Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Weston during CMS and state inspections, most recent first.
The facility failed to maintain required RN coverage for at least 8 consecutive hours daily and did not have a full-time RN DON for a defined period. Records and staffing documents showed multiple days with no RN on duty and no separate RN charge nurse when the census exceeded 60 residents, with LVNs functioning as charge nurses and relying on phone contact with RNs or an NP. Interviews with the ADM, CRN, SC, and nursing staff confirmed that a recently hired DON left after a few days, no interim DON was designated, and the CRN only provided intermittent onsite support while not serving as DON, despite the facility assessment specifying RN and DON staffing needs and 8-hour RN coverage.
Two residents with significant cognitive and physical impairments, including TBI, dementia, dysphagia, and seizure disorders, were not treated with appropriate dignity during care. A CMA stood over a resident seated in the dining room and fed her an entire dose of medication mixed in pudding from a cup during mealtime, rather than sitting beside her, despite the resident’s documented swallowing problems and need for supervised setup assistance. In a separate incident, a CNA described another resident who required substantial assistance with eating as “a feeder,” later acknowledging this was not a respectful or dignified way to refer to the resident. These actions conflicted with the facility’s dignity policy, which requires respectful language and prohibits labeling residents by their care needs.
A resident with severe protein-calorie malnutrition, dysphagia, and other comorbidities had a standing physician order for nighttime PEG tube feeding with Nutren 2.0 at 65 ml/hr over 10 hours, along with a mechanically altered diet. On one night, the ordered tube feeding was not administered by the night-shift LVN, who later stated she was confused about the timing of the feeding and did not verify the order. The DON confirmed the feeding was missed and that the order should have been followed, and documentation showed the NP was notified the next morning that the tube feeding had not been provided.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A resident with a seizure disorder and complex medical history did not receive two scheduled doses of Lacosamide after readmission, due to medication order entry errors and lack of medication availability. The missed doses led to seizure-like activity and hospital admission for acute respiratory failure and encephalopathy. Staff interviews and record reviews confirmed failures in medication administration and communication processes.
Three residents who required assistance with ADLs did not receive adequate oral or nail care. One resident with quadriplegia and complex medical needs was observed with poor oral hygiene and reported not having his teeth brushed for a month, while two other residents had excessively long, unclean fingernails despite care plans specifying regular nail care. Staff interviews confirmed that these care tasks were the responsibility of CNAs, but observations indicated they were not performed as required.
Surveyors found that food items in the kitchen cooler were not consistently labeled or dated, with some items past their recommended use-by dates and others missing labels entirely. Staff interviews confirmed that all kitchen staff were responsible for ensuring proper labeling and dating, and that failure to do so could result in expired or incorrect food being served. The facility's food storage policy and the FDA Food Code were not followed, leading to this deficiency.
The facility did not maintain accurate documentation of controlled drug counts at shift changes, with multiple instances of missing signatures and incomplete narcotic count sheets across several halls and shifts. Staff interviews confirmed the expectation for narcotic counts and signatures at each shift change, but the process was not consistently followed or included in new employee orientation, contrary to facility policy.
A resident with complex medical needs was not given scheduled anticonvulsant, antipsychotic, antidepressant, and pain medications before leaving for a painful offsite procedure. The nurse responsible did not adjust the medication schedule or consult with clinical leadership, resulting in the resident experiencing increased pain and distress after the appointment.
An LVN failed to disinfect a blood pressure cuff between use on two cognitively intact residents with hypertension, despite facility policy and available supplies. The LVN, unfamiliar with the supply locations, did not sanitize the equipment before, between, or after use, resulting in a breach of infection control protocols.
A resident with significant cognitive and physical impairments did not have PASRR Level II recommendations incorporated into their assessment and care plan, and the facility failed to submit required NFSS forms for PT, OT, SLP, and a customized wheelchair within the mandated 20 business days after the IDT meeting, as confirmed by staff interviews and record review.
A resident's narcotic medications, including Oxycodone and Tramadol, were misappropriated due to inadequate medication management and security protocols. The medications were delivered and signed for by an RN but went missing after being improperly stored in the medication room. Staff interviews revealed confusion and lack of communication regarding the handling and storage of the medications, leading to their disappearance.
Two residents in an LTC facility did not receive necessary wound care, leading to the worsening of their pressure ulcers. One resident's Stage 3 ulcer progressed to Stage 4 due to missed treatments and delayed wound doctor consultation. Another resident did not receive prescribed wound vac changes, and their care plan was outdated. Staff interviews revealed inadequate training and documentation practices, contributing to the deficiencies.
A facility failed to provide effective pain management for a resident with a recent above-the-knee amputation, leading to an Immediate Jeopardy finding. Despite having a care plan, the facility did not adjust pain medication or notify the NP, resulting in persistent severe pain. The resident's pain levels were inconsistently documented, and a Buprenorphine patch was not applied as ordered. The resident's representative reported insufficient pain relief, and the resident required a procedure for an infection at the amputation site.
