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 Winnsboro during CMS and state inspections, most recent first.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed that the environment did not meet safety standards and lacked proper oversight.
Surveyors found that pulled pork was thawed at room temperature, frozen foods were not labeled or dated, and cooking trays were stored improperly. Staff interviews confirmed these actions did not follow required food safety standards or facility policy.
Residents and staff reported that meals were often bland, cold, or unappetizing, with several residents relying on snacks due to dissatisfaction with facility food. A test tray evaluation confirmed that food lacked flavor and proper temperature, and the dietary manager identified the absence of plate warmers as a contributing factor. These issues were corroborated by multiple resident complaints and observations by the survey team.
A resident with a JP drain did not have this device or its required care interventions included in their care plan, despite physician orders and ongoing need for monitoring and site care. The omission was not identified by staff until surveyors intervened, and the facility's policy requiring comprehensive, person-centered, and current care plans was not followed.
A resident with multiple medical conditions and impaired cognition, who required oxygen therapy, was found to have an oxygen concentrator without a filter on several occasions, despite documentation indicating weekly maintenance had been completed. Staff interviews confirmed the filter should have been present and clean, in accordance with physician orders and facility policy.
A resident with PTSD and a history of trauma did not have his specific triggers, such as loud noises and water, included in his care plan. Direct care staff were unaware of these triggers, and the facility lacked a trauma-informed care policy, resulting in a failure to provide care in accordance with professional standards.
A resident with multiple diagnoses, including Alzheimer's and depression, continued to receive a higher dose of mirtazapine than ordered after a physician signed off on a pharmacy recommendation to reduce the dose. The medication order was not updated due to a breakdown in communication and follow-up among nursing staff, resulting in the resident receiving unnecessary medication.
The facility had a medication error rate of 6.9% after two residents did not receive their medications as ordered: one received an insufficient dose of Omeprazole, and another received only one spray of fluticasone instead of two. Nursing staff did not follow physician orders during medication administration, contrary to facility policy.
A resident with severe cognitive impairment was found to have hibiclens antiseptic skin cleanser stored on a bathroom shelf in her room on multiple occasions. Facility staff, including an LVN, DON, and Administrator, confirmed that the cleanser should not have been accessible and should have been stored in a locked medication room or cart, in accordance with facility policy. The failure to secure the hibiclens was acknowledged as a breach of protocol.
The facility did not accurately document its facility-wide assessment, omitting a resident who required dialysis from its records. This resident, who had chronic kidney disease and other significant health conditions, was receiving dialysis multiple times per week. The administrator acknowledged the oversight, and the DON confirmed there was no policy in place for facility assessments.
A resident with dementia and high elopement risk left the facility unsupervised, walking 0.5 miles and crossing a busy road. Despite being classified as high risk, the facility failed to implement effective measures to prevent the resident from leaving. The ADON witnessed the resident climbing the fence but did not prevent the elopement. The resident was eventually found by a hospice nurse and family members, highlighting a lack of supervision and communication among staff.
Two residents in a facility experienced abuse due to inadequate monitoring and intervention. One resident was choked and struck by another, while another resident was slapped due to agitation over noise. The facility failed to prevent these incidents, despite one resident having a history of aggressive behavior.
A CNA/Van Driver misappropriated a resident's debit/credit card, conducting 59 unauthorized transactions. The resident, with dementia and moderate cognitive impairment, was unable to protect their financial resources. The facility's social worker and fiduciary noticed unusual transactions, leading to a police investigation that confirmed the CNA/Van Driver's actions. The CNA/Van Driver was terminated following the confirmation of misappropriation.
The facility failed to provide a safe, clean, and comfortable environment for a resident and the dining room. A resident's bathroom had a strong odor of urine and broken tiles, while the dining room used plastic, folding tables that were not conducive to comfortable dining. Despite staff awareness, no corrective actions were taken.
The facility failed to address grievances from residents about unmade beds and cold food, as documented in Resident Council meetings. Observations confirmed these issues, with unmade beds and cold meal trays reported by residents. Staff interviews revealed inadequate grievance management, with the DON expecting departments to resolve issues, but the process was not effectively implemented.
The facility failed to deliver resident mail on weekends, impacting their right to communication and potentially affecting their psychosocial well-being. Residents reported not receiving mail on weekends, and interviews revealed confusion about mail delivery responsibilities. The local Postmaster indicated mail was stopped on weekends, and there was no facility policy regarding mail delivery.
A facility failed to update a resident's care plan to reflect a change in code status from full code to DNR, despite having a signed DNR order. The resident, with severe cognitive impairment, was at risk of receiving unwanted CPR due to this oversight. Interviews indicated that nursing leadership was responsible for timely updates, which were not made according to facility policy.
The facility failed to develop comprehensive care plans for residents, leading to deficiencies in addressing specific needs such as secure unit placement, smoking habits, prophylactic antibiotic use, and PTSD triggers. Observations and interviews revealed a lack of documentation and oversight, posing risks to resident safety and care.
The facility failed to ensure a fall mat was in place for a resident as required by her care plan, and did not conduct monthly smoking assessments for two residents, contrary to facility policy. The absence of a fall mat was acknowledged by an RN and the DON, while the lack of smoking assessments was due to a misunderstanding of the policy by the social worker, who believed assessments were annual rather than monthly.
A long-term care facility failed to administer medications on time for four residents, including those with severe cognitive impairment and chronic conditions. Medications were given significantly later than scheduled due to a staff member arriving late for an unscheduled shift. The delay in administration was acknowledged by the DON and other staff, highlighting the importance of timely medication delivery.
A resident with dementia and severely impaired cognition continued to receive the antipsychotic medication Seroquel despite a pharmacy recommendation and physician agreement to discontinue it. The facility failed to implement the physician's order, resulting in the resident receiving 13 additional doses. The DON and Regional Director acknowledged the oversight and emphasized the responsibility of nurse management in following pharmacy recommendations.
A long-term care facility reported a 38% medication error rate, with four residents receiving medications late due to a medication aide's late arrival for a shift. Residents with cognitive impairments and various diagnoses, including seizures and high blood pressure, were affected. The facility's DON and RDO acknowledged the potential impact on medication effectiveness and resident health.
The facility failed to provide food at a palatable and safe temperature for seven residents. Residents reported receiving cold meal trays, and observations confirmed that food was not served on warmed plates. Interviews with staff highlighted the lack of a policy on food palatability and the shared responsibility between nursing and dietary departments to ensure meals are served at the correct temperature.
