Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Veterans Memorial during CMS and state inspections, most recent first.
Ineffective pest control program with roach activity in resident rooms and common areas. Surveyors observed a live roach in one room and a dead roach in another, while records showed repeated treatments for German roaches across the kitchen, hallways, offices, laundry, therapy room, dining room, medication room, and multiple resident rooms. The pest log also documented dead and live roaches, sanitation issues, damaged baseboards, and other conditions associated with ongoing infestation.
A facility failed to protect two residents from abuse by the same CNA. One resident with severe dementia was captured on video being pulled on during care and then struck on the hand after swatting at the CNA, while a second resident with intact cognition reported the CNA was rough during ADLs, lowered the bed in a way that caused pain, left her in distress, and was witnessed pulling on her legs during care.
A resident with severe cognitive impairment and multiple mobility-related diagnoses was observed with a painful, bruised, and misaligned lower extremity. Nursing staff called the provider for a STAT x-ray instead of immediately transferring the resident by EMS, and the x-ray later showed displaced tibia and fibula fractures. The resident was not sent to the ER until several hours later, after ongoing pain and abnormal findings were documented.
A resident with severe dementia and a left tibia/fibula fracture had pain signs documented throughout the day, including grimacing, clenched fists, pulling away, and saying “ouch” during turning and incontinent care. Staff noted the leg was discolored, warm, painful, and out of alignment, but the resident remained in the facility for hours before x-ray confirmed displaced fractures and she was later transferred to the hospital. The provider stated the delay was too long for a displaced fracture and that the resident would have been in a high level of pain.
Failure to Maintain Resident Dignity and Respect: A resident with depression and moderate cognitive impairment was unable to watch the TV channels she preferred because staff did not promptly address the programming issue after repeated requests. Another resident with vascular dementia and severe cognitive impairment had a training mannequin stored in the unoccupied bed of his room for about two weeks, and he reported that staff laughed when he asked for it to be removed.
Incomplete Care Plans for ADLs and UTI/Isolation Needs: The facility failed to develop comprehensive person-centered care plans for three residents. One resident with cognitive impairment and extensive ADL assistance needs had no care plan focus, goals, or interventions for bathing, dressing, toileting, transfers, hygiene, or bed mobility. Two other residents had UTI-related diagnoses and were on contact isolation, but their care plans did not address the UTI, isolation status, or antibiotics, despite MDS triggers, physician orders, and resident interviews confirming the conditions.
A resident with dehydration, AKI, and hypokalemia had an IV left in the L hand after IV fluids were held, but the site was not flushed as expected and remained in place despite the MD’s verbal direction to remove it. The resident reported tenderness, and surveyors observed redness, dried blood, and discoloration under the dressing. Staff interviews confirmed the IV should have been checked daily, flushed when not running, and removed when no longer needed, but this did not occur.
Expired medications were found in multiple medication carts and in the medication storage room refrigerator, including glucose strips, calamine lotion, sodium chloride tablets, bisacodyl suppositories, saline nasal spray, eye drops, and insulin lispro. Staff said cart checks were expected each shift, but this did not always happen, and one med aide reported checking her cart only monthly. The DON stated opened eye drops, nose sprays, and insulin were only good for 30 days after opening, and the facility policy required outdated medications to be removed from storage.
A resident admitted with multiple diagnoses, including dementia, CKD, afib, and a right lower leg fracture, had no code status documented on the face sheet, baseline care plan, or physician orders during the chart review period. Although the care plan noted a full code preference, staff interviews showed inconsistent methods for locating code status, the code cart lacked a code book, and the DON stated the admission nurse likely forgot to enter the order, which could delay care if the resident became unresponsive.
Failure to maintain a clean resident room environment: A resident with COPD, Crohn's disease, hemorrhoids, constipation, bowel and bladder incontinence, and moderate cognitive impairment had BM smears in his room, including a thick brown smudge on the wall, stained linens, a strong BM odor, and flies observed in the room. Staff interviews indicated he needed follow-up toileting assistance and that he sometimes smeared BM around his side of the room, while the wall smudge remained in place for several days.
Failure to complete a new PASRR review after a resident developed additional psychiatric diagnoses. A resident with severe cognitive impairment, total ADL dependence, and ongoing psych services had a prior PASRR Level 1 that was negative for MI, ID, DD, or dementia as the primary diagnosis. The record later showed recurrent MDD, GAD, mood disorder with mixed features, and adjustment disorder, with orders for antidepressants, anxiolytic medication, Depakote, and behavior/side effect monitoring. The MDS Coordinator said she did not submit a new PE because she believed the resident would not qualify.
A resident with moderately impaired cognition, incontinence, and ADL dependence did not receive scheduled bathing assistance as ordered. She was supposed to be showered three times weekly, but the last documented bath was over a week earlier, and she told staff she had gone nearly two weeks without a shower. A CNA said showers were documented in the POC and that staffing assignments sometimes prevented her from completing them, while the DON said residents were expected to receive their scheduled showers and whenever needed.
