Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Cowhorn Creek during CMS and state inspections, most recent first.
A resident with a history of stroke-related hemiplegia, atrial fibrillation, seizures, hypertension, and other conditions had 15 scheduled morning medications, including antihypertensives, an anticoagulant, an anticonvulsant, respiratory and GERD medications, urinary and bowel agents, vitamins, allergy medication, and artificial tears, ordered for a specific morning time. An LVN working PRN, unfamiliar with the medication cart, did not administer these medications within the facility’s one-hour window around the ordered time and instead gave them significantly later, without a documented administration time on the MAR. In interviews, the LVN admitted the medications were late, while the RN, DON, Administrator, and ADON all stated that medications were expected to be administered on time and per physician orders, consistent with facility policy requiring administration within one hour of the prescribed time.
A resident with ALS who was dependent on staff for all care and used a communication device was subjected to disrespectful and undignified treatment by multiple CNAs. Staff sprayed air freshener over the resident, made derogatory comments, rushed care, failed to provide privacy, and did not allow adequate time for communication. These actions did not align with the resident's care plan or facility policy, resulting in a failure to maintain the resident's dignity and quality of life.
A resident with ALS and significant care needs reported multiple grievances via email regarding delayed response to call lights, rough care, and missed treatments. These complaints were not documented or investigated according to facility policy, and staff interviews confirmed a lack of follow-through and recordkeeping for the reported concerns.
A resident with ALS and significant care needs was subjected to abuse by two CNAs: one sprayed air freshener directly over the resident despite her respiratory issues, and another roughly repositioned her in bed while speaking in a loud, rude manner and not allowing time for communication. The resident's requests and needs were disregarded, and staff and leadership minimized the incidents, failing to uphold policies protecting residents from abuse.
The facility failed to maintain food safety and sanitation standards in the kitchen. Observations revealed open sugar bins, unlabeled and undated food items in Freezer #1, and significant grease and food residue on kitchen equipment. Staff interviews indicated a lack of cleaning protocols and recent management changes, contributing to these deficiencies.
The facility failed to involve residents in their care planning, as several residents were not invited to or did not attend care plan meetings in the past six months. Interviews and record reviews revealed a lack of coordination and documentation by the MDS Coordinator and social worker, leading to residents not participating in their care plans.
The facility failed to provide palatable and appropriately tempered food and drink to residents, affecting their quality of life. Multiple residents reported dissatisfaction with the taste, temperature, and variety of meals, as well as the lack of condiments. The Dietary Manager, new to the facility, acknowledged these issues, which were exacerbated by the recent departure of the previous manager.
The facility failed to provide snacks between meals, resulting in more than 14 hours between the evening meal and breakfast for residents. Interviews revealed that residents were not offered snacks at bedtime, and staff were unclear about snack preparation and distribution responsibilities. This deficiency could affect all residents, risking unplanned weight loss and medication side effects.
A resident with hemiplegia and moderate cognitive impairment was unable to reach their call button due to improper placement, leading to a deficiency in accommodating their needs. Despite staff awareness of the importance of call light accessibility, the resident's call light was found out of reach, compromising their ability to request assistance.
A facility failed to notify the Ombudsman of a resident's discharge, as required by regulations. The resident, with moderate cognitive impairment and multiple diagnoses, was transferred to another facility without the Ombudsman being informed. Interviews revealed that staff were unaware of the notification requirement, and no procedure was in place to ensure compliance.
The facility failed to provide baseline care plans to two residents upon admission, compromising effective and person-centered care. One resident, a 73-year-old female with hemiplegia and anxiety, did not receive a signed copy of her care plan. Another resident, a male with diabetes and cirrhosis, had no completed care plan or MDS assessments. Staff interviews revealed a lack of awareness and communication regarding the provision of these essential care plans.
A resident with left-sided hemiplegia did not receive necessary ROM exercises or therapy services to prevent further decrease in mobility. Despite the resident's moderate cognitive impairment and desire for therapy, the facility lacked a restorative nursing program and did not document ROM exercises as part of daily care. Staff interviews confirmed the absence of a program and the importance of ROM exercises, but no contracture management policy was provided.