A facility failed to update a resident's comprehensive care plan to reflect a change in code status from full code to DNR, despite having a physician order and family consent for DNR. The resident, with severe cognitive impairment and multiple diagnoses, was at risk due to this oversight. Interviews with the DON and Regional Clinical Consultant confirmed the expectation for timely updates to care plans.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper handling of a resident's catheter bag, inadequate incontinent care by a CNA, and poor laundry practices. A resident's catheter bag was repeatedly observed on the floor, and another resident received improper peri care without proper hand hygiene. Laundry staff handled soiled linen without PPE and transported clean laundry uncovered, risking cross-contamination.
The facility failed to notify the representatives of two residents immediately following significant changes in their conditions due to falls. Despite the facility's policy, the responsible nurse forgot to inform the families, and the Director of Nursing acknowledged the oversight.
Two residents experienced a lack of dignity in their care at an LTC facility. One resident's catheter bag was left uncovered, visible from the hallway, against care plan instructions. Another resident was fed by a CNA standing over them, contrary to the practice of sitting at eye level. Staff interviews confirmed these actions were not in line with dignity-preserving practices.
A resident with dementia and a history of falls had her call light repeatedly found out of reach, despite care plan instructions. Staff interviews confirmed the responsibility to ensure call lights are accessible, but the facility lacked a specific policy on this matter.
A medication aide in an LTC facility left the EMR of two residents open and visible on the medication cart during medication administration, potentially exposing sensitive information. The residents involved had conditions such as heart failure, keratoconjunctivitis, and major depressive disorder. Staff interviews confirmed the expectation to protect resident privacy.
The facility failed to report injuries of unknown origin for two residents, as required by their abuse prevention policy. One resident, with Alzheimer's and other conditions, was found with bruising on her perineum after a fall, but the injury was not reported to HHSC. Another resident, with multiple diagnoses, was found with bruising on his buttocks and chest, which was also not reported. The facility's failure to adhere to reporting requirements represents a significant deficiency.
The facility failed to report injuries of unknown origin for two residents to the appropriate authorities within the required timeframes. One resident, a female with Alzheimer's, was found with bruising on her perineum after a fall, which staff attributed to the fall and did not report. Another resident, a male with severe cognitive impairment, was found with bruising on his buttocks and chest, which was also not reported. This deficiency could place residents at risk for further neglect.
A resident's MDS assessment inaccurately recorded a weight loss despite a documented weight gain, due to a human error by the MDS Coordinator. The resident, with multiple medical conditions, was noted to have gained 9.3% of his body weight, but the MDS indicated a loss. The DON and Regional Director acknowledged the importance of accurate assessments, though the facility lacked a specific policy on MDS accuracy.
A resident with a diabetic ulcer did not receive proper monitoring and care as required by professional standards. Despite having a care plan for regular wound assessments, the facility failed to document necessary measurements, relying instead on podiatrist visits. Interviews with staff revealed a lack of adherence to the facility's skin integrity monitoring policy, which required regular documentation of skin conditions.
A facility failed to provide trauma-informed care for a resident with PTSD, as a trauma assessment was not completed upon admission, and staff were unaware of the resident's triggers. The resident's care plan did not reflect his PTSD diagnosis, leading to potential risks of re-traumatization due to loud noises and water.
The facility failed to secure drugs properly, with a medication cart left unlocked and a lock box for controlled drugs not affixed in the refrigerator. A medication aide admitted to leaving the cart unlocked, and a liquid Lorazepam bottle was found in an unaffixed lock box. The DON and RDO were unaware of these issues, which could lead to drug diversion.
A resident lost his dentures, and the facility failed to provide necessary dental services due to a lack of policy and communication. Despite a physician's order for dental consults, no referral was made, and the resident's family expressed concerns. The Social Worker and DON were unaware of any policy regarding lost dentures, leading to inaction.
The facility's kitchen was found to have unsanitary conditions, including grease buildup on sheet pans, carbon buildup on cast iron skillets, and dust on a juice machine. Staff interviews revealed that these items were not included in the cleaning schedule, and the Dietary Manager acknowledged the potential risk of illness. The facility's policies emphasize the need for clean food-contact surfaces to prevent food-borne illnesses.
The facility failed to coordinate hospice care and maintain documentation for two residents receiving hospice services. One resident's hospice binder was missing, hindering communication and care management, while another resident's hospice plan of care was outdated, risking incorrect medication administration. Interviews revealed that hospice staff were behind in updating care plans, and there was no facility policy on hospice services, leading to inadequate coordination and communication.
A facility failed to ensure proper documentation for the use of Zithromax in a resident with metabolic encephalopathy, dementia, and diabetes. Despite the absence of documented symptoms like fever or cough, the resident was administered the antibiotic. Interviews with staff revealed a lack of documentation supporting the antibiotic's use, contrary to the facility's antibiotic stewardship policy.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to accidents occurring. Specific actions or inactions leading to this deficiency include the lack of proper oversight and the presence of hazards in the area, as directly observed by surveyors.
Improper Food Thawing, Labeling, and Storage in Dietary Services
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and handling practices. Three packages of pulled pork were found thawing at room temperature on a table, still solid and not submerged in water or under refrigeration as required. Several bags of frozen cinnamon rolls and sweet potato fries were stored in freezer bags without labels or dates, and peas and an unidentified breaded meat were also found in sealed bags with no labeling or dating, with the peas showing frost buildup. Additionally, cooking trays and muffin trays were improperly stored in an office between open cardboard boxes, rather than in a designated storage area. Interviews with the dietician and dietary manager confirmed that these practices did not align with professional standards or the facility's own policies, which require proper thawing methods, labeling, and storage of food and equipment. The administrator acknowledged that it was the responsibility of all relevant staff to ensure compliance with safe food handling procedures, including proper thawing, labeling, and storage of food and cookware. The facility's documented policies also specify that food must be thawed in a refrigerator or under running cold water, and all stored food must be labeled and dated.
Failure to Provide Palatable and Properly Tempered Food to Residents
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Multiple residents reported dissatisfaction with the quality and temperature of the food, describing it as bland, overcooked, cold, or having unusual flavors. One resident stated he avoided eating facility meals and relied on snacks in his room, while others echoed concerns about the food being consistently cold and unappetizing. Anonymous complaints during a resident council meeting also highlighted issues with food temperature and meal timing. During a test tray evaluation, both the dietary manager and state survey team found the sampled meal to be lacking in flavor and temperature, with specific items such as lemon butter chicken and vegetables described as bland or overpowered by certain flavors. The dietary manager noted that the lack of plate warmers contributed to the food cooling quickly after plating. The DON and administrator acknowledged that residents who disliked the food might be at risk for malnutrition and weight loss, and it was noted that resident satisfaction declined after a change in food providers. The facility's policy required regular test tray evaluations, but the issues persisted as observed and reported.