The facility failed to develop baseline care plans within 48 hours of admission for three residents, including a male with no documented diagnoses, a female with altered mental status, and another female with multiple diagnoses. Staff interviews revealed confusion over responsibility for completing these plans, which are crucial for understanding residents' needs. The facility's policy requires these plans to be developed within 48 hours, but this was not followed, potentially compromising care.
The facility failed to administer medications as ordered for two residents, leading to missed doses of critical medications. A resident with chronic conditions did not receive several prescribed medications, while another resident missed doses of Atorvastatin, Latanoprost, and Levothyroxine. Staff interviews revealed expectations for proper medication administration and documentation, but these were not consistently followed. The facility's policy lacked guidance on medication administration, contributing to the deficiency.
The facility failed to document nursing notes in the EMRs of three residents for several days post-admission, lacking admission MDS assessments and baseline care plans. Interviews with staff, including an LVN, DON, and ADM, confirmed that this deficiency could lead to errors in care, as it hindered communication and awareness of residents' conditions.
The facility failed to maintain an effective infection prevention and control program, resulting in inadequate PPE use during high-contact care for residents with medical devices or wounds. Staff did not consistently wear gowns and gloves, and there was a lack of signage indicating PPE requirements. Additionally, staff were not adequately trained on Enhanced Barrier Precautions, contributing to potential infection risks.
The facility failed to develop comprehensive care plans for two residents, omitting necessary interventions for a stage 4 pressure ulcer and other medical needs. One resident's care plan lacked instructions for NPWT, while another's did not address ADL status, catheter use, and CPAP. Staff interviews revealed confusion over care plan responsibilities, contributing to these deficiencies.
The facility failed to maintain proper nail care and hygiene for three residents, leading to long, dirty, and jagged fingernails despite care plans indicating the need for assistance. Interviews with staff revealed inadequate monitoring and execution of nail care responsibilities, and the facility lacked a specific policy addressing this aspect of resident hygiene.
The facility failed to secure medication carts and properly store medications, as observed with two unlocked and unattended medication carts near the nurses' station. An unopened bag containing medication bottles was also improperly stored on a treatment cart. Interviews with the RN and DON confirmed awareness of the storage requirements, but the facility did not adhere to its policy, allowing unauthorized access to medications.
The facility failed to ensure that four residents were free from physical restraints, specifically wheelchair seat belts, without proper documentation or assessment. The residents, with conditions like cerebral palsy and quadriplegia, used seat belts perceived as safety devices. However, the facility lacked a restraint policy, and there were no consents or assessments for the seat belts, leading to a deficiency.
A facility reported a medication error rate of 6.72%, exceeding the acceptable threshold, due to two errors involving two residents. One resident did not receive Vitamin D 100 mg, and another did not receive Terazosin 1 mg, as the medications were unavailable during administration. The MA responsible did not restock the cart due to being off for two days and running behind schedule. The DON confirmed the expectation for medications to be administered as ordered and reported if unavailable.
The facility failed to ensure a resident's drug regimen was free from unnecessary medications and did not monitor for side effects or effectiveness of prescribed psychotropic medications, despite recommendations from the pharmacist and facility policy.
The facility failed to post daily nurse staffing data, including total numbers and actual hours worked by RNs, LPNs, and CNAs, for several days. The CNA Scheduler, responsible for posting, did not work over the weekend and was unaware of the requirement to post actual hours. The DON acknowledged the oversight, attributing it to a missed update over the weekend, with no immediate negative outcomes reported.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The deficiency involves the facility’s failure to provide the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, and to maintain a full-time RN as Director of Nursing (DON), as required. Record review of the facility’s FY Quarter 1 CASPER report and direct care staff timesheets showed multiple dates on which there were no RN hours recorded and no evidence of an RN on duty for 8 consecutive hours. These dates included numerous days from October through December 2025 and from January through March 2026. Review of agency personnel records confirmed that no agency RNs were used on several of those dates, and a posted daily staffing sheet for one of the cited dates showed zero RN hours for both day and night shifts. The facility also failed to ensure a full-time DON licensed in Texas was in place for a period from late March to early April 2026. Interviews with the Administrator (ADM) and the Clinical Resource Nurse (CRN) revealed that a newly hired DON had only remained in the position for approximately four days and that, after the DON’s departure around 3/20/26, there was no interim DON designated. The CRN stated she was not serving as the DON but was overseeing clinical systems and infection prevention and was only physically present in the building on specific, intermittent dates. The Staffing Coordinator (SC) confirmed that on certain dates after the DON left, there was no DON in the building and only LVNs were serving as charge nurses. Additionally, the facility did not ensure that a separate RN serving as charge nurse was on duty for 8 consecutive hours on multiple dates when the census exceeded 60 residents, instead utilizing the DON as the RN on duty. The SC, ADM, and nursing staff described that LVNs functioned as charge nurses, passed medications, conducted skin assessments, and completed charting, while RNs typically performed admission assessments and initial education. Staff interviews indicated that when no RN was onsite, LVNs relied on calling an RN, the CRN, or an on-call NP by phone. The facility assessment for 2026 documented that overall staffing needs included at least one RN providing direct care, two RNs available including the DON, and RN coverage of 8 hours, which was not met on the cited dates.