Delayed STAT Chest X-Ray: An LPN notified the on-call NP after a resident with COPD and oxygen use reported chest pain, and a STAT CXR was ordered. The resident was told the x-ray would be done that night, but it was not completed until the next day. Staff gave inconsistent accounts of the expected STAT timeframe, and the physician/NP was not notified when the test was not completed during the overnight shift.
Improper Food Storage and Kitchen Door Left Open: The kitchen refrigerator contained an open bag of shredded lettuce that was brown with liquid at the bottom and an unopened bag of mozzarella cheese, both lacking a clear use-by/discard date. Dietary Staff A also propped open the kitchen door while taking out trash, allowing two flies into the kitchen despite a posted sign to keep the door closed. The FSD, DON, and Administrator stated that food should be labeled and discarded by the use-by date and that the kitchen door should remain closed to keep pests out.
Two residents with significant cognitive impairment and high assistance needs had nonfunctioning call lights in their rooms. One resident reported pressing the call light for repositioning without receiving help, and testing confirmed that the bedside and hallway indicators did not activate in either room. Staff, including an LPN, CNA, EVS Director, DON, and Administrator, acknowledged that residents should have functioning call lights, while records showed no outstanding repair requests and only selected rooms were included in routine call system testing.
A resident with severe cognitive impairment and total dependence for transfers was injured when a CNA attempted a mechanical lift transfer alone, without the required second staff member. The sling failed during the process, causing the resident to fall and sustain head lacerations that required medical treatment. The CNA did not follow facility policy mandating two-person assistance and proper equipment inspection prior to transfer.
A resident with a PICC line for IV antibiotics did not have the dressing changed as required after returning from the hospital. Nursing staff failed to obtain or follow orders for weekly dressing changes, and the outdated dressing remained in place until the resident was readmitted to the hospital with a fever. Staff interviews confirmed that the facility's protocol for PICC line care was not followed.
Several residents with complex medical and psychological needs reported being treated disrespectfully and without dignity by a CNA, including feeling threatened, spoken to in a rude or abrupt manner, and being treated like a child. Staff interviews and resident feedback confirmed that the CNA's approach and communication did not honor residents' rights or emotional well-being, leading to a deficiency in upholding resident dignity.
A resident with multiple comorbidities and an indwelling urinary catheter did not have a comprehensive care plan that addressed catheter care, despite physician orders and baseline documentation indicating its presence and required interventions. The omission was confirmed by interviews with the DON and MDS Nurse, who acknowledged that the catheter care was not included in the comprehensive care plan, potentially leaving staff uninformed about necessary care procedures.
The facility failed to store, label, and date foods properly, and did not maintain correct food temperatures on the service line. Unsealed and unlabeled food items were found in storage, and a thermometer used to check food temperature was not calibrated correctly. The Dietary Manager and Aide were unaware of the calibration issue, and the facility did not provide the requested policy and training records.
A medication cart in the facility was found with loose, unlabeled pills and an expired bottle of Thick It thickened water, contrary to professional principles. LVN M, responsible for the cart, acknowledged the oversight, while the DON emphasized the expectation for regular cleaning and organization of medication carts. The facility's policy requires proper labeling and disposal of outdated drugs, which was not followed, risking incorrect medication administration.
A facility failed to maintain accurate medical records for a resident who was hospitalized, with LVNs documenting medication administration and monitoring while the resident was not present. The resident had severe cognitive impairment and multiple medical conditions. The MAR inaccurately showed medications and monitoring as completed during shifts when the resident was at the hospital, violating the facility's documentation policies.
Ineffective Pest Control Program With Roach Activity in Resident Rooms
Penalty
Summary
The facility failed to maintain an effective pest control program, and surveyors observed roach activity in multiple resident rooms and common areas. Record review showed repeated pest control treatments over several months for roaches, gnats, ants, spiders, and rodents, including treatments in the kitchen, hallways, offices, laundry room, therapy room, dining room, medication room, and numerous resident rooms. Despite these repeated services, the records continued to document live and dead German cockroaches, including activity in rooms 102 and 305, as well as other rooms throughout the facility. The pest control log also documented ongoing infestation concerns and contributing conditions. Entries noted roach activity behind the microwave in the kitchen, dead roaches around beds, activity inside a resident phone, harborages inside nightstands and a damaged wall void, and major sanitation issues in one room that were described as directly attracting and supporting roach activity. Additional notes identified loose or damaged baseboards, corner walls, toilet seals needing repair, and a toilet that was not properly fixed, all of which were recorded in connection with pest concerns. On 5/21/2026, the surveyor and the Director of Environmental Service observed a live roach in one room and a dead roach in another while checking rooms on each hall for roach activity. The Environmental Service Director stated the facility had monthly pest control service and that he was responsible for ensuring effective pest control. The Administrator stated staff were responsible for ensuring pest control concerns were logged and communicated, and she acknowledged the risk to residents as possible germs. The facility policy stated that the facility shall maintain an effective pest control program.