Failure to Care Plan JP Drain for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had a Jackson Pratt (JP) drain following surgery. Despite physician orders specifying that the JP drain should be emptied and drainage documented each shift, the site cleansed and dressed every shift, and the site monitored for signs of infection, these interventions were not included in the resident's care plan. The resident's admission MDS assessment did not mention the JP drain, and the care plan, as of its last revision prior to surveyor intervention, did not address the presence or care of the JP drain. Observations confirmed the resident had a JP drain in place, and interviews with staff revealed that the omission was not recognized until brought to their attention by surveyors. The MDS coordinator and other members of the interdisciplinary team (IDT) were responsible for developing and updating care plans, but the JP drain was not care planned despite being present since admission. The Director of Nursing (DON) and Administrator both acknowledged that the care plan should reflect all aspects of a resident's care, and that the omission could impact the resident's care. Facility policy required that care plans be comprehensive, person-centered, and kept current, but this was not followed in the case of the resident with the JP drain.
Failure to Maintain Oxygen Concentrator Filter for Resident Receiving Respiratory Care
Penalty
Summary
A deficiency occurred when a resident who required oxygen therapy did not have a filter in her oxygen concentrator, as observed on multiple occasions over several days. The resident, an elderly female with diagnoses including heart failure, a history of COVID, altered mental status, anxiety, and high blood pressure, had severely impaired cognition and was dependent on staff for activities of daily living. Her care plan and physician orders specified that oxygen tubing, bubble humidification, and filters were to be changed and cleaned weekly by the night shift nurse. Documentation indicated that the required maintenance was signed off as completed, but direct observation revealed the filter was missing from the concentrator. Interviews with staff, including an LVN, the DON, and the Administrator, confirmed that the filter should have been present and clean, and that its absence was contrary to facility policy and physician orders. The facility's policy required filters to be washed every seven days, and only trained licensed staff were to administer and maintain respiratory therapy equipment. The failure to ensure the filter was in place was acknowledged by staff and administration during interviews, and it was noted that the responsible night shift nurse could not be reached for clarification.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of trauma and a diagnosis of PTSD received trauma-informed, culturally competent care in accordance with professional standards. The resident's care plan did not include specific triggers related to his PTSD, despite documentation in his trauma assessment and direct communication from the resident about his triggers, which included loud noises, war pictures, and water. Staff interviews revealed that direct care staff, including a CNA and an LVN, were either unaware of the resident's PTSD diagnosis or did not know his specific triggers. The care plan only generally referenced the risk of the resident being startled, without specifying the known triggers. Further, the social worker and MDS coordinator acknowledged that the resident's triggers were not included in the care plan, and the social worker confirmed that this information should have been documented to inform staff. The DON and administrator both stated that the care plan should reflect the trauma assessment and include specific triggers so staff could provide appropriate care. At the time of the survey, the facility did not have a policy on trauma-informed care, and there was no evidence that staff had been formally in-serviced on the resident's specific triggers.
Failure to Implement Physician-Ordered Antidepressant Dose Reduction
Penalty
Summary
A deficiency occurred when a resident with Alzheimer's disease, diabetes, heart disease, depression, and anxiety continued to receive an unnecessary dose of Remeron (mirtazapine), an antidepressant medication, despite a signed physician order to decrease the dose. The pharmacy had recommended, and the medical director agreed, to reduce the resident's Remeron from 22.5mg to 15mg nightly. However, the medication administration record showed that the resident continued to receive the higher dose for an extended period after the order was signed. The failure was attributed to a breakdown in the facility's process for implementing pharmacy recommendations and physician orders. The DON stated that the charge nurse is responsible for updating orders and providing documentation for follow-up, but in this case, the signed order to decrease the medication was not properly communicated or acted upon. As a result, the resident continued to receive a higher dose of medication than was necessary, contrary to facility policy and regulatory requirements.
Medication Error Rate Exceeds 5% Due to Incorrect Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.9% based on 2 errors out of 29 observed opportunities. One error involved a male resident with coronary artery disease, dementia, GERD, and hypertension, who was ordered to receive Omeprazole 20 mg, two tablets by mouth twice daily. On the observed date, the nurse administered only one 20 mg tablet instead of the prescribed two, resulting in an underdose. The resident's care plan required medications to be administered as ordered and for staff to monitor and document side effects and effectiveness. A second error involved a female resident with heart failure, dementia, GERD, and hypertension, who was ordered to receive Flonase Allergy Relief (fluticasone) nasal spray, two sprays in each nostril twice daily. During medication administration, the nurse administered only one spray instead of the prescribed two. The nurse later acknowledged the mistake, stating she thought she had given two sprays but realized she had not. The facility's policy required medications to be administered and documented as ordered by the physician and in accordance with state regulations.
Improper Storage of Antiseptic Cleanser in Resident Room
Penalty
Summary
A deficiency occurred when a resident with severely impaired cognition, as indicated by a BIMS score of 3 and a care plan noting an ADL self-care deficit, was found to have hibiclens antiseptic skin cleanser stored on a bathroom shelf in her room. Multiple observations on consecutive days confirmed the presence of the hibiclens in the resident's bathroom. The resident's medical history included heart failure, altered mental status, anxiety, and high blood pressure, and she required supervision and assistance with activities of daily living, including bathroom use and showers. Interviews with facility staff, including an LVN, the DON, and the Administrator, confirmed that the hibiclens antiseptic cleanser should not have been accessible in the resident's room and should have been stored in a locked medication room or cart. The facility's policy required that medications be stored securely and only accessible to authorized personnel. Staff acknowledged that the presence of the hibiclens in the resident's bathroom was a failure to follow policy and placed the resident and others at risk, as the cleanser is not intended for resident possession.