Failure to Maintain Resident Dignity During Medication Administration and Mealtime Assistance
Penalty
Summary
The deficiency involves failures to ensure residents were treated with respect and dignity and cared for in a manner that promotes quality of life. For Resident #1, a female with pneumonia, hemiplegia/hemiparesis, traumatic brain injury, seizure disorder, respiratory failure, dysphagia, and cognitive communication deficit, the quarterly MDS showed she required setup or clean-up assistance for eating and had a BIMS score of 08, indicating moderately impaired cognition. Her care plan documented an ADL self-care performance deficit related to traumatic brain injury with hemiplegia, requiring supervision/setup assistance, and a swallowing problem related to difficulty or pain with swallowing, coughing or choking during meals or when swallowing medications, and difficulty with thin liquids. On 4/7/26 at 5:11 PM, a CMA was observed standing over Resident #1 at a dining table in the dining room and administering her entire dose of medication mixed in pudding, feeding her from the pudding cup until it was empty. In a subsequent interview, the CMA acknowledged this was not typical practice, that medications were not usually administered in the dining room during mealtimes, and that she should have been seated next to the resident out of respect while administering the medication. For Resident #2, an elderly female with non-traumatic brain dysfunction, heart failure, Alzheimer’s disease, and seizure disorder, the comprehensive MDS indicated she required setup or clean-up assistance for eating and had a BIMS score of 03, indicating severe cognitive impairment. Her care plan documented an ADL self-care performance deficit related to dementia and a need for substantial/maximum assistance from staff to eat. On 4/7/26 at 5:25 PM, a CNA stated that Resident #2 had already been fed and that she had fed the resident because she was “a feeder.” In the same interview, the CNA acknowledged that “feeder” was not a term she should use to describe a resident and that a more respectful term should have been used because it was not a dignified way to talk about a resident. Additional interviews with an RN and the Administrator confirmed that staff should not stand while feeding or administering food-based medications and should not refer to residents by labels such as “feeders,” in accordance with the facility’s dignity policy, which requires staff to speak respectfully to residents and not label or refer to them by diagnosis or care needs.
Failure to Follow Physician Order for Nighttime Enteral Feeding
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for enteral nutrition for a resident with significant nutritional and medical needs. The resident had diagnoses including unspecified severe protein-calorie malnutrition, dysphagia, gastritis, cerebral palsy, vitamin D deficiency, and iron deficiency, and required extensive assistance with ADLs. The care plan included a feeding tube and mechanically altered diet, with a physician order for Nutren 2.0 at 65 ml/hr continuously for 10 hours from 8 p.m. to 6 a.m., providing specified calories, protein, and free water, with no end date to the order. Despite this standing order, the resident’s nighttime tube feeding was not administered during the 8 p.m. to 6 a.m. shift on 01/27/2026. The missed feeding was confirmed through record review and staff interviews. A progress note documented that the NP was notified the following morning that the tube feeding had not been done by the night shift nurse. The DON stated that the night nurse did not give the ordered feeding and acknowledged that the nurse should have followed the physician’s order. In an interview, the LVN responsible for the night shift admitted she did not follow the physician’s order and failed to provide the tube feeding, explaining she was confused and thought the feeding was to be done during the day shift and that she should have double-checked the order. The facility’s enteral nutrition policy stated that adequate nutritional support through enteral nutrition is to be provided as ordered, but this was not followed in this instance, resulting in the resident missing the prescribed nighttime tube feeding.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Significant Medication Error Due to Missed Anticonvulsant Doses
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, seizures, and nontraumatic intracerebral hemorrhage was not administered two consecutive doses of a prescribed anticonvulsant medication, Lacosamide, following readmission to the facility. The resident's medication administration records showed missed doses on two occasions, and interviews with nursing staff revealed that the medication was not available on hand and that there was a discrepancy between the ordered tablet form and the available liquid form. The agency nurse entered incorrect medication administration times, and the issue was not resolved in time to administer the missed doses. Following the missed doses, the resident exhibited seizure-like activity, including facial twitching and head turning, which prompted notification of the nurse practitioner and subsequent transfer to the emergency department. Hospital records indicated the resident was admitted for acute hypercapnic and hypoxemic respiratory failure, acute metabolic encephalopathy, and seizure disorder. The medical director confirmed that the missed doses of Lacosamide could have contributed to the resident's seizure activity. Record reviews and staff interviews confirmed that the medication error resulted from failures in medication order entry, communication regarding medication availability, and timely notification of providers. The facility's policy required that medications be administered as prescribed and that staff be properly oriented to the medication distribution system, but these procedures were not followed, leading to the significant medication error.