A resident experienced significant weight loss shortly after admission, which was not promptly addressed by the facility. Despite having a care plan in place for potential nutritional issues, the facility failed to follow its weight policy, resulting in a delay in notifying the dietitian and primary physician. The resident's weight loss was linked to recent pneumonia and a UTI, but the facility's inaction placed the resident at risk for further health complications.
A facility failed to attempt a gradual dose reduction (GDR) for a resident on Abilify, despite a pharmacy recommendation to reduce the dose. The resident, with severe cognitive impairment and schizophrenia, continued to receive the medication daily. The Nurse Practitioner disagreed with the GDR due to ongoing symptoms and a previous failed reduction, but the GDR was not reviewed or signed in a timely manner, potentially leading to overmedication.
A resident with dementia and glaucoma was not transported to scheduled ophthalmologist appointments due to facility transportation issues. The resident's RP had to arrange transportation for a rescheduled appointment, as the facility cited distance and insurance coverage as barriers. Staff interviews revealed a lack of coordination and communication regarding the resident's transportation needs.
A facility failed to submit a timely MDS discharge assessment for a resident with insomnia, repeated falls, and schizophrenia, who was discharged to another nursing facility. The MDS Coordinator was responsible for the submission, but the assessment was neither completed nor transmitted within the required timeframe, contrary to facility policy and CMS guidelines.
A resident with amyotrophic lateral sclerosis was fed by a CNA who stood while feeding, contrary to the facility's policy of sitting at eye level to promote dignity. The resident felt rushed and ignored, and the DON and Administrator acknowledged this could be a dignity issue, potentially leading to negative outcomes.
A resident with dementia was verbally abused by another resident, who called her derogatory names on two occasions. Despite the incidents being reported by the resident's family, the facility's DON and Administrator did not consider it abuse and failed to document or report it to HHSC. Staff interviews indicated that verbal abuse should be reported, highlighting a lapse in following the facility's abuse prevention policy.
A facility failed to report an alleged verbal abuse incident between two residents to the appropriate authorities within the required timeframe. Despite one resident's family member reporting the incident to the Administrator, it was not documented or reported to the Health and Human Services Commission (HHSC). Interviews with staff indicated that such behavior should be considered verbal abuse and reported, but the facility's policy was not followed.
A facility failed to report and investigate an incident where a resident was verbally abused by another resident. Despite being informed by the family member of the affected resident, the facility's DON and Administrator did not consider the incident as verbal abuse requiring reporting. Interviews with staff indicated that such behavior should be reported, but the facility's inaction could place residents at risk of further abuse.
A resident with multiple diagnoses, including parkinsonism and dementia, experienced a fall during a transfer due to inadequate supervision and failure to use two-person assistance as required. The incident revealed gaps in communication and training among staff, who relied on verbal reports rather than consulting the electronic care plan. The facility acknowledged deficiencies in ensuring staff proficiency in accessing and understanding care plans.
A facility failed to maintain an effective infection control program when an LVN did not perform hand hygiene between glove changes during incontinent care for a resident with multiple health issues, including a urinary tract infection. The LVN admitted to forgetting this critical step, and the facility's policy lacked specific guidance on hand hygiene.