Failure to Accurately Document Facility Assessment for Dialysis Care
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Specifically, the assessment did not accurately reflect the presence of a resident receiving dialysis, as it listed zero residents requiring this special treatment. This omission was identified during a review of the facility assessment, which had not been updated to include the dialysis patient, despite the resident's ongoing need for dialysis services. A male resident with chronic kidney disease, malignant neoplasm of the kidney, diabetes, and high blood pressure was admitted to the facility and required dialysis three times a week. Documentation confirmed the resident's cognitive intactness and dependence on staff for multiple activities of daily living. The administrator acknowledged the oversight during an interview, stating that the dialysis patient should have been included in the facility assessment. Additionally, the Director of Nursing confirmed that the facility did not have a policy for conducting facility assessments.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent avoidable accidents for a resident who was at high risk for elopement. The resident, who had a history of dementia with behavioral disturbances, anxiety, depression, and hypertension, was able to leave the facility unsupervised. This resident had a severely impaired cognition with a BIMS score of 4 and was receiving hospice care. Despite being classified as high risk for wandering, the facility did not implement effective measures to prevent the resident from leaving the premises. On the day of the incident, the resident expressed a desire to go home and exhibited agitated behavior. The resident was taken outside for a scheduled break but refused to return inside. The Assistant Director of Nursing (ADON) witnessed the resident climbing the fence and leaving the facility. Although the ADON followed the resident in her car, the resident managed to walk approximately 0.5 miles and cross a busy two-lane road. The facility staff, including the Licensed Vocational Nurse (LVN) and Certified Nursing Assistant (CNA), failed to maintain constant supervision, and the resident was eventually found by a hospice nurse and family members. Interviews with facility staff revealed inconsistencies in their accounts of the incident, with some staff members claiming the resident was never out of sight, while others acknowledged the resident was missing. The facility's policy on elopement was not effectively followed, as there was no immediate notification to the police or a coordinated search effort. The lack of documentation and communication among staff members further contributed to the failure to prevent the resident's elopement.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in incidents involving resident-to-resident altercations. Resident #5 was subjected to abuse when Resident #6 attempted to choke and struck him on the back. This incident occurred in the bathroom of Resident #5's room and was witnessed by LVN E and other staff members. Despite Resident #6 having no prior aggressive behaviors, the facility did not have measures in place to prevent this occurrence, leading to a failure in ensuring Resident #5's safety. In another incident, Resident #2 was slapped on the upper arm by Resident #3, who was agitated by Resident #2's repetitive noise. This altercation was witnessed by LVN E, who was across the room at the nurse's station. Resident #3 had a history of aggressive behavior, yet the facility's interventions were insufficient to prevent the incident. The facility's failure to monitor and manage Resident #3's behavior contributed to the abuse of Resident #2. Both incidents highlight the facility's inability to maintain a safe environment for residents, particularly those with cognitive impairments and behavioral issues. The lack of effective monitoring and intervention strategies allowed these abusive interactions to occur, placing residents at risk of physical harm and emotional distress.
Misappropriation of Resident's Debit/Credit Card by CNA/Van Driver
Penalty
Summary
The facility failed to protect a resident from the misappropriation of their property, specifically their debit/credit card, by a CNA/Van Driver. The resident, who had a diagnosis of dementia, depression, and anxiety, was moderately cognitively impaired and required assistance with decision-making. The CNA/Van Driver was observed being unusually attentive to the resident's needs, which raised suspicions. It was later confirmed that the CNA/Van Driver had taken the resident's debit/credit card and used it for personal transactions. The misappropriation was discovered through a police investigation, which revealed that the CNA/Van Driver had conducted 59 fraudulent transactions using the resident's card. The transactions were captured on camera, and the CNA/Van Driver was seen withdrawing money from an ATM. The facility's social worker and the resident's fiduciary noticed unusual transactions and took steps to close the resident's account to prevent further unauthorized access. The facility's Director of Nursing and Administrator were involved in addressing the issue once it was identified. The CNA/Van Driver was terminated from employment following the confirmation of the misappropriation by police officers. The facility had a policy in place to protect residents from abuse and misappropriation, but the incident highlighted a failure in preventing the CNA/Van Driver from exploiting the resident's financial resources.
Failure to Maintain a Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for Resident #9 and the dining room. Resident #9's bathroom had a strong odor of urine and broken, misshaped tiles around the base of the toilet, exposing large areas of grout. Despite the maintenance supervisor being aware of the issue, the repairs had not been completed, and the bathroom continued to have an offensive odor. Housekeeping staff also noticed the odor but did not place a work order for maintenance, assuming the supervisor was already aware. The Director of Nursing (DON) and the Regional Director acknowledged the importance of maintaining a clean and odor-free environment but had not taken action to address the issue in Resident #9's bathroom. The dining room environment was also found to be lacking in comfort and homeliness. Approximately 17 residents were observed seated at plastic, folding tables that did not allow proper positioning for eating comfortably, especially for those in wheelchairs. The tables were described as institutional-like and not conducive to a pleasant dining experience. The Regional Director admitted that the plastic tables were not homelike and mentioned plans to purchase better tables, but no action had been taken yet. Interviews with staff, including an RN, housekeeping aide, maintenance supervisor, and the DON, revealed a lack of communication and follow-through on maintenance and housekeeping issues. The DON and Regional Director both emphasized the importance of a homelike environment but had not implemented policies or taken steps to ensure this standard was met. The facility's inaction in addressing these environmental deficiencies compromised the residents' quality of life and comfort.
Failure to Address Resident Grievances on Unmade Beds and Cold Food
Penalty
Summary
The facility failed to address and document the grievances raised by resident groups concerning unmade beds and cold food. During Resident Council meetings on three separate occasions, residents expressed concerns about their beds not being made daily and meals being served cold. Despite these grievances being recorded, there was no documentation on how these issues would be managed or resolved, indicating a lack of prompt action and response from the facility. Observations and interviews conducted during the survey confirmed the ongoing issues. A confidential resident's bed was observed unmade, and multiple residents reported receiving cold meal trays, consistent with their complaints during council meetings. The Dietary Manager acknowledged that a test tray was not served at the appropriate temperature, further corroborating the residents' grievances about meal quality. Interviews with facility staff, including the DON and the Activity Director, revealed a lack of effective grievance management. The DON expected grievances to be resolved by the respective departments, but the process was not effectively implemented. The Activity Director, who was responsible for documenting and distributing grievances, admitted to being new to the role and still learning the process. The facility's policy required prompt resolution of grievances, but this was not adhered to, as evidenced by the unresolved issues reported by residents.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure that residents received their mail on weekends, affecting their right to communication and potentially impacting their psychosocial well-being and quality of life. This issue was identified through interviews and record reviews, where it was noted that residents consistently reported not receiving mail on weekends during Resident Council Meetings over several months. A group interview with five residents confirmed that mail was not distributed on Saturdays, and they were unsure of the reason. The Director of Nursing (DON) and the Regional Director of Operations (RDO) acknowledged the issue, with the DON indicating that the Activity Director was believed to be responsible for mail delivery, and the RDO stating that the Administrator was expected to ensure timely mail delivery. Further investigation revealed that the local Postmaster indicated the facility did not receive mail on weekends because the business had stopped their mail, affecting resident mail delivery. The Clinical Director confirmed there was no facility policy regarding mail. The report also referenced the Texas Department of Aging and Disability Services and the HUMAN RESOURCES CODE CHAPTER 102, which state that residents have the right to send and receive unopened mail promptly. This deficiency highlights a failure in the facility's processes to uphold residents' rights to communication and privacy.