Failure to Provide Adequate Oral and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. Specifically, one resident with quadriplegia and multiple complex medical conditions, including dysphagia and cerebral palsy, was not provided with adequate oral care. Observations over several days revealed the resident had bad breath, dry lips, and a thick white film on his teeth. The resident reported that his teeth had not been brushed in a month and denied refusing oral care. Staff interviews confirmed that the resident required total assistance and that oral care was the responsibility of the CNAs assigned to his hall. Two other residents, both with intact cognition and requiring assistance with personal hygiene, were not provided with adequate nail care. Observations showed that their fingernails were more than half an inch past the fingertips, jagged, and had dark debris underneath. Both residents expressed dissatisfaction with the condition of their nails and stated they wanted them trimmed. Despite care plans indicating that nail care should be performed on bath days and as needed, there was no evidence that nail care was provided during the survey period. Staff interviews confirmed that CNAs were responsible for providing nail care, except for diabetic residents, and that nail care was typically performed on shower days. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. However, the observed lack of oral and nail care for these residents demonstrated a failure to follow care plans and facility policy.
Failure to Properly Label and Date Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, label, and date food items in accordance with professional standards and the facility's own food storage policy. During an inspection of the kitchen cooler, several food items were found either not labeled, not dated, or past their recommended use-by dates. Specifically, hamburger patties, mayonnaise, juice, tortillas, and tomato soup were either missing labels or had dates indicating they were expired. Staff interviews confirmed that all kitchen staff were responsible for labeling and dating food, and that there was a posted list in the cooler specifying how long items could be stored. Staff also acknowledged that serving out-of-date food could result in residents being served expired or incorrect food items. Record review of the facility's food storage policy indicated that all food should be covered, labeled with the name, date stored, and date to be used or discarded, with a recommended use-by date of three days after preparation or purchase. The FDA Food Code was also referenced as applicable to these failures. The facility's failure to consistently label and date food items in the kitchen could result in expired food being served to residents, as confirmed by staff and administrative interviews.
Failure to Maintain Accurate Narcotic Count Documentation at Shift Changes
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically, the facility did not establish or maintain a system of record for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation at each shift change. Record reviews revealed missing documentation on the Change of Shift Narcotic Count Sheets for multiple halls and shifts, with several instances where both on-coming and off-going staff did not sign or complete the required narcotic counts. Interviews with certified medication aides (CMAs) and the Assistant Director of Nursing (ADON) confirmed that it was the facility's expectation for both off-going and on-coming staff to count narcotic medications and sign the count sheets at each shift change. The Regional Director of Clinical Services acknowledged that the narcotic count process was not consistently included in new employee orientation. Review of the facility's contracted pharmacy policy indicated that a system must be in place to record the receipt, usage, and disposition of all controlled substances in sufficient detail for accurate reconciliation, which was not followed as evidenced by the missing documentation.
Failure to Administer Scheduled Medications Prior to Offsite Procedure
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including epilepsy, major depressive disorder, quadriplegia, and chronic pain, was not administered his prescribed and scheduled medications prior to leaving the facility for a post-surgical appointment. The resident was nonverbal, received medications via PEG tube, and had a care plan that required timely administration of medications for seizure control, pain management, and behavioral health. On the morning of the appointment, the nurse responsible did not administer the resident's scheduled 9:00am medications, including CarBAMazepine, Keppra, RisperDAL, Venlafaxine, and HYDROcodone-Acetaminophen, marking them as 'Out on Appointment' in the MAR. The nurse stated that the resident left the facility at 7:45am, which was outside the standard medication administration window, and therefore the medications were not given. She also indicated unfamiliarity with the specifics of the appointment and did not consult with the nurse practitioner or physician about adjusting the medication schedule. As a result, the resident underwent a painful procedure without having received his scheduled pain and other essential medications. Upon return, the resident exhibited signs of distress, agitation, and pain, which were not present prior to leaving for the appointment. Interviews with facility staff and the resident's family member confirmed that the resident was calm before leaving but became agitated and in pain after the procedure, with the family member noting the absence of mood and pain medications. The nurse practitioner and assistant director of nursing both acknowledged that the resident should have received his medications before leaving for the appointment, and the facility's policies required anticipation and management of pain and administration of medications as ordered. The failure to administer scheduled medications prior to the appointment constituted a deficiency in providing pharmaceutical services to meet the resident's needs.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of an LVN who did not disinfect a blood pressure cuff between use on two residents. Observations showed that the LVN, who was an agency nurse filling in for an absent medication aide, did not sanitize the blood pressure cuff before, between, or after checking the blood pressure of two residents. The LVN acknowledged awareness of the need to disinfect equipment between residents but stated she was unfamiliar with the location of sanitizing supplies on the medication cart and did not ask for assistance before beginning her medication pass. Both residents involved were cognitively intact and had medical histories including hypertension, with care plans requiring regular blood pressure monitoring. The facility's policy, revised in September 2022, required that reusable resident-care equipment be cleaned and disinfected between residents according to CDC recommendations. Interviews with facility leadership confirmed that supplies were available and that the expectation for disinfection was clearly outlined in policy, but the LVN did not follow these procedures during her shift.
