded squash, fruit cups, ground beef, and ham. Staff interviews confirmed that food should be dated and labeled upon delivery, when opened, or when removed from original containers, but this was not consistently done. The facility's own policy and federal food codes require all food items to be properly labeled and dated to ensure safety and prevent contamination. Staff members, including the dietary manager, cooks, dietitian, and administrator, acknowledged during interviews that the lack of dating and labeling could result in the use of expired or contaminated food, and that proper procedures were not followed. Record review of facility policy and federal regulations further supported the requirement for labeling and dating all food items. No specific residents were identified as being directly affected at the time of the deficiency.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection control measures were not established or maintained as mandated. The report specifically notes the absence of a comprehensive program designed to prevent and control infections within the facility. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
A deficiency occurred when the Assistant Director of Nursing (ADON) failed to provide full privacy to a male resident during gastrostomy tube care. The resident, who had a history of tracheostomy, gastrostomy, cerebral ischemia, muscle wasting, and dysphagia, was observed receiving care with the privacy curtain not pulled and the door to the hallway left open. This allowed the resident to be visible from the hallway while visitors, staff, and other residents passed by. The resident was dependent on staff for gastrostomy tube care and had intact cognition, as indicated by a BIMS score of 14. Interviews with the ADON, a CNA, the Director of Nursing (DON), and the Administrator confirmed that all staff had been trained on the importance of maintaining resident privacy and dignity, and that the privacy curtain should have been used during care. The resident indicated feeling exposed and embarrassed when privacy was not maintained. Facility policy also required that each resident be cared for in a manner that promotes well-being and self-esteem, which was not followed in this instance.
Failure to Repair Broken Window Frame Compromises Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for a resident by not repairing a broken window frame in the resident's room. The window frame was detached from the wall, with exposed screws and nails protruding about half an inch, and this issue was not reported or addressed until it was observed during the survey. Staff members, including CNAs and the social worker, were either unaware of the problem or had not checked the window due to closed blinds or lack of observation. Maintenance records showed no prior request for repair, and the Maintenance Supervisor was not aware of the issue until the day of the survey. The resident affected had multiple medical conditions, including schizoaffective disorder, atherosclerotic heart disease, and polyosteoarthritis, and required substantial assistance with personal hygiene and bed mobility. The facility had procedures in place for staff to report maintenance issues, such as scanning QR codes or reporting during morning meetings, but these were not utilized in this instance. Daily environmental rounds were conducted by department heads, but the deficiency was not identified or communicated, resulting in the resident living in a room with an unrepaired, unsafe window frame.
Inappropriate Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and with resident agreement, as well as deficiencies in the ongoing care and management of residents with feeding tubes.
Failure to Maintain Smoking Area Safety and Enforce Smoking Policy
Penalty
Summary
The facility failed to enforce its smoking policy and maintain smoking safety in one of two designated smoking areas, specifically the secured unit smoking area. During an observation, a red fire can in the smoking area was found to contain a plastic liner, cigarette butts, and paper and plastic trash. Staff interviews revealed uncertainty about who was responsible for maintaining the fire cans, with a CNA stating that everyone was responsible but unsure who placed the liner or trash in the can. The Maintenance Director, who was new to the position, was also unaware of the proper procedures for the fire cans and acknowledged the potential fire hazard. The facility's Resident Smoking Policy required accessible metal containers with self-closing covers for ash disposal, but the observed fire can did not meet these requirements due to the presence of inappropriate materials. The Administrator confirmed that the Maintenance Director was responsible for maintaining the smoking areas, but all staff assisting residents with smoking should ensure proper use of the fire cans. The lack of clear responsibility and adherence to the smoking policy led to improper disposal of trash in the fire can, creating an unsafe smoking environment.
Failure to Ensure Safe Storage of Resident's Food
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of a resident's food items, specifically in the personal refrigerator of a resident with cerebral palsy, mild intellectual disabilities, and GERD. The resident's refrigerator contained a plastic bag of sliced cheese that was not in its original packaging and was dated beyond the facility's policy of disposing of food within five days. The resident, who required supervision or assistance with eating, mentioned that his best friend helped him with food from the refrigerator, but there was a discrepancy in their accounts regarding the preparation of a sandwich using the cheese. The facility's policy required housekeeping and/or nursing staff to clean the refrigerators weekly and discard any non-compliant foods. However, there was confusion among staff about who was responsible for checking the expiration of foods in personal refrigerators. Housekeeping staff believed they were only responsible for cleaning and checking temperatures, while the nursing staff were supposed to check for expired foods. The Director of Nursing and the Administrator were unaware of the expired food in the resident's refrigerator, indicating a lack of communication and adherence to the facility's policy, which could place residents at risk for foodborne illnesses.