Failure to Update Resident's Code Status in Care Plan
Penalty
Summary
The facility failed to ensure that a resident had the right to formulate an advance directive, specifically by not accurately updating the resident's comprehensive care plan with her code status. The resident, an elderly female with severe cognitive impairment due to Alzheimer's, was admitted with several diagnoses including atrial fibrillation, depression, and anxiety. Despite having a Do-Not-Resuscitate (DNR) order signed by a family member and notarized, the resident's care plan still indicated a full code status, which was not updated in a timely manner. Interviews with the Director of Nursing (DON) and the Regional Clinical Consultant revealed that the nursing leadership was responsible for updating care plans, and the failure to do so could have placed the resident at risk of receiving unwanted CPR. The facility's policy required that care plans be kept current and updated to reflect changes in the resident's condition and code status, but this was not adhered to in this case.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in addressing their specific needs. Resident #40, a male with dementia, depression, and paranoid schizophrenia, was identified as being at high risk of elopement. Despite physician orders indicating the need for him to reside in a secure unit, his care plan did not include any interventions related to this requirement. Observations confirmed that Resident #40 was in the secure unit, but the lack of a documented care plan posed a risk to his safety. Resident #33, a male with severe cognitive impairment and a history of smoking, also lacked a comprehensive care plan addressing his need to be in a secure unit and his smoking habits. Although he was observed smoking with staff and residing in the secure unit, there were no physician orders or care plan interventions documented for these needs. Interviews with staff, including the MDS nurse and DON, revealed a lack of awareness and oversight in ensuring that care plans were updated to reflect these critical aspects of Resident #33's care. Additionally, Resident #4, a female with dementia and a history of urinary tract infections, was receiving a prophylactic antibiotic, Macrodantin, as per physician orders. However, her care plan did not reflect this ongoing treatment. Similarly, Resident #23, a male with PTSD, did not have his diagnosis or triggers documented in his care plan, despite his acknowledgment of loud noises as a trigger. The DON and Regional Clinical Consultant confirmed that these omissions in care planning were not in line with the facility's policy, which requires care plans to be comprehensive and current to ensure appropriate care for residents.
Failure to Ensure Safety Measures and Conduct Required Assessments
Penalty
Summary
The facility failed to maintain a safe environment for Resident #38 by not ensuring the presence of a fall mat as required by her care plan. Despite the care plan and medication administration record (MAR) indicating the need for a fall mat, observations revealed that the mat was not in place. RN B admitted to signing off on the MAR without verifying the mat's presence, and the Director of Nursing (DON) confirmed that the mat should have been in place for the resident's safety. Additionally, the facility did not conduct monthly smoking assessments for Resident #12 and Resident #33, as mandated by the facility's policy. Resident #12, who was moderately cognitively impaired, and Resident #33, who had significant cognitive and communication challenges, were both identified as smokers. However, their electronic medical records lacked smoking assessments for March and April 2024. The oversight was acknowledged by RN G and the DON, who were unaware of the monthly requirement until prompted by the surveyor. The social worker, responsible for completing smoking assessments, was under the impression that these assessments were annual until the surveyor's inquiry. Upon realizing the policy required monthly assessments, the social worker conducted the necessary evaluations. The facility's policy, dated December 2017, clearly stated that smoking safety evaluations should be completed monthly and upon any change in condition, but this was not adhered to, potentially compromising resident safety.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure the timely administration of medications for four residents, leading to a deficiency in pharmaceutical services. The medications for these residents were not administered at the scheduled times as per the physician's orders. This issue was observed during a survey where the medications were given significantly later than the prescribed times, potentially affecting the therapeutic outcomes for the residents involved. Resident #11, a female with severe cognitive impairment and multiple diagnoses including seizures and high blood pressure, did not receive her medications, including Clindamycin, Eliquis, Keppra, and Vimpat, at the scheduled time of 8:30 a.m. Instead, they were administered at 10:31 a.m. Similarly, Resident #54, who has chronic pain and high blood pressure, received her medications, including Tylenol, Coreg, Gabapentin, and Isosorbide, at 10:31 a.m. instead of the scheduled 8:30 a.m. Resident #50, a male with a history of stroke and kidney disease, was also affected, receiving his Tylenol at 10:44 a.m. instead of 8:30 a.m. Lastly, Resident #55, who has dementia and bipolar disorder, received his Oxcarbazepine at 10:53 a.m. instead of the scheduled 9:00 a.m. The delay in medication administration was attributed to MA K arriving late for her shift, which was not her usual schedule, and this was noted as a recurring issue. The Director of Nursing and other staff acknowledged the importance of timely medication administration and the potential adverse effects of delays.