Abuse and Rough ADL Care by CNA
Penalty
Summary
The facility failed to ensure residents were free from abuse for 2 of 7 residents reviewed for abuse. One resident, an older female with Alzheimer’s disease and a BIMS score of 3 indicating severe impairment in thinking and memory, was resistive to ADL care and often refused showers. Her care plan directed staff to allow her to make decisions about ADL care, encourage participation, explain care clearly, and return later if she resisted care. During a family interview, the resident’s family member reported placing a surveillance camera in the room after concerns that the resident was repeatedly left in the same clothing and with a soiled brief. The family member stated the video showed a CNA pulling on the resident, the resident telling the CNA to stop, the resident swatting at the CNA, and the CNA hitting the resident on the hand while trying to get her up from bed. The video review confirmed the family member’s account: the resident swatted at the CNA in an attempt to make her stop pulling on her, and the CNA hit the resident on her right hand while the resident was lying on her side. The CNA then told the resident not to do that and said she was trying to help her sit up. When interviewed, the resident denied being hit and stated her aide was nice. The DON stated she was informed of the allegation, completed an assessment, notified the administrator, physician, and police, and suspended the CNA pending investigation. The CNA later stated she had gone in to wake the resident for breakfast, tried to get her up by grabbing her shoulders, and admitted she tapped the resident’s hand back after the resident tapped her hand. A second resident, who had intact cognition with a BIMS score of 13, reported that the same CNA was rough during ADL care. The resident stated the CNA lowered the bed all the way, causing pressure and pain in her legs and back, and on some occasions left the room after saying she would return with a gown but did not come back, leaving the resident in pain and crying. The resident also stated she did not report the behavior earlier because she did not want to get anyone in trouble or face retaliation. A roommate stated she witnessed the CNA pull on the resident’s legs during care while the resident said it hurt. Another staff member documented that the resident said the CNA was rough with her during ADLs and that the CNA told her she could do a lot for herself when she asked for help moving items on her bedside table. The CNA denied treating residents badly and denied the specific allegations.
Delayed EMS Transfer for Suspected Fracture
Penalty
Summary
The facility failed to transfer a resident to the hospital by emergency services after she was observed with pain, bruising, and an extremity that was out of normal alignment. The resident had severe cognitive impairment, was dependent for all ADLs, and had diagnoses including dementia, lack of coordination, unsteadiness on feet, muscle weakness, osteoarthritis, malnutrition, and sarcopenia. Her care plan included prior falls and a left tibia fracture requiring splinting. On the day of the event, a nurse documented that the resident’s left lower extremity was discolored, warm to touch, painful when touched, and out of normal alignment. The nurse called the provider, who ordered a STAT x-ray. The x-ray later showed displaced fractures of the mid tibia and fibula. Later nursing notes documented continued pain, discoloration, warmth, a temperature of 100.4 degrees Fahrenheit, and a heart rate of 109. After the x-ray results were reported to the provider, the resident was ordered to be sent to the ER, and 911 was eventually called. The resident was transferred to the hospital several hours after the abnormal limb findings were first observed. Hospital records documented bruising, edema, and a tibio-fibular fracture, and the resident was treated with splinting and fentanyl before admission. Interviews with nursing staff, the NP, ADON, and DON reflected that visible trauma, suspected fracture, or a limb that was not symmetrical would warrant immediate transfer to the hospital by EMS, and that the delay in transfer resulted in delayed treatment.
Pain Not Managed for Resident With Displaced Leg Fracture
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with severe cognitive impairment who had a left tibia and fibula fracture. The resident’s record showed a BIMS score of 3 out of 15, dependence for all ADLs, and chronic diagnoses including dementia, weakness, osteoarthritis, malnutrition, and sarcopenia. Her care plan included pain medication therapy and specific interventions for the left tibia fracture, including monitoring and documenting pain and repositioning as necessary. On 3/29/26, staff identified bruising, swelling, discoloration, warmth, and an extremity that appeared out of normal alignment/misaligned. A CNA reported that when the resident was repositioned around 11:00 a.m., she said “ouch” each time she was turned or provided incontinent care, and the CNA continued to report pain with movement throughout the day. An SBAR at 12:30 p.m. documented grimacing, clenched fists, knees pulled up, pulling or pushing away, striking out, and that the resident was repositioned every 2 hours. A nurse note documented the left lower extremity as discolored, warm to touch, painful, and out of normal alignment, with a timeline showing calls to the provider, notification of the DON and house supervisor, and a delay before x-ray was completed. The x-ray completed that afternoon showed displaced fractures of the mid tibia and fibula. Later that evening, the resident remained painful to touch, hot, and discolored, with a temperature of 100.4 and heart rate of 109. She received scheduled tramadol earlier in the day and PRN Tylenol at 7:37 p.m., and was transferred to the hospital at 8:55 p.m. The provider later stated that the resident would have been experiencing a high level of pain and that 9 hours was too long to wait with a displaced fracture, and facility leadership stated that visible trauma and an injury that could not be managed in house warranted 911 transfer.