Failure to Timely Submit PASRR Specialized Services Requests
Penalty
Summary
The facility failed to incorporate PASRR Level II recommendations into the assessment and care planning process for a resident with multiple diagnoses, including cerebral palsy, epilepsy, intellectual disabilities, and dysphagia. Despite the resident being identified as PASRR positive and requiring specialized services such as PT, OT, SLP, and a customized wheelchair, the facility did not submit the Nursing Facility Specialized Services (NFSS) forms for these services within the required 20 business days following the interdisciplinary team (IDT) meeting. The MDS Coordinator acknowledged that the NFSS forms were not accepted multiple times and that attempts were made to resolve the issue, but the forms were still not submitted on time. Interviews with facility staff and the PASRR Program Specialist confirmed that the required forms were not sent within the mandated timeframe, regardless of the resident's hospitalization and readmission. Observations showed the resident in a high-back wheelchair and unresponsive to verbal interaction. The facility's own PASRR policy required initiation of specialized service requests within 20 business days of the IDT meeting, but this was not followed, resulting in a failure to ensure timely access to needed care and services for the resident.
Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to ensure the resident's right to be free from misappropriation of property, specifically involving the diversion of narcotic medications. The incident involved a resident who was cognitively intact and had a history of chronic pain conditions, including Sciatica and Chronic Pain Syndrome. The resident was prescribed Oxycodone and Tramadol for pain management. On a specific date, the pharmacy delivered these medications to the facility, and they were signed as received by an RN. However, the medications were reported missing four days later, indicating a failure in the facility's medication management and security protocols. The investigation revealed that the medications were initially received by an agency RN who placed them in a narcotics box until the day shift arrived. The RN handed off the medications to an LVN and a CMA, who were unsure of the resident's current location within the facility. The medications were then placed in the medication room for returns, as advised by the staff present. However, the medications were not properly secured or accounted for, leading to their disappearance. Interviews with various staff members, including LVNs and CMAs, highlighted a lack of clarity and communication regarding the handling and storage of the medications, contributing to the misappropriation. The facility's policy on controlled substances required that medications be counted upon delivery and signed for by both the receiving nurse and the delivery person. This procedure was not followed, as evidenced by the missing medications and the lack of accountability among the staff. The facility's administration acknowledged the oversight and indicated that all nurses had access to the medication room during the period in question, further complicating the investigation into the missing medications. The incident underscores a significant lapse in the facility's medication management practices, resulting in the misappropriation of narcotic medications intended for a resident's pain management.
Failure to Provide Adequate Wound Care
Penalty
Summary
The facility failed to provide necessary wound care treatment and services to two residents, leading to the worsening of their pressure ulcers. Resident #9, who was admitted with no pressure injuries, developed a Stage 3 pressure ulcer on the right buttock, which was not treated as ordered on multiple occasions. The wound care was not documented on several dates, and the resident's condition deteriorated to a Stage 4 ulcer with infection. The resident was not seen by the wound doctor until two weeks after the initial referral, and the new wound care orders were not implemented until a week after the doctor's visit. Resident #1, who had a Stage 4 pressure ulcer, also did not receive the prescribed wound vac dressing changes on two occasions. The resident's care plan was not updated to reflect the current wound vac settings, and the wound clinic physician noted that the wound vac was changed less frequently than ordered. Interviews with staff revealed a lack of training and documentation regarding wound care procedures, contributing to the deficiencies in care. The facility's documentation policy requires all treatments and changes in resident conditions to be recorded, but this was not consistently followed. Staff interviews indicated that wound care was not always performed as ordered, and there was confusion about the implementation of new orders. The facility's failure to adhere to professional standards of practice for wound care placed residents at risk of worsening conditions and potential complications.
Removal Plan
- Facility had wound physician complete rounds on resident who have consented. All other wound treatments not referred or consented to wound care physician will be directed by primary care until otherwise directed by primary physician. Nurse Consultant and Director of Clinical Services have conducted an audit to ensure all wounds identified have a current treatment in place.
- Nurse Consultant and Director of Clinical Services provided in-service education to all nursing staff regarding following physician ordered wound care and documentation of wound care.
- All nursing staff will be provided with in-service following physician ordered wound care and documentation of wound care, including new hires, PRN, Vacation, Agency and Leave of Absence staff.