Failure to Discontinue Unnecessary Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident who was prescribed psychotropic drugs was only given those drugs when necessary to treat a specific condition as diagnosed and documented in the clinical record. Specifically, the facility did not follow the pharmacy's recommendation to discontinue the antipsychotic medication Seroquel (quetiapine) for a resident, resulting in the resident receiving 13 additional doses of the medication. This oversight occurred despite the physician agreeing to discontinue the medication, as indicated in the pharmacy recommendation signed on 04/25/24. The resident involved was an elderly male with diagnoses including dementia, insomnia, a left femur fracture, and weakness. His admission MDS assessment indicated severely impaired cognition. The facility's Director of Nursing (DON) acknowledged the failure to implement the physician's order to discontinue the medication, citing uncertainty about how the oversight occurred. The Regional Director also expressed that the pharmacy recommendations should have been followed through by the nursing staff, emphasizing that nurse management was responsible for ensuring the completion of these recommendations.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported error rate of 38% based on 16 errors out of 42 opportunities. This involved four residents who did not receive their medications at the scheduled times, as per physician orders. The errors were observed during a survey, where medications were administered late by a medication aide (MA K) due to arriving late for a shift. Resident #11, a female with severe cognitive impairment and multiple diagnoses including seizures and high blood pressure, did not receive her medications at the scheduled times. Her medications, including Buspirone, Clindamycin, Eliquis, Lasix, and Keppra, were administered at 10:31 a.m. instead of the scheduled 8:30 a.m. This delay was observed during a medication pass by MA K. Similarly, Resident #54, with moderate cognitive impairment and diagnoses of chronic pain and high blood pressure, received her medications late. Medications such as Tylenol, Coreg, Fluoxetine, Gabapentin, Isosorbide ER, and Spironolactone were administered at 10:31 a.m. instead of the scheduled 8:30 a.m. The facility's Director of Nursing (DON) and Regional Director of Operations (RDO) acknowledged the issue, noting that late administration could affect medication effectiveness and resident health.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for seven residents reviewed for food and nutrition services. During an initial tour interview, two residents reported that their meal trays were cold. A subsequent group interview with five residents confirmed that the food trays served on the halls were cold. The food temperature log indicated that the regular meat was served at 188 degrees Fahrenheit, cooked vegetables at 170 and 171 degrees Fahrenheit, and dessert at 33 degrees Fahrenheit. However, during an observation, it was noted that the resident trays and the test tray were not prepared on warmed plates using a plate warmer, which contributed to the food being served at incorrect temperatures. Interviews with the Dietary Manager, Director of Nursing (DON), and Regional Dietary Officer (RDO) revealed that there was an expectation for meals to be served at standard required temperatures to ensure palatability and prevent decreased intake and weight loss. The Dietary Manager acknowledged that the test tray tasted good but needed improvement in temperature, attributing the issue to the use of cold plates. The DON and RDO emphasized the importance of serving meals at palatable temperatures, with the responsibility shared between nursing and the dietary department. The report also noted that there was no existing policy on the palatability of food.
Failure to Update Resident's Code Status in Care Plan
Penalty
Summary
The facility failed to ensure the medical record was complete and accurately documented for a resident reviewed for resident records. Specifically, the facility did not update the comprehensive care plan of a resident with her correct code status. The resident, who was admitted with diagnoses including Alzheimer's, atrial fibrillation, depression, and anxiety, had a significant change in status assessment indicating severe cognitive impairment. Despite having a physician order for a DNR (do not resuscitate) status, the resident's care plan still indicated a full code CPR order. Interviews with the Director of Nursing (DON) and the Regional Clinical Consultant revealed that the care plan should have been updated to reflect the resident's DNR status. The DON acknowledged that the failure to update the care plan could place the resident at risk of receiving unwanted CPR. The facility's policy requires that care plans be kept current and updated to meet the individual needs of residents, consistent with the physician's plan of care.
Infection Control Deficiencies in Resident Care and Laundry Services
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Resident #14's indwelling urinary catheter bag was repeatedly observed lying on the floor, which is against the care plan's instructions to keep the bag off the floor to prevent infection. Despite multiple observations throughout the day, the staff, including CNA H and LVN F, did not notice or correct the issue, indicating a lack of adherence to infection control protocols. The Director of Nursing (DON) acknowledged the risk of cross-contamination and stated that all staff were responsible for infection prevention. Resident #17 received improper incontinent care from CNA H, who failed to perform hand hygiene and change gloves between clean and dirty tasks. CNA H used the same wipe inappropriately and did not follow the correct front-to-back wiping technique, which could lead to infection. The DON confirmed that the CNA did not meet the expected standards for peri care and hand hygiene, which are crucial for preventing infections. The facility's laundry services also demonstrated significant lapses in infection control. Laundry staff L was observed handling soiled linen without appropriate PPE and transporting dirty linen in an open container, which could lead to cross-contamination. Additionally, clean laundry was transported uncovered within the facility, further risking contamination. The DON and Housekeeping Supervisor acknowledged these issues, with the latter admitting a lack of specific policies regarding linen handling and distribution.
Failure to Notify Resident Representatives of Falls
Penalty
Summary
The facility failed to notify the representatives of two residents immediately following significant changes in their conditions. Resident #9, an elderly female with severe cognitive impairment and multiple health issues, experienced an unwitnessed fall resulting in a scratched eyebrow. Despite the fall and subsequent neurological checks, the facility did not inform her family member about the incident or the new injury. Similarly, Resident #39, also an elderly female with severe cognitive impairment and various health conditions, had an unwitnessed fall that caused a small bump on her forehead and bruising under her eyes. The facility did not notify her family member about the fall or the injuries sustained. Interviews with the family members of both residents confirmed that they were not informed about the falls. The responsible nurse admitted to forgetting to notify the families due to the workload and paperwork. The Director of Nursing (DON) acknowledged that the families should have been notified immediately and that it was the charge nurse's responsibility to do so. The Regional Director also emphasized the importance of notifying the residents' representatives and documenting the notifications. The facility's policy on observing, reporting, and recording changes in condition mandates notifying the resident's responsible party and documenting the notification in the clinical software. However, the facility failed to adhere to this policy, resulting in the families of Resident #9 and Resident #39 not being informed about the significant changes in their conditions following their falls.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to uphold the dignity and respect of two residents, as observed during a survey. Resident #14, who has multiple medical conditions including schizoaffective disorder, dementia, and urinary retention requiring a catheter, was found with an uncovered catheter drainage bag visible from the hallway on multiple occasions throughout the day. This was contrary to the care plan and physician's orders, which specified that the urinary bag should be covered to maintain the resident's dignity. Interviews with staff, including LVN F and LVN A, confirmed that the urinary bag should have been covered, but it was not noticed or addressed. Resident #36, who is severely cognitively impaired and requires total dependence for most activities of daily living, was observed being fed by CNA C while the CNA was standing. This action was not in line with the facility's practice of sitting at eye level with residents during feeding to promote dignity. Interviews with other CNAs and the DON confirmed that feeding should be done at eye level to ensure the resident's dignity is maintained. Attempts to reach CNA C for further clarification were unsuccessful. The DON and Regional Director acknowledged the importance of covering urinary bags and feeding residents at eye level to preserve dignity. The facility's Resident Rights policy, dated November 2021, emphasizes treating residents with dignity, courtesy, consideration, and respect. These observations and interviews highlight the facility's failure to adhere to these standards, resulting in a deficiency in maintaining the dignity and quality of life for the residents involved.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was accessible, which is a deficiency in accommodating the needs and preferences of residents. The resident in question, a female with dementia, depression, and a urinary tract infection, was observed on multiple occasions with her call light out of reach, under her bed. This was despite her care plan specifying that the call light should be within reach due to her history of falls and unsteady gait. The resident's family member also reported the issue to the Director of Nursing (DON), who confirmed retrieving the call light from the floor. Interviews with staff, including a CNA, RN, and the DON, revealed that it was the responsibility of all staff to ensure call lights were within reach. The staff acknowledged that failure to do so could prevent residents from calling for assistance, potentially leading to falls. The Regional Director also emphasized the importance of call lights being within reach. However, it was noted that the facility did not have a specific policy on call lights, which may have contributed to the oversight.