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that Resident #4 was treated with respect and dignity when her television was not programmed to view all of the channels she wanted to watch. Resident #4 was a woman with diagnoses including generalized anxiety disorder, mood disorder with depressive features, and moderate major depressive disorder. Her care plan identified that she enjoyed watching TV and that she was at risk for poor mood stability, increased depression, and poor quality of life. During observation and interview, she stated that storms caused her TV channels to stop working and that she had asked staff multiple times to fix the problem. She reported that she could not get channels 2, 13, 11, and the game channel, and that staff told her it might take a while because there were visitors in the building. She also stated that staff could do everything for everybody else but not tend to her TV. Further observation showed that Resident #4’s TV was skipping channels and displaying a black and white pixelated screen when those channels were selected directly. A CNA stated that Resident #4 had mentioned the problem but that she did not tell maintenance or the nurse because she was busy. The EVS Director later stated that the channels had probably been knocked off that day and needed to be rescanned, and he was observed resetting the TV. The record also showed that Resident #4 had a BIMS score of 12, indicating moderate cognitive impairment. The facility also failed to ensure that Resident #43 was treated with dignity when a training mannequin was stored in the unoccupied bed of his room. Resident #43 was a male with vascular dementia and severe cognitive impairment, with a BIMS score of 07. His care plan directed staff to use simple communication, consistent routines, and cues to support his needs. On observation, the mannequin was found in the unoccupied bed of the room occupied by Resident #43. Staff members stated that training supplies should not be stored in a resident-occupied room and that the mannequin was usually kept in the DON’s office or an empty room. Resident #43 stated that the mannequin had been in his room for two weeks, that he had asked multiple times for it to be removed, and that staff laughed at him when he asked. He said it felt like a cruel joke and that the facility was his home and he should be treated with dignity and respect.
Incomplete Care Plans for ADLs and UTI/Isolation Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents to address their identified needs. Resident #3, a female admitted with left vertebral artery occlusion and stenosis, had a Quarterly MDS showing moderate cognitive impairment and dependence or assistance needs for bathing, bed mobility, dressing, personal hygiene, toilet use, and transfers, but her undated care plan did not include a focus, goal, or interventions for ADLs. During interview, she stated she could stand with little assistance and usually had one aide present when she needed help with transfers, repositioning, toileting, and hygiene. Resident #9, a cognitively intact female admitted with a wedge compression fracture of the second lumbar vertebra, had a Quarterly MDS that triggered for UTI as an active diagnosis. Her care plan dated 04/01/2026 did not address UTI or contact isolation. During interview, she stated she was on contact isolation for a UTI, had started antibiotics on 4/14/26, and expected to complete them on 4/17/26. She also reported having issues with UTI prior to admission. Resident #12, a female admitted with metabolic encephalopathy, hypertension, cirrhosis, heart failure, chronic kidney disease, acute cystitis with hematuria, and asthma, had an admission MDS showing moderately impaired cognition and that she was always incontinent of bowel and bladder. Her care plan dated 1/13/26 did not mention her UTI, contact isolation, or antibiotics. Physician orders dated 4/1/26 included contact isolation for VRE/UTI and recollection of UA C&S 48 hours after antibiotics were completed. Progress notes documented completion of Macrobid for VRE UTI and a pending follow-up urine culture, while interviews and observations showed she remained on contact isolation.
Failure to Manage an IV Site Consistent With Orders and Standards
Penalty
Summary
Safe, appropriate administration of IV fluids was not provided for one resident with COPD, anxiety, morbid obesity, PTSD, mood disorder, depression, impaired mobility, incontinence, and altered respiratory status related to sleep apnea. The resident had an IV in the left hand for hydration and electrolyte management after being treated for acute kidney injury, dehydration, and hypokalemia. Physician orders and NMAR documentation showed IV normal saline flushes were ordered, then later held and discontinued while oral fluid intake was encouraged, but the IV remained in place after the order was no longer active. During observation, the resident reported the IV had been changed but had not been flushed since that time and stated the site was tender. The IV was observed in the left hand under a transparent dressing with visible dried blood beneath the dressing, redness at the insertion site, and yellow discoloration of the surrounding skin. The resident also stated the IV had not been changed or flushed since the prior week. Later observation showed gauze and paper tape where the IV had been removed. Staff interviews showed the IV was expected to be checked daily, flushed when not running, and removed when no longer needed, but this did not occur. An LVN stated IVs should be assessed for date, redness, swelling, and infiltration, and that flushing should occur daily. The MD stated she had verbally told RN G to remove the IV, but this was not documented in the progress note, and she did not know the IV had not been flushed since 4/10/26. RN G stated she forgot to remove the IV despite being told to do so and believed she had flushed it, but she did not document it and could not recall updating the NMAR.