Late Administration of Multiple Scheduled Medications by LVN
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and procedures that assure accurate and timely administration of medications for one resident. The resident was an older adult with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, atrial fibrillation, seizures, and hypertension. Physician orders included numerous scheduled medications such as antihypertensives (Amlodipine, Carvedilol, Losartan), an anticoagulant (Eliquis), an anticonvulsant (Keppra), medications for respiratory issues (Mucinex), GERD (Pantoprazole), urinary incontinence (Myrbetriq), constipation (Senna), vitamin supplements, allergy medication (Zyrtec), and artificial tears. The resident’s care plan identified risks related to impaired breathing pattern, decreased cardiac output, seizures, incontinence, bruising and bleeding due to anticoagulant therapy, and high blood pressure, with repeated interventions to administer medications as ordered. Record review of the MAR for the first part of the month showed that these medications were scheduled for administration at 7:00 a.m. on a specific date, but the MAR did not reflect an actual administration time. During an observation at 8:54 a.m. that same morning, LVN A was seen preparing and administering all 15 of the resident’s scheduled morning medications, including the antihypertensives, anticoagulant, anticonvulsant, respiratory medication, GERD medication, urinary incontinence medication, constipation medication, vitamins, allergy medication, and artificial tears. LVN A stated she worked on an as-needed basis and that the only time she was late passing medications was when she was unfamiliar with the medication cart and needed extra time to find items. In interviews later that day, LVN A acknowledged that the resident’s morning medications were late, confirming that even with the one-hour window before and after the scheduled time, the medications were still administered late beyond the 7:00 a.m. order. RN B, the DON, the Administrator, and the ADON each stated that medications were expected to be given on time and in accordance with physician orders, and that the facility’s practice allowed a one-hour window before and after the scheduled administration time. The facility’s “Administering Medications” policy, last revised in 04/2019, specified that medications are to be administered in a safe and timely manner, in accordance with prescriber orders and required time frames, and within one hour of their prescribed time, with administration times documented in the medical record. The late administration of the 15 ordered medications for this resident constituted a failure to follow these policy requirements and physician orders.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to treat a resident with respect and dignity, and did not provide care in a manner that promoted or enhanced her quality of life. Multiple certified nursing assistants (CNAs) engaged in actions that were disrespectful and failed to honor the resident's rights. These included a CNA spraying air freshener over the resident's bed, pillow, and head, then making derogatory comments about the odor in the room. Another CNA told the resident she wished she would not have to return to the room, and stated she would not be back that day. Additional CNAs rushed the resident during care, failed to provide privacy during incontinent care, and did not allow the resident adequate time to communicate her needs using her communication device. One CNA told the resident she had only ten minutes to use the bedpan and that she should be thankful for the care she received, while another CNA did not take the time to listen to the resident's needs and stated she did not have time for all of it. The resident involved had a diagnosis of ALS, resulting in significant muscle weakness, impaired coordination, speech disturbances, and required substantial assistance with most activities of daily living (ADLs). She was dependent on staff for all care, used a communication device to express her needs, and was on hospice services. The resident's care plan included interventions to ensure privacy, allow time for communication, and provide a calm environment. Despite these documented needs, staff failed to follow the care plan and did not provide care in a manner that respected the resident's dignity or communication limitations. Video footage and interviews confirmed that staff interactions were often rushed, dismissive, and at times rough or abrupt. Staff did not consistently provide privacy, failed to allow the resident time to respond, and made inappropriate comments in the resident's presence. The resident's representative reported that concerns about staff behavior were brought to facility administration, but no action was taken. Facility policy required all employees to treat residents with kindness, respect, and dignity, but these standards were not upheld in the care provided to this resident.
Failure to Investigate and Document Resident Grievances
Penalty
Summary
The facility failed to file and investigate grievances reported by a resident's representative for one resident who had significant care needs due to ALS and other medical conditions. The resident, who had limited mobility and communication abilities, sent multiple emails to the ADON reporting that staff were not responding to her call light, were rough and rude during care, and were not providing timely assistance with toileting and breathing treatments. These grievances were sent on three separate occasions, but there was no documentation that they were logged or investigated according to facility policy. Interviews with facility staff revealed that the ADON received the resident's emails and forwarded them to the administrator, but did not retain access to the emails after a company change. The DON and social worker both stated that grievances should be documented and addressed promptly, but neither recalled receiving or documenting the specific complaints from this resident. The administrator acknowledged receiving some complaints but did not have documentation of addressing the emails sent to the ADON, and stated that if she was not aware of a grievance, she could not address it. A review of the facility's grievance log showed only one complaint from the resident during the relevant period, despite multiple emails and verbal reports of concerns. The facility's grievance policy requires staff to guide residents in filing grievances and to document and address all complaints, but this process was not followed for the resident's reported issues. As a result, the resident's grievances were not formally investigated or resolved as required by policy.