Inadequate Care Leads to Wound Development in Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, leading to the development and worsening of two facility-acquired wounds. The resident, a male with a history of type 2 diabetes, end-stage renal disease, and chronic ulcers, was admitted without any pressure injuries. However, the facility did not conduct weekly skin assessments as required, with only two assessments documented over a period of time. This lack of regular monitoring contributed to the resident developing diabetic ulcers on his toes. Additionally, the facility did not provide a bed of appropriate size for the resident, who was 6 feet 8 inches tall. The resident's feet were pressing against the footboard, which was later removed, and a mattress extension was added. Despite these adjustments, the resident's feet were still not adequately supported, leading to discomfort and potential skin breakdown. The staff, including a CNA and an LVN, reported the bed size issue to the administration, but the problem persisted until corrective actions were taken. The facility's failure to adhere to professional standards of practice and the resident's comprehensive care plan resulted in harm to the resident. The lack of timely skin assessments and the inappropriate bed size were significant factors in the development of the resident's wounds. These deficiencies highlight the facility's inability to prevent the development and worsening of pressure injuries, placing residents with limited mobility at risk.
Inadequate Bed Size Leads to Resident Harm
Penalty
Summary
The facility failed to provide a resident with a bed of proper size and height, which was necessary for the resident's safety and comfort. The resident, who was 80 inches tall, had been admitted with diagnoses including end-stage renal disease and chronic diabetic ulcers on both feet. Upon admission, the resident informed the staff that the bed was too small and uncomfortable, as his feet pressed against the footboard. Despite this, the facility did not initially provide a suitable bed, leading to the resident's feet hanging over the edge of the mattress and resting on a mattress extension. Interviews with staff revealed that the resident's bed was indeed too small, and the footboard had been removed after the resident developed diabetic ulcers on his feet. The Licensed Vocational Nurse (LVN) reported the issue to the Administrator (ADM), Director of Nursing (DON), and Assistant Director of Nursing (ADON), but was told that the bed was the largest available. The DON acknowledged that a mattress extension had been ordered upon the resident's admission but was misplaced, necessitating a reorder. The ADM confirmed the bed's length was measured and deemed sufficient, but the resident's mobility caused him to slide down, exacerbating the issue. The facility's policy on bed safety required the interdisciplinary team to assess the resident's sleeping environment, considering factors such as safety, medical conditions, and comfort. However, the failure to provide a bed of appropriate size resulted in harm to the resident, as evidenced by the development of diabetic ulcers on January 9, 2025. The facility's actions and inactions in addressing the resident's needs led to this deficiency, as the resident's comfort and safety were compromised due to inadequate bed accommodations.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified for four days in June 2024, specifically on the 15th, 16th, 29th, and 30th. During this period, the facility did not have any RN coverage due to the departure of the Director of Nurses (DON) and the unavailability of corporate travel nurses. The facility relied on agency registered nursing staff to meet the required coverage, but on these occasions, the scheduled nurses called in prior to their shifts, and the staffing agency did not provide replacements. Interviews with the facility's Administrator and the corporate compliance officer confirmed the lack of RN coverage on the specified dates. The Administrator, who had been employed since August 2023, acknowledged the absence of RN staff during the reporting period and noted that the DON was the only RN on staff at that time. The corporate compliance officer corroborated that there was no RN employed by the facility on those dates, and corporate RNs were unavailable. The facility's policy, dated September 28, 2023, stated the requirement for RN services for at least eight consecutive hours daily, seven days a week, which was not met during the identified days.