Expired Medications Stored in Medication Carts and Refrigerator
Penalty
Summary
The facility failed to ensure expired medications were not stored with current medications in the 100 hall nurse medication cart, the 200 hall nurse medication cart, the 200 hall med aide medication cart, and the medication storage room. During observation, surveyors found expired Glucose Control Strips, Calamine Lotion, Sodium Chloride Tablets, and Bisacodyl Suppositories in the 100 hall nurse cart; an expired Saline Nasal Spray in the 200 hall nurse cart; and 10 bottles of expired eye drops on the 200 hall med aide cart. In interview, the LVNs and med aide stated they were expected to check carts for expired medications, but this did not always happen, and the med aide reported checking her cart only once a month. Surveyors also found an expired bottle of Insulin Lispro 100u/ml in the medication storage room refrigerator. The insulin had been opened on 2/8/26 and expired on 3/8/26. The DON stated staff were expected to check carts at the beginning of each shift and the medication storage room daily, and that opened eye drops, nose sprays, and insulin were only good for 30 days after opening because bacteria could get inside and they could be less effective. The facility policy stated nursing staff were responsible for maintaining medication storage areas and that outdated medications should be handled through the dispensing pharmacy, and opened multi-dose vials were to be dated and discarded within 28 days unless otherwise specified.
Missing Code Status Documentation
Penalty
Summary
The facility failed to ensure that Resident #80 had a code status on file from admission through the date the record was reviewed. Resident #80 was an [AGE]-year-old female admitted with diagnoses including injury of the right lower leg, orthostatic hypotension, pain in the right ankle and joints of the right foot, dementia, anemia, chronic kidney disease, atrial fibrillation, rheumatoid arthritis, acute kidney failure, and fracture of the right lower leg. Her face sheet and baseline care plan both had the code status left blank, and the admission MDS showed a BIMS score of 14 out of 15, indicating normal cognition. Record review showed a care plan entry stating that Resident #80 desired full code status, but the physician orders reviewed did not contain any advance directive or code status order anywhere in the chart. During observation, the code cart did not have a code book. Staff interviews showed that CNA M said code status was only listed in the EMR, Med Aide F said she would check orders or the physical chart and would perform CPR if no code status could be found, and LVN D said he would check orders or the face sheet and would perform CPR until further notice if no code status was located. The DON stated that code status was only in the orders and that if no code status was available, staff would perform CPR until it could be determined. The DON also said the admission nurse probably forgot to enter the code status and that it could cause a delay in care. The MDS Coordinator said she looked in the EMR, medical records, and physical chart for code status information and stated she was not the one who entered Resident #80's code status on the care plan. The facility policy required the admitting nurse to obtain code status orders and the Social Service Director or designee to verify advance directives and code status within 72 hours of admission.
Failure to Maintain Clean Resident Room Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #85 by leaving a mud brown smudge with a solid consistency on the wall inside his room for 3 days. Resident #85 was an [AGE] year-old man admitted with diagnoses including diverticulosis of the large intestine, COPD, Crohn's disease of the large intestine, hemorrhage of the anus and rectum, hemorrhoids, and slow transit constipation. His record also showed a BIMS score of 9, indicating moderate cognitive impairment, and his care plan identified that he required assistance with ADLs and was incontinent of bowel and bladder. The care plan was updated to note that Resident #85 had a behavior problem of smearing BM everywhere on his side of the room and would try to clean it up at times but would still smear it everywhere. During observation, he was standing near the wall in his room, wearing a t-shirt and an adult brief that appeared full, and the room had a strong BM odor. On the wall where he had been standing was an approximately 8-inch-long mud brown smudge that appeared thick and raised on one side, with no drip lines. Brown stains that appeared to be BM were also observed on his bed linens, and two flies were seen buzzing around the room. In interviews, Resident #85 stated that staff assisted him as needed and that housekeeping cleaned his room daily, while also stating that the stains on his sheets had been given to him and the machine could not get everything out. CNA G stated he needed follow-up assistance after toileting to ensure cleanliness, and CNA R stated he sometimes had loose stool that leaked onto his sheets and that she had not yet gotten to his room to repeat care. The mud brown smudge remained on the wall during a later observation, and the EVS Director stated housekeeping was supposed to clean walls and all areas in resident rooms and that harm in keeping the smudge on the wall could be sickness. The DON stated the harm in leaving substances like the smudge on the wall would be the potential for infections.