Failure to Protect Resident from Abuse by Staff
Penalty
Summary
The facility failed to protect a resident from abuse in two separate incidents involving certified nursing assistants (CNAs). In the first incident, a CNA entered the resident's room with an aerosol can of air freshener, concealed it, and sprayed it over the resident's bed, pillow, and head, despite the resident's known respiratory issues and use of oxygen. The resident had previously communicated to staff that air fresheners irritated her breathing, but her request was disregarded. Video footage confirmed the CNA's actions and the resident's immediate distress, including crying out and facial grimacing. The CNA made dismissive remarks about the odor in the room and the resident's response, and then left the room. In the second incident, another CNA was observed abruptly grabbing the resident by both shoulders and roughly repositioning her in bed. The CNA spoke to the resident in a loud and rude tone, telling her not to "do all that hollering" and did not allow the resident time to respond using her communication device. The resident, who had ALS and was dependent on staff for all activities of daily living, reported feeling that staff were often rough, rude, and did not take the time to listen to her needs. She described feeling ignored and anxious when staff did not answer her call light promptly or provide adequate time for her to communicate. Interviews with staff and facility leadership revealed a lack of awareness regarding the resident's request to avoid air fresheners and a general minimization of the incidents, with some staff characterizing the actions as poor customer service rather than abuse. The facility's policies require protection from abuse and support for resident rights, but these were not upheld in the documented incidents. The resident's representative also reported bringing video evidence of the abuse to facility administration, but no action was taken at that time.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed in their kitchen. Specifically, the sugar was stored in a bin that was left open, which could lead to contamination. Additionally, several food items in Freezer #1 were not labeled or dated, including packages of beef franks and various other food items, which could result in serving expired or unidentified foods. The kitchen equipment was not maintained in a clean condition. The deep fryer and stove were observed to have a significant buildup of grease and food particles, and the doors of Freezer #1, Refrigerator #1, and the milk cooler lid were smeared with food residues. These unsanitary conditions were noted over multiple days, indicating a lack of regular cleaning and maintenance. Interviews with staff revealed that the responsibility for cleaning and labeling fell to the cooks, but there was no cleaning checklist in place. The previous Dietary Manager had left recently, and the interim manager acknowledged the issues but had not yet implemented corrective measures. The Administrator confirmed that dietary staff were expected to maintain cleanliness and proper labeling, but these standards were not being met, potentially risking foodborne illness and contamination.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were involved in the development and implementation of their person-centered care plans. Specifically, residents identified as AR #1, AR #2, AR #44, AR #6, and AR #8 were not invited to or did not attend care plan meetings within the last six months. These residents expressed a desire to participate in their care planning and were aware of their right to be present at these meetings. Record reviews revealed that care plan meetings were either not documented or not conducted with resident participation, as evidenced by the absence of meeting notes in the electronic health records (EHR) for these residents. Interviews with facility staff, including the MDS Coordinator, social worker, DON, and Administrator, highlighted a lack of coordination and communication regarding the scheduling and documentation of care plan meetings. The social worker was responsible for inviting residents and their families, but often did not document refusals to participate. The MDS Coordinator and social worker typically conducted meetings without resident or family involvement. The Administrator was unaware of the residents' concerns about not attending their meetings, despite the facility's policy requiring interdisciplinary team involvement and resident participation in care planning.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. This deficiency was observed in eight residents and four anonymous residents. Several residents reported that the food did not taste good, was often cold, and lacked necessary condiments such as salad dressing, sugar, and coffee creamer. These issues were identified through interviews, observations, and record reviews. Resident #4, who has moderate cognitive impairment, expressed dissatisfaction with the taste and temperature of the food. Resident #19, with intact cognition, also reported that the food was terrible and often cold. During an observation, Resident #19 received a meal that did not match her order and lacked salad dressing. Resident #27, with intact cognition, mentioned that the food was never served on time and was always cold. Resident #29, also with intact cognition, complained about cold coffee and the lack of sugar or cream. Additional residents, including Resident #36 with severe cognitive impairment, Resident #38 with intact cognition, and Resident #54 with intact cognition, echoed similar concerns about the food being cold, burnt, or repetitive. Resident #64, with intact cognition, noted that the food was often hard and overcooked. During a group interview, anonymous residents reported having the same meals repeatedly and expressed dissatisfaction with the quality and variety of the food. The Dietary Manager, who was new to the facility, acknowledged the issues and mentioned that the previous manager had recently quit, which may have contributed to the problems.