Sanitation and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. The dish machine's chemical sanitizer was not maintained at the appropriate levels according to the manufacturer's guidelines. The dish machine was consistently operating with a sanitizer concentration between 100-200 ppm, whereas the manufacturer's label required a minimum of 50 ppm. This discrepancy was noted throughout September 2024, and the kitchen staff, including the Dietary Manager (DM), were aware of the issue but did not take corrective action until the surveyor's visit. Additionally, the facility did not ensure proper storage of kitchen utensils. During an observation, a scoop was found inside a bin containing flour, contrary to the facility's policy that required scoops to be stored in a protected area. The DM acknowledged this oversight and stated that all kitchen staff were responsible for ensuring proper storage of utensils. Furthermore, the facility had baking sheets with brown and black baked-on buildup, indicating inadequate cleaning practices. Interviews with the DM and the Administrator revealed a lack of understanding regarding the correct sanitization levels for the dish machine. The DM admitted to being unsure of the potential risks to residents from high sanitizer levels, and the Administrator believed the sanitization levels were within acceptable limits. The facility's policies and the Food and Drug Code require accurate testing and maintenance of sanitizing solutions to prevent foodborne illnesses, but these were not adhered to, leading to the identified deficiencies.
Incomplete RN Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the third quarter of fiscal year 2024. Specifically, the facility did not report RN hours for several dates in April, May, and June 2024. Although the monthly staffing schedules indicated that an RN was scheduled for most of these days, the time sheets provided proof of RN coverage for all dates except June 15, 16, 29, and 30. During this period, the facility lacked RN coverage due to the departure of the Director of Nurses and the absence of other RNs on staff. The corporate office was responsible for reporting the hours, but the hours of the DON, traveling corporate nurses, and agency nurses were not reflected in the payroll system, leading to incomplete reporting. Interviews with the facility's Administrator, corporate compliance officer, and corporate director of data analysis revealed that the oversight occurred because the hours were assessed through the payroll system, which did not capture hours for the DON, traveling nurses, or agency nurses. The Administrator admitted that the hours were not reviewed before submission to ensure accuracy. The corporate compliance officer confirmed that there was no RN employed by the facility on the dates without RN coverage, and the corporate RNs were unavailable. The corporate director of data analysis acknowledged that the omission of hours was an oversight and that a new system has since been implemented to ensure accurate reporting.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident in advance of the risks and benefits of proposed care and treatment related to psychotropic medications. Specifically, the facility did not obtain signed consent for several psychotropic medications administered to the resident, including mirtazapine, risperidone, trazodone, Depakote, clonazepam, and Zyprexa. This oversight was identified during a review of the resident's records, which showed no consents for these medications. The resident, who was admitted to the facility with diagnoses including manic episodes, senile degeneration of the brain, alcohol abuse with alcohol-induced psychotic disorder, anxiety, and dementia, was receiving multiple psychotropic medications. The facility's records indicated that the resident was rarely or never understood, and during a specific period, she was administered antipsychotic, antianxiety, and antidepressant medications. Despite these treatments, there was no documentation of informed consent for the medications in the resident's electronic health record. Interviews with facility staff revealed that a previous Travel DON was responsible for ensuring consents were obtained, but this was not done for the resident in question. The current ADON and Travel DON acknowledged the lack of consents and stated that they had begun an audit to address this issue. The facility's policy required consent to be obtained before administering psychotropic medications, but this was not adhered to in this case, leading to the deficiency.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and equipment cleaning practices observed during care for two residents. Resident #14, a male with hemiplegia and moderately impaired cognition, was provided incontinent care by two CNAs. During the care, CNA B did not change gloves or perform hand hygiene before applying a clean brief and barrier cream, which could lead to cross-contamination and infection. Resident #25, also a male with hemiplegia and moderately impaired cognition, received ostomy care from an LVN. During the procedure, the LVN dropped scissors on the floor, rinsed them under cold water, and continued to use them without proper disinfection. This action violated infection control protocols and posed a risk of infection to the resident. Interviews with the staff involved revealed that both CNA B and LVN A were aware of the correct procedures but failed to follow them. The facility's infection preventionist and DON acknowledged the deficiencies and noted ongoing efforts to retrain staff due to recent management turnover. The facility's policies on hand hygiene and equipment cleaning were not adhered to during these incidents.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for four residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #15, an elderly male with severe cognitive impairment and dysphagia, was observed eating without the necessary physical assistance and verbal cueing, despite his care plan indicating the need for such support. This lack of assistance led to the resident eating quickly, taking large bites, and occasionally coughing, which could pose a risk of choking or aspiration. Resident #25, an elderly female with severe cognitive impairment, was not provided with the fortified foods required by her therapeutic diet during a lunch meal. This oversight occurred despite her care plan indicating the need for fortified foods due to significant weight loss. Similarly, Resident #24, who required supervision and one-person assistance with meals, was observed eating alone without any staff assistance or supervision. Additionally, Resident #24's care plan included weekly weight checks, which were not consistently performed, missing weights on two specified weeks. Resident #33, an elderly male with dementia and dysphagia, also had a care plan that required weekly weight checks due to significant weight loss. However, the facility failed to perform these weight checks on two specified weeks. These failures in implementing care plan interventions could place residents at risk of not receiving the necessary care to meet their identified needs, particularly in terms of nutrition and safety during meals.