Failure to Complete New PASRR Review After Change in Psychiatric Status
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental disorder for a PASRR Level II resident review after a significant change in status assessment. Resident #44 was admitted with diagnoses including mood affective disorder, recurrent major depressive disorder, adjustment disorder with disturbance of conduct, generalized anxiety disorder, and mood disorder due to a known physiological condition with manic features. The resident’s quarterly MDS showed severely impaired cognition with a BIMS score of 4, dependence for all ADLs, wheelchair use, and bowel and bladder incontinence. The resident’s record also showed ongoing psychiatric involvement and treatment. The care plan documented psychology/psychiatry services, anti-anxiety medication use for anxiety disorder, and antidepressant medication use for depression. A PASRR Level 1 screening completed on admission indicated no evidence of mental illness, intellectual disability, developmental disability, or dementia as the primary diagnosis. Later records documented psychiatric diagnoses and treatment that included recurrent major depressive disorder, generalized anxiety disorder, mood disorder due to known physiological condition with mixed features, and adjustment disorder with mixed disturbance of conduct. Physician orders included Depakote, sertraline, bupropion, trazodone, and lorazepam, along with behavior and side effect monitoring. During interview, the MDS Coordinator stated she remembered the resident was negative for the PE when first admitted, then developed other medical conditions, and she did not submit a new PE because she knew he was not going to qualify since he had not been in any psychiatric facilities.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure Resident #12 received scheduled bathing assistance to maintain grooming and personal hygiene. Resident #12 was an older female admitted with diagnoses including metabolic encephalopathy, hypertension, cirrhosis, heart failure, chronic kidney disease, acute cystitis with hematuria, and asthma. Her MDS showed a BIMS score of 9 out of 15, indicating moderately impaired cognition, and she required substantial/max assistance with showers and baths. She was also always incontinent of bowel and bladder, had shortness of breath when lying flat, took diuretics, and used oxygen. Her care plan identified an ADL self-care performance deficit related to weakness and a risk for skin breakdown due to incontinence, with interventions to keep skin clean and dry. Record review showed Resident #12 was scheduled for showers/baths three times weekly on Tuesday, Thursday, and Saturday, but her last documented shower/bath was on 4/9/26. On 4/14/26, she was observed in contact isolation with brown, dirty-looking nails and stated she had not had a bath/shower since moving to the 400 hall and that it had been almost two weeks since her last one. On 4/16/26, she again stated she had not received a shower/bath yet. A CNA said showers were documented in the POC and that if she could not provide a shower because she was pulled to the floor, the CNAs for that hall were responsible for giving their own showers/baths. The DON stated residents were expected to get their scheduled showers/baths and whenever needed, and that there was enough help for every resident to get theirs.
Delayed STAT Chest X-Ray
Penalty
Summary
The facility failed to ensure radiology services were obtained and reported in a timely manner for one resident with COPD who used oxygen and had moderately impaired cognition. The resident developed increasing aching chest pain upon exhalation and was assessed by an LVN, who documented vital signs within normal limits, oxygen saturation of 97% on 2 liters nasal cannula, and pain rated 6 out of 10. Nitroglycerin and PRN pain medication were given, the on-call nurse practitioner was notified, and a STAT chest x-ray was ordered. The resident was told the chest x-ray would be completed the same night, but it was not performed during that shift. The next morning, the resident asked for an update because the x-ray had not yet been done. The resident stated she had chest pain the prior day, that the night nurse had called the NP and said the x-ray would be completed that night, and that she had not received it. The resident was not in pain at the time of the later interview and declined transfer to the hospital when offered. Staff interviews showed inconsistent understanding of the expected timeframe for STAT testing, with responses ranging from 2-4 hours, 3-5 hours, and 4-6 hours. The LVN who received the order stated the lab company had not arrived by the end of the shift and said the information was passed to the next shift because the technician was still within the stated window. Other staff stated that if the x-ray could not be completed within the expected window, the physician or NP should have been notified, but that did not occur during the night shift. The chest x-ray was ultimately completed the next day and showed no abnormal results.
Improper Food Storage and Kitchen Door Left Open
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation on 04/14/2026, the refrigerator contained an open bag of shredded lettuce that was brown with brown liquid at the bottom of the bag, with a handwritten date of 03/29/2026 and no use-by or discard date written on the package. The refrigerator also contained an unopened bag of mozzarella cheese with a manufacture package date of 02/25/2026 and a handwritten date of 03/26/2026, but no use-by or discard date written on the package. The Food Service Director stated that food items in the refrigerator should be labeled with a delivery date if a manufacture date does not exist, an open date, and a use-by date, and said the lettuce and mozzarella cheese should have been thrown out. On 04/15/2026, Dietary Staff A used a cardboard box to prop open the kitchen door while taking trash out, and two flies entered the kitchen. The staff member then used a towel to swat the flies and closed the door. The kitchen door had a sign posted to keep it closed. In interviews, Dietary Staff A, the Food Service Director, and the Administrator stated that the kitchen door should be closed immediately when entering and exiting to keep pests out and prevent cross contamination and food borne illness. The record review of the policy titled Food Receiving and Storage stated that foods shall be received and stored in a manner that complies with safe food handling practices, and that refrigerated foods are to be labeled, dated, monitored, and used by their use-by date, frozen, or discarded.
Nonfunctioning Resident Call Lights
Penalty
Summary
The facility failed to ensure that resident rooms were equipped with a functioning call system for 2 of 8 residents reviewed, Resident #69 and Resident #109. Both residents had significant cognitive impairment and required substantial assistance or dependence for transfers and other care needs. Resident #69 had diagnoses including Alzheimer's Disease, a BIMS score of 0 out of 15, and a care plan that directed staff to keep the call light within reach and assist with all transfers. Resident #109 had hypertensive chronic kidney disease, a BIMS score of 7 out of 15, and a care plan that directed staff to keep the call light within reach and respond promptly to requests for assistance. During observation and interview, Resident #109 stated she had pressed the call light to request repositioning in bed, but no staff had come. When the call light was tested in her room, the indicator light did not flash at the bedside and did not illuminate in the hallway. LVN H confirmed the call light was not functioning and stated residents had a right to a functioning call light at all times. The EVS Director was notified and also observed that the call light did not function in the room. Resident #69's call light was also tested and did not activate the bedside or hallway indicator lights. CNA P confirmed the malfunction and stated residents had a right to a functioning call light at all times. The EVS Director, DON, and Administrator all stated that residents should have functioning call lights and that staff should report malfunctions to EVS. Record review showed no outstanding repair requests for either room, and the facility's nurse call system testing reports showed that only selected rooms were checked on the listed dates rather than all resident rooms. The facility policy stated that each resident is provided a means to call staff from the bed, toileting/bathing facilities, and the floor, and that the resident call system remains functional at all times.