Failure to Provide Snacks Between Meals
Penalty
Summary
The facility failed to ensure that there were no more than 14 hours between the evening meal and breakfast the following day, unless a nourishing snack was provided at bedtime, which could extend the time to 16 hours if agreed upon by a resident group. This deficiency was identified for 6 out of 8 residents reviewed for meal frequency. The facility did not offer snacks at bedtime as required, leading to extended periods without food for residents. Interviews with residents and staff revealed that residents were not provided snacks during the day or at bedtime, and requests for snacks were denied due to the kitchen being closed. Staff interviews indicated a lack of clarity and responsibility regarding snack preparation and distribution. The facility's policies stated that nursing staff should offer bedtime snacks, but there was no system in place to ensure this was done, and no training was provided to staff on preparing snacks. The deficiency could affect all residents, putting them at risk for unplanned weight loss, medication side effects, and diminished quality of life.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call button was within reach while in bed, which is a deficiency in accommodating the resident's needs and preferences. The resident, who was moderately cognitively impaired and required extensive assistance with activities of daily living due to hemiplegia and hemiparesis following a stroke, was unable to reach the call button placed on the left side, out of reach of his functional left hand. This situation was observed during an interview, where the resident expressed difficulty in pushing the button and resorted to yelling for assistance. Interviews with staff, including CNAs and LVNs, revealed that there was an expectation for the call light to be placed within reach of the resident's stronger side. However, the call light was found in the trash can during one observation, indicating it was not accessible. The staff acknowledged the importance of proper call light placement to prevent falls and ensure residents can call for help. The facility's policy on call light usage emphasized the need for the call light to be within easy reach, but this was not adhered to in the case of the resident.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the Office of the State Long-Term Care Ombudsman of a facility-initiated discharge for a resident, which is a regulatory requirement. The resident, a male with moderate cognitive impairment and diagnoses including insomnia, repeated falls, and schizophrenia, was discharged to another nursing facility. The facility did not send a copy of the discharge notice to the Ombudsman, which could prevent residents from accessing advocacy services and understanding their discharge/transfer options and appeal processes. Interviews revealed that the Ombudsman was not informed of the discharge and had to request discharge lists multiple times. The Social Worker (SW) and Director of Nursing (DON) were unaware of the requirement to notify the Ombudsman, and there was no procedure in place for this task. The Administrator (ADM) confirmed that the SW was now responsible for notifying the Ombudsman, but prior to the survey, no one was assigned this responsibility. The facility did not provide a related policy upon request, indicating a lack of established procedures for notifying the Ombudsman of discharges.
Failure to Provide Baseline Care Plans to New Residents
Penalty
Summary
The facility failed to ensure that baseline care plans, which are essential for providing effective and person-centered care, were completed and provided to two residents upon their admission. For one resident, a 73-year-old female with hemiplegia, cerebral infarction, and anxiety, the baseline care plan was completed but not signed by the resident or her representative. During an interview, the resident expressed that she did not remember the baseline care plan meeting and had not received a copy of the care plan, which she wanted to review to understand her discharge timeline. Another resident, a male with diabetes mellitus, cirrhosis, and anxiety, had no completed MDS assessments or baseline care plan in his electronic health record. He reported that no care plan had been discussed with him, and he was unsure of his goals or the medications prescribed to him. Interviews with facility staff, including the MDS nurse and social worker, revealed a lack of awareness and communication regarding the provision of baseline care plans to residents. The Director of Nursing and the Administrator acknowledged the importance of these care plans and the need for timely completion and communication with residents, but they were unaware of the lapses in this process.