- Identify any new wounds through orders, weekly skin assessments and admission assessments review completed during clinical morning meeting will be referred to primary care physician and wound care physician if ordered by primary care physician.
- Wound care physician will be notified via telephone by DON or designee when wound care consultation is ordered.
- AD HOC QAPI meeting conducted to discuss plan of correction for compliance.
- Medical Director notified of alleged deficient practice.
Failure in Pain Management for Resident with Amputation
Penalty
Summary
The facility failed to provide effective pain management for a resident who had a recent above-the-knee amputation and was experiencing excruciating pain. Despite having a care plan in place that required monitoring and notifying the physician if pain interventions were unsuccessful, the facility did not adjust the resident's pain medication or notify her nurse practitioner. The resident's medical records showed inconsistent administration of prescribed pain medications, including Hydrocodone-Acetaminophen and a Buprenorphine patch, which was only applied once despite being ordered for weekly use. The resident's pain levels were documented as high, with some instances marked as ineffective or unknown in terms of pain relief. Additionally, there was a lack of documentation regarding the resident's pain during peri care, despite reports from CNAs that the resident was in significant pain and that the nurse was aware of the situation. The resident's nurse practitioner stated that she was not informed of the unmanaged pain and emphasized the importance of following the Buprenorphine patch orders. The resident's representative reported that the pain medication was insufficient and that the resident's severe pain persisted throughout her stay at the facility. The resident eventually required a procedure to address an infection at the amputation site, which contributed to her pain. The facility's failure to manage the resident's pain effectively resulted in an Immediate Jeopardy finding, indicating a serious risk to the resident's health and quality of life.
Removal Plan
- Regional Director of Clinical Services and Nurse Consultant began a review of residents charts for pain assessment orders.
- DON began inservice education for all nurses regarding pain assessments for all resident to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by regimen in place and how to conduct a pain assessment properly. Nursing Administration will complete a second pain assessment on 5 residents to ensure proper assessment of resident pain and level of nurse proficiency.
- All licensed nursing staff will be provided with in-service education on regarding pain assessments for all resident to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by current regimen, including new hires, PRN, Vacation, Agency and Leave of Absence staff.
- Confirm that pain assessment order was placed on the resident chart for all new admissions, readmissions or new complaints.
- Review all residents currently identified for increased or change in pain during WE CARE clinical meeting to confirm ongoing interventions and physician notification.
- AD HOC QAPI meeting conducted to discuss plan of correction for compliance.
- Medical Director notified of alleged deficient practice.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for three residents, which is a requirement to ensure effective and person-centered care. Resident #6, a male with no documented diagnoses, Resident #7, a female with altered mental status, and Resident #8, a female with multiple diagnoses including hypotension, repeated falls, dementia, and acute respiratory failure, all lacked completed admission MDS assessments and baseline care plans. This oversight was identified during a review of their electronic medical records. Interviews with facility staff revealed a lack of clarity and execution regarding the responsibility for completing baseline care plans. LVN A admitted to conducting resident assessments but not baseline care plans, highlighting the importance of these plans in understanding residents' needs, such as transfer assistance and medical equipment requirements. The DON and ADM both acknowledged that admitting nurses and charge nurses were responsible for completing these plans, which should include essential information like code status, medications, and skin issues. The facility's policy, revised in March 2022, mandates that a baseline care plan be developed within 48 hours of admission, but this was not adhered to, potentially compromising resident care.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, resulting in missed medication administrations. Resident #10, a female with multiple diagnoses including chronic respiratory failure and heart disease, did not receive several medications as ordered by her physician. These medications included Calcium, Fluorometholone Ophthalmic Suspension, Lidoderm Patch, Valacyclovir, Carvedilol, Revatio, and Levothyroxine. The missed doses were documented in the January 2025 Medication Administration Record (MAR), indicating specific dates when the medications were not administered. Resident #11, who had diagnoses such as malnutrition and osteoporosis, also experienced missed medication administrations. The December 2024 MAR showed that Atorvastatin, Latanoprost Ophthalmic Solution, and Levothyroxine were not given as prescribed. Interviews with staff, including the Assistant Director of Nursing (ADON) and the MDS Nurse, revealed expectations for medication administration and documentation, but these were not consistently met. The facility's policy on medication orders did not address the administration or documentation of medications, contributing to the deficiency. Observations and interviews with Resident #10 indicated that she was unsure if she was receiving all her medications as prescribed. The ADON and other staff members acknowledged the importance of administering medications as ordered and documenting them accurately. However, the facility's failure to adhere to these practices resulted in the potential for adverse effects on the residents' health. The absence of a comprehensive policy on medication administration further exacerbated the issue, as highlighted by the lack of documentation and communication regarding missed doses.