Confidentiality Breach During Medication Administration
Penalty
Summary
The facility failed to ensure the confidentiality of medical records for two residents during medication administration. Specifically, a medication aide (MA E) left the electronic medical records (EMR) of two residents open and visible on the medication cart while she walked away to locate the residents. This action occurred during the passing of medications, which could potentially expose sensitive medical information to unauthorized individuals, including other residents and visitors. The first resident involved was an elderly female with a history of heart failure and keratoconjunctivitis. Her comprehensive care plan included interventions for visual function problems and anxiety, with specific medication orders for eye drops. During an observation, MA E left this resident's medication regimen open on the EMR while searching for her, acknowledging that this could breach privacy. The second resident was an elderly female diagnosed with major depressive disorder and weakness. Her care plan aimed to manage depression and anxiety, with prescribed medications including aspirin, buspirone, and Claritin. Similarly, MA E left this resident's medication regimen open on the EMR while entering her room, admitting uncertainty about the last privacy training. Interviews with the Director of Nursing (DON) and other staff confirmed the expectation to protect resident privacy, highlighting the facility's monitoring practices for privacy breaches.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Specifically, the facility did not adhere to its policy on abuse for two residents reviewed for abuse. The facility did not report injuries of unknown origin for these residents to the Health and Human Services Commission (HHSC) as required. This failure could place residents at risk of being abused and neglected. Resident #10, a female with Alzheimer's, atrial fibrillation, depression, and anxiety, was found with bruising on her perineum. Despite the facility's policy requiring the reporting of injuries of unknown origin, the injury was not reported to HHSC. The resident had a history of falls and was found on the floor next to her bed, sitting in urine with a trash can overturned. Staff suspected the bruising was caused by the fall, but the injury was not reported as suspicious. Interviews with staff indicated that the bruising was believed to be related to the fall, and the Director of Nursing (DON) did not find the injury suspicious enough to report. Resident #36, a male with multiple diagnoses including Alzheimer's and major depressive disorder, was found with bruising of unknown origin on his buttocks and chest. The bruising was discovered during a shower with family present, and the resident denied any pain or falls. The current DON stated that typically such bruises should have been reported, but she was not in the position at the time of the incident. The previous DON could not be reached for comment. The facility's failure to report these injuries as required by their policy and state law represents a significant deficiency in their abuse prevention and reporting procedures.
Failure to Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, within the required timeframes. Specifically, the facility did not report injuries of unknown origin for two residents to the appropriate authorities, including the State Survey Agency and adult protective services, as mandated by state law. This deficiency was identified during a review of records and interviews with staff members. One resident, a female with Alzheimer's and other medical conditions, was found with bruising on her perineum. The bruising was discovered after an unwitnessed fall where the resident was found sitting on the floor next to her bed. Staff members, including an LVN and a CNA, believed the bruising was caused by the resident's fall onto a trash can. Despite the bruising being large and located in a sensitive area, it was not reported to the Health and Human Services Commission (HHSC) as required. Interviews with staff revealed that they did not find the bruising suspicious and attributed it to the fall, thus failing to report it as an injury of unknown source. Another resident, a male with severe cognitive impairment and multiple medical diagnoses, was found with bruising on his buttocks and chest. The bruising was discovered during a shower with family present, and the resident denied any falls or pain. The facility's policy requires that any injury of unknown source be reported immediately, but this was not done. The facility's Director of Nursing (DON) and other staff members did not report the bruising to the appropriate authorities, as they did not consider it suspicious. This lack of reporting could potentially place residents at risk for further neglect due to unreported and uninvestigated allegations of abuse and neglect.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for one resident, leading to a deficiency in the assessment process. Specifically, the MDS assessment inaccurately recorded a weight loss for a resident who had actually experienced a significant weight gain. The resident, a male with quadriplegia, dysphagia, anemia, and neurofibromatosis, was noted to have gained 9.3% of his body weight in the last 60 days, as documented in his care plan and confirmed by the registered dietician's progress note. Despite this, the MDS assessment incorrectly indicated a weight loss, which was acknowledged as a human error by the MDS Coordinator during an interview. The MDS Coordinator admitted to mistakenly selecting the wrong option on the assessment, resulting in the inaccurate documentation. The Director of Nursing (DON) and the Regional Director both expressed expectations for accurate MDS assessments, acknowledging that inaccuracies could lead to inappropriate interventions and affect quality measures and reimbursement. However, the facility did not have a specific policy on MDS accuracy, which may have contributed to the oversight. The deficiency was identified through interviews and record reviews, highlighting the importance of accurate assessments in meeting residents' care needs.
Failure to Monitor Diabetic Wound
Penalty
Summary
The facility failed to ensure that a resident with a diabetic wound received appropriate monitoring and care in accordance with professional standards of practice. The resident, a male with a history of metabolic encephalopathy, dementia, and type 2 diabetes mellitus, had a diabetic ulcer on his right foot. Despite having a comprehensive care plan that required regular monitoring and documentation of the wound's condition, including size, depth, and other characteristics, the facility did not perform these assessments. The resident's medical records, including podiatrist notes and weekly skin assessments, lacked necessary wound measurements, indicating a failure to track the wound's progression. Observations and interviews revealed that the treatment nurse did not keep up with the wound measurements, relying instead on the podiatrist's visits. The Director of Nursing (DON) and the Regional Director both acknowledged the importance of documenting wound measurements to track improvement or worsening of the condition. The facility's policy on skin integrity monitoring required regular assessment and documentation of skin conditions, but this was not adhered to, placing the resident at risk of complications from the unmonitored diabetic wound.