Failure to Provide Contracture Prevention Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM) for a resident with left-sided hemiplegia. The resident, a male with a history of hemiplegia, diabetes mellitus type II, and cerebral infarction, was admitted to the facility and had a moderate cognitive impairment. Despite his condition, which included upper and lower ROM impairment on one side of his body, the resident did not receive occupational therapy (OT), physical therapy (PT), or restorative nursing for ROM. The resident expressed a desire for therapy to maintain mobility and prevent stiffness, noting that it had been over 60 days since he last received therapy services. Interviews with facility staff revealed that there was no restorative nursing program in place for residents discharged from therapy. The Director of Rehabilitation (DOR) and the Director of Nursing (DON) acknowledged the importance of ROM exercises to prevent contractures, but confirmed that no such program existed, and ROM exercises were not documented as part of daily care. The Administrator stated that it was the nursing staff's responsibility to ensure contracture management and prevention, and that CNAs should be trained to perform ROM exercises. Despite requests, the facility did not provide a contracture management policy before the survey exit.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, resulting in a significant weight loss that was not promptly addressed. The resident, a male with multiple medical conditions including neuromuscular dysfunction of the bladder, pulmonary candidiasis, and dysphagia following a cerebral infarction, experienced an 11.3-pound weight loss from admission to a few days later, indicating a 5.51% weight loss. Despite the facility's policy requiring a re-weigh within 24 hours of a significant weight loss, this was not done, and the resident's weight was not monitored according to the facility's protocol. The resident's care plan included interventions for potential nutritional problems, such as monitoring lab work, serving diet as ordered, and weighing per facility protocol. However, the facility did not adhere to these interventions, as evidenced by the lack of timely weight monitoring and failure to notify the dietitian and primary physician of the significant weight loss. Interviews with staff revealed that there were discrepancies in weight entries, and a performance improvement project was initiated to address these issues, but the deficiency had already occurred. The resident's weight loss was attributed to recent pneumonia and a urinary tract infection, as noted by the resident's responsible party. The facility's interim DON and other staff acknowledged the importance of identifying and addressing weight loss to prevent further health decline. However, the facility's failure to follow its weight policy and promptly address the resident's weight loss placed the resident at risk for malnourishment and other health complications.
Failure to Attempt Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure a gradual dose reduction (GDR) was attempted or documented as contraindicated for a resident receiving Abilify, an antipsychotic medication. The resident, who had a history of stroke, schizophrenia, and muscle weakness, was admitted to the facility and had a severe cognitive impairment with a BIMS score of 3. The resident was dependent on staff for activities of daily living and received antipsychotic medication daily. Despite a pharmacy recommendation to reduce the dose of Abilify from 5 milligrams to 2.5 milligrams, there was no indication that the physician reviewed or responded to this recommendation. The Nurse Practitioner disagreed with the GDR recommendation due to the resident's continued symptoms and a previous failed reduction attempt. However, the GDR was not reviewed or signed in a timely manner, as it was only signed in December, nearly a year after the recommendation was made. The facility's policy requires that residents receiving psychoactive medications are monitored for effectiveness and that periodic dosage reductions are attempted unless medically contraindicated. The delay in reviewing and signing the GDR could lead to residents being overmedicated.
Failure to Transport Resident to Vision Appointments
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities. The resident, an elderly female with diagnoses including dementia and glaucoma, was not transported to scheduled appointments with an ophthalmologist on two occasions. The resident had moderately impaired vision and required corrective lenses, and her care plan indicated she needed assistance with daily activities due to her cognitive impairment and physical limitations. The resident's responsible party (RP) had arranged an appointment with a specialist ophthalmologist, as local doctors were unable to provide the necessary care due to the resident's inability to lie flat. However, the facility did not transport the resident to her appointment in October, citing transportation issues and the need for the van for other residents. The RP was informed that the facility could not transport the resident to the specialist due to distance, and the resident's insurance did not cover transportation to the appointment. Interviews with facility staff revealed a lack of coordination and communication regarding the resident's transportation needs. The social worker and ADON were aware of the transportation issues, but the facility did not provide a solution, leaving the RP to arrange transportation for the rescheduled appointment in December. The facility's policy indicated that the social services department should coordinate care for ancillary medical services, but this was not effectively implemented in this case.