Failure to Maintain Nutritional Status and Dietary Management
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for 15 of 34 residents reviewed for weight loss and nutrition. The deficiencies included a lack of communication with dietary staff on dietary changes, inadequate systems to monitor weight changes, and failure to weigh residents according to physician orders and dietary recommendations. Additionally, the facility did not provide assistance and supervision with meals as indicated by resident care plans, nor did it provide therapeutic meals as ordered by physicians and dietary recommendations. The facility also failed to obtain updated baseline weights after replacing the facility scale until state surveyor intervention. For instance, Resident #33, who had diagnoses including unspecified dementia and dysphagia, experienced significant weight fluctuations and was not weighed weekly as ordered. Observations revealed that Resident #33 received incorrect meal portions, contrary to his dietary requirements. Similarly, Resident #13, who had moderately impaired cognition, did not receive the large portions indicated on his tray card, and Resident #18, with moderate cognitive impairment, did not receive the large portions or fortified foods as ordered. Other residents, such as Resident #24, who had a cognitive communication deficit, were observed eating without the necessary supervision or assistance, leading to potential risks. Resident #25, with severe cognitive impairment, did not receive fortified foods as required, and Resident #34 was served the wrong meal tray, posing a risk of allergic reactions or choking. These failures in dietary management and monitoring placed all residents at risk of severe weight loss, delayed interventions, hospitalization, worsening health conditions, and death.
Failure to Notify Physician and Responsible Party of Choking Incident
Penalty
Summary
The facility failed to notify the resident's physician and responsible party when there was a significant change in the physical status of a resident who experienced a choking incident. The resident, who had a history of dysphagia and was at risk for aspiration, choked on every bite of food during breakfast. Despite this, there was no documentation that the resident's primary care provider or responsible party was notified of the incident. The resident's diet was downgraded to pureed with thickened liquids without proper notification to the physician or responsible party. During observations, the resident was seen eating alone and without assistance, despite requiring substantial help with eating. The resident was observed eating quickly, taking large bites, and occasionally coughing when swallowing. Interviews with staff revealed that the nurse who downgraded the resident's diet was an agency nurse unfamiliar with the resident's history. The MDS coordinator and other staff acknowledged that the physician should have been notified immediately, and the incident should have been documented. The facility's policy required prompt notification of the resident's physician and responsible party in the event of significant changes in the resident's condition. However, this policy was not followed, leading to a delay in appropriate medical intervention. The failure to notify the physician and responsible party of the resident's choking incident could have resulted in improper and untimely treatment for the resident.
Failure to Properly Store and Discard Expired Food
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. During an observation in the dry storage area, several food items were found to be expired or improperly labeled, including white frosting, bread pudding, yellow cake mix, pasta, grits, thickened coffee packets, soy sauce, and flour. Additionally, the refrigerator contained expired items such as yogurt, prune juice, strawberry topping, and an employee's energy drink. The Dietary Manager (DM) confirmed that these items were not discarded by their expiration dates and acknowledged that consuming expired foods could put residents at risk of foodborne illnesses. The DM also mentioned that the responsibility for checking the fridge, freezer, and dry storage for expired foods was shared among the dietary staff, but due to being short-staffed, these checks were not performed as frequently as required. The Administrator, who had been working at the facility for about eight months, stated that it was the DM's responsibility to ensure all expired food was removed from the kitchen. The facility's policy on food storage, dated 2018, mandates that all food served must be of good quality and safe for consumption, with specific guidelines for labeling and dating opened and bulk items in both dry storage and refrigerators. The policy also requires that leftovers be used within 72 hours and discarded if older. The failure to adhere to these policies and procedures resulted in the presence of expired and improperly stored food items, posing a risk of foodborne illness to the residents.