Failure to Provide Trauma-Informed Care for a Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident who is a trauma survivor, specifically Resident #23. Upon admission, the facility did not complete a trauma screening for Resident #23, who has a diagnosis of post-traumatic stress disorder (PTSD) from his experiences in the Vietnam and Kuwait wars. The resident's comprehensive care plan did not reflect his PTSD diagnosis or identify any triggers, such as loud noises and water, which could lead to re-traumatization. This oversight was identified during a review of the resident's records and interviews with staff. The Social Worker (SW) acknowledged that the trauma assessment was not documented in the resident's electronic medical record until it was requested, despite having completed it earlier. The Director of Nursing (DON) and the Regional Director were unaware of the reasons for the delay in documentation and the absence of a policy on trauma-informed care. Interviews with staff, including RN B and CNA D, revealed a lack of awareness regarding the resident's PTSD diagnosis and triggers, indicating a gap in communication and documentation that could impact the quality of care provided to the resident.
Medication Storage and Security Lapses
Penalty
Summary
The facility failed to ensure proper storage and security of drugs and biologicals, specifically in the medication storage refrigerator and a medication cart. During an observation, it was noted that a medication aide left a medication cart unlocked with the keys on top while administering medications to a resident. This oversight was acknowledged by the medication aide, who admitted that the cart should have been locked and the keys kept with her to prevent unauthorized access to medications. Additionally, the facility did not provide a separately locked, permanently affixed compartment for controlled drugs in the medication room's refrigerator. A liquid Lorazepam bottle was found inside an unaffixed lock box, which could be easily removed. The Licensed Vocational Nurse (LVN) responsible for the medication room acknowledged the issue, stating that the lock box had not been reattached after a new refrigerator was purchased. The Director of Nursing (DON) and Regional Director of Operations (RDO) were unaware of these security lapses, which could lead to drug diversion.
Failure to Provide Dental Services for Lost Dentures
Penalty
Summary
The facility failed to provide or obtain necessary dental services for a resident who lost his dentures. The resident, who was moderately cognitively impaired, had been readmitted to the facility with multiple medical conditions, including chronic pain and muscle wasting. Despite having a physician's order allowing for dental consults and treatment as needed, no dental referral was made for the resident after his dentures were lost. Interviews revealed that the resident's family member expressed concerns about the lack of dental services, and the resident himself indicated a desire to have his dentures replaced. The facility also lacked a policy regarding the loss or damage of dentures, which contributed to the inaction. The Social Worker acknowledged reaching out to the corporate office about the lost dentures but was informed that the facility was not responsible and that no policy existed. The Director of Nursing, who was new to the facility, was unaware of the incident and the lack of a policy. This deficiency in policy and communication led to the resident not receiving timely dental care, potentially affecting his quality of life.
Sanitation Deficiencies in Kitchen Equipment
Penalty
Summary
The facility failed to maintain proper sanitation standards in its kitchen, as observed during a survey. Specifically, three sheet pans were found with a brown grease-like buildup in the corners, and two cast iron skillets had a significant carbon buildup on both the inside and outside surfaces. Additionally, the juice machine was observed to have a dusty buildup on its front and sides. These unsanitary conditions were noted during an initial tour of the kitchen, and the cook acknowledged that the pans were not clean enough for cooking. Interviews with facility staff, including the Director of Nursing (DON), Regional Director of Operations (RDO), and the Dietary Manager, revealed an expectation for the kitchen to be maintained according to basic sanitation standards. The Dietary Manager admitted that the cast iron skillets could not be adequately cleaned and might pose a risk of illness. A review of the facility's cleaning schedule showed that the sheet pans, cast iron skillets, and juice machine were not included in the cleaning duties. The facility's General Kitchen Sanitation policy and the Food Code emphasize the importance of maintaining clean food-contact surfaces to prevent food-borne illnesses.
Failure to Coordinate Hospice Care and Maintain Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was observed in the cases of two residents, who were receiving hospice care. The facility did not maintain a hospice binder for one resident, which is crucial for communication and management of care between the hospice and the facility. The binder, which should contain the resident's diagnosis, care plan, and medication list, was missing, and the facility staff were unable to locate it. Interviews with the facility's RN and the hospice RN revealed that the hospice binder is essential for documenting concerns and ensuring continuity of care. In the case of another resident, the facility failed to obtain the most recent hospice plan of care. The resident's hospice binder had not been updated with the latest care plan, which should have included orders for medications such as Xanax and acetaminophen. Interviews with the Hospice DON and the Hospice Case Manager indicated that the hospice staff were behind in updating the care plans and delivering them to the facility. The lack of updated documentation in the resident's medical record posed a risk of the resident not receiving the correct medications or care. The Director of Nursing (DON) and the Regional Director both expressed expectations that the hospice provider should keep the hospice binders updated with notes, status updates, and any order changes. However, there was no policy in place at the facility regarding hospice services, which contributed to the lack of coordination and communication between the hospice and the facility. This deficiency in maintaining updated hospice documentation and coordinating care could lead to inadequate end-of-life care for residents.
Failure in Antibiotic Stewardship Documentation
Penalty
Summary
The facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy for a resident, specifically with the use of Zithromax. The deficiency was identified when it was found that there was no documented rationale or signs and symptoms to support the use of the antibiotic for the resident. The resident, a male with a history of metabolic encephalopathy, dementia, diabetic foot ulcer, and type 2 diabetes mellitus, was administered Zithromax without documented evidence of symptoms such as fever, cough, or upper respiratory infection that would justify its use. The progress notes during the period of antibiotic administration did not indicate any symptoms that warranted the prescription, and the comprehensive care plan did not address the antibiotic use since the resident was no longer taking it. Interviews with facility staff, including an RN, the DON, and the Regional Director, revealed that there was a lack of proper documentation regarding the resident's symptoms and the rationale for the antibiotic order. The RN acknowledged that the progress notes did not reflect the symptoms that were reportedly present, and the DON confirmed that there was no solid documentation to justify the antibiotic use. The Regional Director emphasized the importance of proper documentation to avoid unwarranted orders. The facility's policy on antibiotic stewardship requires a complete assessment and documentation when initiating antibiotics, but this protocol was not followed in this case.
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Illustrative
What surveyors actually found near you
We read the 189 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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Winnsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeview Rehabilitation & Healthcare Center | 0.1 mi | ★★★★★ | 13 | 0 |
| Quitman Wellness & Rehabilitation | 13.4 mi | ★★★★★ | 11 | 0 |
| Cypress Springs Wellness & Rehabilitation | 16.7 mi | ★★★★★ | 4 | 0 |
| Avir At Pittsburg | 19.5 mi | ★★★★★ | 13 | 0 |
| Rock Creek Health And Rehabilitation | 20.8 mi | ★★★★★ | 15 | 1 |
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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.