Failure to Ensure Two-Person Mechanical Lift Transfer and Equipment Safety
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) attempted to transfer a resident with severe cognitive impairment, limited mobility, and total dependence for transfers, using a mechanical lift without the required assistance of a second staff member. The resident, who had diagnoses including epilepsy, contracture, and dementia with agitation, was being prepared for transfer from bed to wheelchair. The CNA positioned the resident in the sling and began lifting her before the second CNA arrived, contrary to facility policy requiring two staff for mechanical lift transfers. During the transfer, the mechanical lift sling failed, with the hooks on one side coming undone. This caused the resident to fall from the bed to the floor, resulting in lacerations to her head that required stitches and staples. The incident was witnessed after the fact by the second CNA, who arrived to find the resident on the floor. The resident was assessed by nursing staff, and emergency medical services were called for further evaluation and treatment at the hospital. The resident returned to the facility the same day and was monitored post-fall. Interviews and record reviews confirmed that the CNA was aware of the two-person requirement for mechanical lift transfers but proceeded alone. The facility's policies clearly stated that at least two nursing assistants are needed for safe mechanical lift use, and that slings and equipment must be inspected for defects prior to use. The sling used in the incident was found to be defective, and the CNA did not wait for assistance before initiating the transfer, directly leading to the resident's fall and injury.
Failure to Follow PICC Line Dressing Change Protocols for IV Therapy
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident by not following professional standards of practice and physician orders regarding the care and maintenance of a PICC line. After returning from the hospital with a PICC line in place for IV antibiotic therapy, the resident did not have the PICC line dressing changed as required by facility protocol and standard practice. The dressing, dated from the time of hospital discharge, remained unchanged for an extended period, as confirmed by both observation and photographic evidence provided by the resident's family member. Record reviews revealed that there was no order for changing the PICC line dressing upon the resident's readmission, and nursing staff failed to initiate or follow up on obtaining such an order. Multiple nurses interviewed acknowledged that dressing changes were scheduled weekly, typically on Sundays, but none noticed or addressed the lack of a current order or the outdated dressing. The responsibility for obtaining the order was not fulfilled by the admitting nurse, and subsequent staff did not identify or correct the oversight. The resident, who had a history of recurrent infections and sepsis, was eventually sent back to the hospital with a fever, where it was discovered that the PICC line dressing had not been changed since the initial hospital discharge. Interviews with staff and the DON confirmed that the dressing was not changed during the resident's stay, and the facility's protocol for weekly dressing changes and daily site assessments was not followed. The failure to adhere to these protocols was acknowledged by the DON and staff during interviews.
Failure to Ensure Respectful and Dignified Treatment of Residents
Penalty
Summary
The facility failed to ensure that multiple residents were treated with respect and dignity, resulting in a deficient practice that affected at least four residents. Certified Nursing Assistant (CNA) G was identified as the staff member whose interactions with residents led to feelings of being threatened, treated like a child, having their feelings hurt, and not being treated as a human. Specific incidents included CNA G making a comment to a resident about taking him outside and 'whooping his butt' when he refused to get out of bed, which the resident reported made him feel uncomfortable and as though he was being threatened, even if not physically. Other residents described CNA G as abrupt, rude, and rough in her approach, with one resident stating that CNA G treated her like a child and another stating that CNA G's tone was boisterous and explosive, making her feel bad. The residents involved had various medical and psychological conditions, including hemiplegia, diabetes, chronic kidney disease, Parkinson's disease, bipolar disorder, dementia, chronic obstructive pulmonary disease, morbid obesity, and epilepsy. Several residents had documented histories of depression and moderate cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores. These conditions made them particularly vulnerable to the negative effects of disrespectful or undignified treatment. Residents reported that CNA G's manner of communication and approach to care did not honor their preferences or emotional well-being, with some residents stating they did not feel safe or respected and that their feelings were hurt by her actions. Interviews with other staff members, including CNAs, LVNs, the DON, and the Administrator, confirmed that residents have the right to be treated with dignity, to refuse care, to ask questions, and to be treated as adults. Staff were trained in resident rights and recognized that failing to respect these rights could negatively affect residents emotionally. The facility's own policy required employees to treat all residents with kindness, respect, and dignity, and to honor their rights to a dignified existence. Despite this, the actions and approach of CNA G, as reported by multiple residents and corroborated by life satisfaction rounds, did not meet these standards, resulting in a deficiency related to resident rights and dignity.
Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with an indwelling urinary catheter. Despite the resident having a catheter from late January to early April, the comprehensive care plan did not include a care area addressing the catheter, its management, or related interventions. The baseline care plan and physician orders documented the presence and care requirements for the catheter, but this information was not carried over to the comprehensive care plan, leaving a gap in the documentation and communication of care needs. The resident in question had significant medical complexities, including chronic kidney disease stage 4, type 2 diabetes mellitus, hypertensive heart disease with heart failure, and a cognitive communication deficit. The resident was dependent on staff for toileting and had a history of urinary tract infection and renal insufficiency. Although the care plan addressed risks related to renal failure, skin breakdown, and urinary incontinence, it did not specifically address the indwelling catheter, its care, or monitoring for complications such as infection or obstruction. Interviews with facility staff, including the DON and MDS Nurse, confirmed that the catheter was not included in the comprehensive care plan. The MDS Nurse acknowledged that the catheter was documented in the baseline care plan and MDS but was not transferred to the comprehensive care plan. Both the DON and MDS Nurse recognized that the omission could result in staff not being informed about the catheter care requirements, which could lead to negative outcomes such as infection. The facility's policy required that care plans include measurable objectives and timeframes for all identified needs, but this was not followed in this case.
Deficiencies in Food Storage and Temperature Control
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, the facility did not ensure that foods were properly sealed, labeled, or dated while in storage. During an inspection, it was noted that the dry storage container was left open, with unsealed bags of blueberry muffin mix and cereal. Additionally, the walk-in cooler contained an open bag of cheese and three trays of drinks that were not labeled or dated. These oversights in food storage practices could potentially compromise the freshness and safety of the food served to residents. Furthermore, the facility did not maintain proper food temperatures on the service line. Ground meat was found to be held at a temperature of 140 degrees, but the thermometer used by the Dietary Aide was reading 8 degrees too high, indicating it was not calibrated correctly. Interviews with the Dietary Manager and Dietary Aide revealed that they were unaware of the thermometer's calibration issue and did not know how to calibrate it. The Dietary Manager acknowledged the importance of proper food storage and temperature maintenance to prevent foodborne illness, but failed to provide the requested policy on food storage and hot holding, as well as dietary staff training records, before the survey exit.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed in one of the four medication carts reviewed. Specifically, the 300-hall nurse medication cart, assigned to LVN M, contained 35 multicolored pills of different shapes, 5 1/2 white pills of various shapes, and 6 multicolored pills loose at the bottom of a drawer. Additionally, an opened bottle of Thick It thickened water, which was past its recommended usage date, was found in the cart. The manufacturer's instructions required refrigeration after opening and use within 14 days, which was not adhered to. During interviews, LVN M acknowledged responsibility for maintaining the cleanliness and order of the medication cart, including the removal of expired medications and loose pills. The DON confirmed that nurses and medication aides were expected to clean and organize medication carts each shift, removing expired or loose medications. The facility's policy on medication storage emphasized the importance of maintaining a clean, safe, and orderly environment, with proper labeling and disposal of outdated or improperly labeled drugs. The failure to adhere to these protocols posed a risk of residents receiving incorrect or expired medications, potentially leading to adverse side effects.
Inaccurate Medication Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices for one resident reviewed for medication administration. Licensed Vocational Nurses (LVN) A and B documented that the resident was being monitored for behaviors and medication side effects and that medication was administered on specific dates while the resident was actually at the hospital. This inaccurate documentation could potentially lead to resident injury due to the misrepresentation of the resident's health and care. The resident in question was a male with multiple medical diagnoses, including Bipolar Disorder, Unspecified Dementia, and Congestive Heart Failure, among others. He had a Brief Interview of Mental Status (BIMS) score indicating severely impaired cognition and required varying levels of assistance with daily activities. The resident was transferred to the hospital due to a change in condition, specifically respiratory arrest, yet the facility's records inaccurately reflected that he was still present and receiving care at the facility. The Medication Administration Record (MAR) for December showed that medications and monitoring were documented as completed during shifts when the resident was not present. This included antidepressant monitoring and behavior monitoring, as well as the administration of aspirin and the use of a pressure-reducing mattress. The facility's policies on pharmaceutical services and documentation of medication administration were not adhered to, as medications were documented as administered without the resident being present, and reasons for withholding or not administering medications were not documented.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Houston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Houston Heights Nursing And Rehabilitation Center | 4.1 mi | ★★★★★ | 2 | 0 |
| Caraday Of Houston | 4.7 mi | ★★★★★ | 1 | 0 |
| Ashford Gardens | 4.7 mi | ★★★★★ | 24 | 0 |
| Villa Toscana At Cypress Woods | 5.5 mi | ★★★★★ | 13 | 0 |
| Legend Oaks Healthcare And Rehabilitation Center - | 6.1 mi | ★★★★★ | 6 | 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 July 2026) and official state health department websites.