Deficiency in Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for three residents, leading to a deficiency in maintaining proper records. Specifically, the facility did not document nursing notes in the electronic medical records (EMR) of three residents for multiple days following their admission. This lack of documentation included the absence of an admission Minimum Data Set (MDS) assessment and a baseline care plan for each resident. The residents involved were an elderly male with no documented diagnoses, an elderly female with a diagnosis of altered mental status, and another elderly female with multiple diagnoses including hypotension, repeated falls, dementia, and acute respiratory failure. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Director of Nursing (DON), and the Administrator (ADM), revealed that the facility's policy required daily skilled notes in residents' EMRs, with a minimum of every 24 hours for Medicare residents. The staff acknowledged that the absence of documentation could lead to errors in care and treatment, as it would prevent nurses from knowing the residents' status and potentially result in missed care. The facility's Charting and Documentation Policy emphasized the importance of documenting all services provided, progress toward care plan goals, and any changes in the residents' conditions to facilitate communication among the interdisciplinary team.
Inadequate Infection Control and PPE Use in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which resulted in inadequate protection against the transmission of communicable diseases and infections for several residents. Specifically, the facility did not ensure that personal protective equipment (PPE) was worn during high-contact resident care activities for residents with medical devices or wounds. Observations revealed that staff did not wear appropriate PPE, such as gowns and gloves, when providing care to residents with indwelling catheters, wound vacs, and other medical devices. Additionally, the facility did not have proper signage on resident doors to indicate the need for PPE during high-contact care. This lack of signage contributed to the staff's failure to adhere to Enhanced Barrier Precautions (EBP), which are critical for preventing the spread of infections. Interviews with staff and residents confirmed that PPE was not consistently used, and there were no isolation carts or PPE caddies available in the facility. The facility also failed to provide adequate education and training to staff on infection control procedures related to EBP. Interviews with various staff members, including the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), revealed a lack of awareness and training on EBP. The facility's infection control policy and guidelines were not effectively implemented, leading to potential risks of infection for residents with wounds and medical devices.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to meet their medical and nursing needs. For one resident, the care plan did not include necessary interventions for Negative Pressure Wound Therapy (NPWT) to treat a stage 4 pressure ulcer. This resident, a female with a history of chronic pain, neuromuscular dysfunction of the bladder, paraplegia, and type 2 diabetes, was observed with a functioning wound vac machine at her bedside, but her care plan lacked specific instructions for the care and maintenance of the NPWT. Another resident's care plan was incomplete, failing to address her Activities of Daily Living (ADL) status, indwelling urinary catheter, stage 4 pressure ulcer, communication deficit, and CPAP usage. This resident, who had a history of aphasia, cerebrovascular accident, and chronic lung disease, was observed with a urinary catheter and tube feeding formula at her bedside. Despite these needs, her care plan did not reflect the necessary interventions to address her medical conditions and support her care. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development and maintenance of care plans. The MDS Nurse, who was responsible for care plans, was on vacation, and the social worker, who scheduled care plan meetings, did not initiate nursing care plans. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) expressed expectations for comprehensive care plans but acknowledged gaps in their completion. The facility's policy required comprehensive care plans to be developed within a specific timeframe and to include measurable objectives, but these requirements were not met for the residents in question.
Failure in Resident Nail Care and Hygiene
Penalty
Summary
The facility failed to provide necessary services for maintaining good nutrition, grooming, and personal and oral hygiene for three residents, specifically in the area of nail care. Residents were observed with long, dirty, and jagged fingernails, which were not addressed despite their care plans indicating the need for assistance with personal hygiene. Resident #1, a male with severe cognitive impairment, had fingernails that were an inch past the nail bed, discolored, and with a brown substance underneath. Resident #2, a female with intact cognition but requiring extensive assistance, had nails extending more than half an inch past the nail bed with similar debris. Resident #3, a female with major depressive disorder, also had unkempt nails with a dark substance underneath. Interviews with staff, including a CNA and the DON, revealed that nail care was supposed to be a shared responsibility among staff, but it was not being adequately monitored or executed. The CNA acknowledged the presence of long nails and the potential adverse outcomes, while the DON admitted to not paying attention to residents' nails and stated that nail care had been assigned to one CNA. The facility lacked a specific policy addressing nail care, which contributed to the oversight and failure to maintain proper hygiene for the residents.