Failure to Ensure Competent Nursing Care for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for the residents' needs, as identified through resident assessments and described in the care plan. This deficiency was observed in the case of a resident who experienced a choking incident. The MDS coordinator changed the resident's diet from mechanical soft to dysphagia pureed with thickened liquids without performing an assessment or notifying the physician, which could place the resident at risk of not receiving appropriate care and result in deterioration in condition. The resident, an elderly male with diagnoses including unspecified dementia, dysphagia, cognitive communication deficit, and gastro-esophageal reflux disease, had a history of eating too fast and requiring staff assistance during meals. Despite this, the resident was observed eating alone and without assistance on multiple occasions following the diet change. The resident was seen eating quickly, taking large bites of pureed food, and occasionally coughing when swallowing, indicating that the necessary supervision and assistance were not provided. Interviews with facility staff revealed that the nurse who downgraded the resident's diet was an agency nurse unfamiliar with the resident's needs. The MDS coordinator and other staff members acknowledged that the physician should have been notified and that the nurse's progress note exaggerated the choking incident. The speech therapist, who was supposed to evaluate the resident, had not done so due to scheduling conflicts. The facility's policies on changes in a resident's condition and dysphagia management were not followed, leading to a lack of appropriate care for the resident.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Specifically, the facility did not have RN coverage for one day in December 2023. This deficiency was identified through a review of the CMS Payroll Based Journal (PBJ) report for the fourth quarter of 2023, which indicated missing RN hours on several dates in October, November, and December 2023. The monthly staffing schedules and time sheets confirmed that RN coverage was missing on 12/17/2023. Interviews with the Administrator, Assistant Director of Nursing (ADON), and Director of Nursing (DON) revealed that the ADON was new to her role in December 2023 and was still learning her responsibilities, which contributed to the oversight in scheduling RN coverage for that day. The DON and ADON stated that they typically provide RN coverage themselves if no other RN is available, but this did not occur on 12/17/2023. The facility's policy, dated 9/28/23, mandates the utilization of a registered nurse for at least eight consecutive hours a day, seven days a week. Despite this policy, the facility failed to adhere to it on multiple occasions, with the most notable lapse occurring on 12/17/2023. The Administrator, who had been employed since August 2023, expected RN coverage to be maintained as per the policy. However, the ADON's inexperience and the lack of a scheduled RN on 12/17/2023 led to a failure in providing the required RN coverage, potentially placing residents at risk due to the absence of supervisory RN-specific nursing activities and coordination of emergency care and disasters.
Failure to Properly Label Insulin Vial
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding the labeling of an insulin vial for a resident. During a medication cart observation, a vial of Levemir insulin was found opened and not labeled with an open date. The nurse responsible for the cart was unaware of when the insulin had been opened and admitted that it must have been missed during daily checks. The Assistant Director of Nursing (ADON) confirmed that the insulin should have been dated by the nurse who opened it and acknowledged the potential risks of administering expired insulin, including reduced effectiveness in controlling blood sugar levels. The resident involved was an elderly individual with multiple diagnoses, including dementia, schizoaffective disorder, bipolar type, type 2 diabetes, and GERD. The resident had a moderately impaired cognition with a BIMS score of 12 and had been receiving insulin injections daily. The facility's policies on medication storage and administration were reviewed, and it was found that the insulin should have been dated upon first use. Interviews with the Regional Nurse and the Administrator further confirmed that the responsibility for dating the insulin lay with the nurse who opened it, and that the failure to do so could result in the medication not being as effective.
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 14 citations issued within 25 miles in the last 12 months — 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 Palestine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy At Town Creek | 1.7 mi | ★★★★★ | 2 | 0 |
| Trucare Living Centers | 2.9 mi | ★★★★★ | 3 | 0 |
| Greenbrier Nursing & Rehabilitation Center Of Pale | 5.1 mi | ★★★★★ | 8 | 0 |
| Avir At Elkhart | 9.7 mi | ★★★★★ | 1 | 0 |
| Fairview Healthcare Residence | 27.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Town Creek.
100% money-back within 48 hours.
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.