Failure to Submit Timely MDS Discharge Assessment
Penalty
Summary
The facility failed to ensure that an encoded, accurate, and complete Minimum Data Set (MDS) discharge assessment for a resident was electronically completed and transmitted to the CMS System within the required 14 days after completion. This deficiency was identified during a review of the records for a resident who was discharged to another nursing facility. The resident, a male with diagnoses including insomnia, repeated falls, and schizophrenia, was discharged without the necessary MDS discharge assessment being completed or transmitted, as required by federal guidelines. Interviews with the MDS Coordinator and the Administrator revealed that the MDS Coordinator was responsible for completing and submitting the MDS assessments, and the corporate MDS Coordinator was expected to monitor these submissions. Despite the facility's policy requiring timely submission of assessments, the discharge assessment for the resident was not completed or submitted, and the MDS Coordinator was unable to explain how this oversight occurred. The facility's policy and the CMS RAI Manual both emphasize the importance of timely submission to ensure compliance with federal and state guidelines.
Failure to Maintain Resident Dignity During Feeding
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity during feeding, as observed with one resident diagnosed with amyotrophic lateral sclerosis and other conditions requiring maximal assistance with activities of daily living. The resident, who had difficulty with communication and required staff assistance for feeding, was fed by a CNA who stood while feeding her, which is against the facility's policy of sitting at eye level to promote dignity and respect. The CNA did not sit due to the presence of a communication device stand, which the resident refused to move, and the CNA did not attempt to relocate it. Interviews with other CNAs and the Director of Nursing (DON) confirmed that sitting while feeding is the expected practice to ensure residents do not feel rushed or disrespected. The resident expressed feeling rushed and ignored when she communicated her discomfort with the feeding pace. The DON and Administrator acknowledged that standing while feeding could be a dignity issue and might lead to negative outcomes such as weight loss or decreased quality of life. The facility's policy emphasizes treating residents with dignity and respect at all times.
Failure to Report and Document Verbal Abuse Incident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, which was not reported or documented as required. A female resident with a history of myocardial infarction, muscle wasting, and dementia, among other conditions, was verbally abused by a male resident who called her derogatory names on two separate occasions. The incidents were not documented in the facility's incident reports, grievance reports, or the resident's progress notes, despite being reported by the resident's family member via email to the facility's administrator. The male resident, who had severe cognitive impairment and was admitted for short-term care following heart surgery, was involved in these incidents. Despite the verbal altercations, the facility's Director of Nursing (DON) and Administrator did not consider the incidents as abuse and did not report them to the Health and Human Services Commission (HHSC). The DON and Administrator believed the name-calling was mutual and did not warrant further investigation or reporting, even though the facility's policy required immediate reporting and investigation of any abuse allegations. Interviews with various staff members, including CNAs and LVNs, revealed a general understanding that verbal abuse, such as cussing and yelling, should be reported to the Abuse Coordinator. However, the facility's failure to document and report the incidents as required by their abuse prevention policy indicates a lapse in following proper procedures to ensure resident safety and compliance with regulatory standards.
Failure to Report Alleged Verbal Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse involving two residents to the appropriate authorities within the required timeframe. Resident #1, a female with a history of myocardial infarction, muscle wasting, and dementia, among other conditions, was allegedly verbally abused by Resident #3, a male with congestive heart failure and severe cognitive impairment. The incident was reported by Resident #1's family member via email to the facility's Administrator, but it was not documented in the facility's incident or grievance reports. Resident #1 reported that Resident #3 called her derogatory names on two separate occasions, once outside on the patio and another time when Resident #3 entered her room uninvited. Despite Resident #1's discomfort and the presence of a staff member during one of the incidents, the Director of Nursing (DON) and the Administrator did not consider the name-calling as verbal abuse and did not report it to the Health and Human Services Commission (HHSC). The Administrator believed there was no need to report the incident as both residents had exchanged derogatory names, and there was no injury involved. Interviews with various staff members, including CNAs and LVNs, indicated that yelling or cussing at a resident is considered verbal abuse and should be reported to the Abuse Coordinator. However, the facility's policy on abuse prevention was not followed, as the incident was not reported or investigated as required. The failure to report the alleged verbal abuse in a timely manner could potentially place other residents at risk, as acknowledged by the DON and other staff members.