Failure to Secure Medication Carts and Store Medications Properly
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with two of the six medication carts. On the morning of December 17, 2024, medication carts #2 and #3 were found unlocked and unattended near the nurses' station, with their drawers facing outward. This occurred while the RN was down the hall, and the carts were not visible from the middle of the hallway. Additionally, an unopened bag containing medication bottles was found sitting on a treatment cart, further indicating improper storage practices. Interviews with the RN and the DON confirmed awareness of the requirement for medication carts to be locked and for delivered medications to be stored promptly. The facility's policy on the delivery, receipt, and storage of medication specifies that only authorized staff should have access to medication storage areas, and that medications should be unpackaged and stored properly upon delivery. The failure to adhere to these protocols allowed unauthorized access to medications, posing a potential risk to residents and staff.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that four residents were free from the use of physical restraints, specifically wheelchair seat belt restraints, which were not documented or assessed as required. The residents involved had various medical conditions, including cerebral palsy, aphasia, epilepsy, and quadriplegia, which necessitated the use of wheelchairs. However, there was no documentation of trunk restraints in their medical records, and no assessments or consents for the use of seat belts were present. The care plans for these residents did not include any problems or interventions related to seatbelt use, and physician orders for the use of seat belts were present without corresponding assessments or consents. Observations revealed that the residents were using seat belts and, in one case, a shoulder strap, while in their wheelchairs. Interviews with the residents and their representatives indicated that the seat belts were perceived as safety devices to prevent sliding or falling out of the wheelchairs. The Director of Nursing (DON) stated that the facility did not have a restraint policy because they did not consider the seat belts as restraints but as safety devices. The physician involved was not aware of the specific type of seat belts used but believed they were necessary for the residents' safety due to their medical conditions. Despite the intention to use seat belts for safety, the lack of proper documentation, assessment, and consent constitutes a deficiency in ensuring residents are free from physical restraints unless medically necessary and properly documented.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported rate of 6.72 percent due to two errors out of 32 opportunities. The errors involved two residents, one with a diagnosis of vitamin deficiencies and moderate cognitive impairment, and another with hypertension and no cognitive impairment. The first resident did not receive Vitamin D 100 mg as ordered, and the second resident did not receive Terazosin 1 mg as prescribed. These medications were not available during the medication administration process. The medication aide (MA A) responsible for administering the medications stated that medications are typically reordered when there are only five days of supply left. However, due to being off for two days and running behind schedule, MA A did not check or restock the medication cart before the medication pass. The Director of Nursing (DON) confirmed that the expectation is for medications to be administered as ordered and for any unavailability to be reported to the charge nurse and herself. The facility's medication administration policy requires medications to be delivered within one hour before or after the scheduled time.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that Resident #48's drug regimen was free from unnecessary medications. Despite the resident's comprehensive assessment indicating no mood indicators, hallucinations, delusions, or other behavioral symptoms, the resident was prescribed multiple psychotropic medications, including Quetiapine, Sertraline, Trazodone, and Hydroxyzine. The facility did not document the necessity of these medications to treat specific conditions as diagnosed and documented in the clinical record. Additionally, the facility did not monitor Resident #48 for side effects or the effectiveness of the prescribed psychotropic medications. The MAR for April 2024 showed that the resident received the medications as ordered, but there was no documentation of side effect monitoring for the antidepressants or antianxiety medications. The MAR also lacked documentation of behavior monitoring related to the use of these medications. The pharmacist had recommended adding behavior and side effect monitoring for the medications, but this recommendation was not followed up within the expected timeframe. Interviews with the DON revealed that the facility's policy required monitoring for side effects and behaviors for all residents on psychotropic medications. However, this policy was not adhered to in the case of Resident #48. The DON acknowledged that not following up on pharmacy recommendations could lead to adverse outcomes. The facility's policy on psychotropic medication use emphasized the importance of monitoring for efficacy and adverse consequences, but this was not implemented for Resident #48.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing data, including the total number and actual hours worked by registered nurses, licensed practical or vocational nurses, and certified nurse aides, for several consecutive days. Specifically, the staffing log was not updated for the dates 04/06/24, 04/07/24, 04/08/24, and 04/09/24. An observation on 04/09/24 revealed that the staffing information posted was outdated, showing data from 04/05/24. The posted information did not include the total number and actual hours worked by the nursing staff, which is a requirement for transparency and accountability. Interviews conducted during the investigation revealed a lack of clarity and responsibility among staff regarding the posting of the staffing log. The CNA Scheduler, who was responsible for posting the information, did not work over the weekend and was unaware of the requirement to post actual hours worked. The Director of Nursing (DON) acknowledged that the staffing should have been posted daily and that department heads were responsible for posting the log in the absence of the CNA Scheduler. However, there was no policy in place to ensure compliance, and the oversight was attributed to a simple miss over the weekend, with no immediate negative outcomes reported.
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What surveyors actually found near you
We read the 86 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Temple
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Baylor Scott & White Continuing Care Hospital Skil | 0.3 mi | ★★★★★ | 1 | 0 |
| Wellington Rehabilitation And Healthcare | 0.6 mi | ★★★★★ | 2 | 1 |
| Avir At Temple West | 0.8 mi | ★★★★★ | 1 | 0 |
| Avir At Temple East | 0.9 mi | ★★★★★ | 3 | 0 |
| Cornerstone Gardens Llp | 1.2 mi | ★★★★★ | 0 | 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.