Failure to Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, as required by state law. Specifically, the facility did not report an incident where a resident was verbally abused by another resident. The incident involved a resident who was called a derogatory name by another resident on two separate occasions. Despite the family member of the affected resident notifying the facility's administrator via email, the incident was not documented in the facility's incident reports, grievance reports, or the resident's progress notes. The Director of Nursing (DON) and the Administrator were aware of the incident but did not consider it as verbal abuse that required reporting. The DON stated that the incident was merely name-calling and did not warrant further documentation or reporting. The Administrator also did not report the incident to the Health and Human Services Commission (HHSC), as she believed there was no injury involved and both residents had exchanged derogatory names. This lack of action was contrary to the facility's abuse prevention policy, which mandates immediate reporting and investigation of all allegations of abuse. Interviews with various staff members, including CNAs and LVNs, indicated that they considered yelling and cussing at a resident as verbal abuse that should be reported to the Abuse Coordinator. However, the facility's failure to report and investigate the incident in a timely manner could potentially place residents at risk of further abuse. The facility's policy requires that all allegations of abuse be reported immediately to ensure the safety of residents and to comply with state and federal guidelines.
Inadequate Supervision and Assistance During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who required two-person assistance for transfers. The incident involved a resident with multiple diagnoses, including parkinsonism, dementia, and impaired range of motion, who was cognitively intact with a BIMS score of 15. The resident was dependent on staff for transfers and other activities of daily living. On the day of the incident, a CNA attempted to transfer the resident from a recliner to a bed without the required two-person assistance, resulting in the resident sliding off the bed and landing on the floor without injury. Interviews with staff revealed a lack of consistent communication and verification of care requirements. Several CNAs reported relying on verbal reports from previous shifts or charge nurses rather than consulting the electronic Kardex system, which contained the resident's care plan. This practice led to a misunderstanding of the resident's need for two-person assistance during transfers. The CNA involved in the incident was not available for comment, and other staff members confirmed the importance of following the care plan to prevent falls and injuries. The facility's administration acknowledged the deficiency in training and communication regarding the use of the electronic charting system and the importance of adhering to the care plan. The DON and ADON were responsible for training CNAs, but there was a gap in ensuring that all staff were proficient in accessing and understanding the care plans. The facility's Fall Prevention Program emphasized the need for an interdisciplinary approach to prevent falls, but the incident highlighted a failure to implement these guidelines effectively.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) who did not perform hand hygiene after removing gloves during the provision of incontinent care to a resident. This resident, a female with multiple diagnoses including amyotrophic lateral sclerosis, muscle weakness, and urinary tract infection, required maximal assistance with activities of daily living. During an observation, the LVN was seen removing gloves and applying new ones without performing hand hygiene, which is a critical step in preventing cross-contamination and infection spread. Interviews with the LVN, the Director of Nursing (DON), and the Administrator confirmed the expectation for proper hand hygiene between glove changes. The LVN admitted to forgetting to perform hand hygiene, acknowledging its importance in preventing urinary tract infections. The DON, who also serves as the infection control preventionist, stated that random checks are conducted to ensure compliance with hand hygiene protocols. However, the facility's infection prevention and control policy did not address handwashing or hand hygiene, highlighting a gap in the facility's infection control measures.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 82 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Texarkana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cornerstone Retirement Community | 0.9 mi | — | 5 | 0 |
| Reunion Plaza Senior Care And Rehabilitation Cente | 1 mi | — | 24 | 2 |
| Avir At Texarkana | 1.6 mi | — | 7 | 3 |
| The Villa At Texarkana | 1.7 mi | — | 9 | 0 |
| Heritage Plaza Nursing Center | 1.8 mi | — | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Avir At Cowhorn Creek.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.