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Complaint Investigation

Advanced Rehabilitation And Healthcare Of Athens

August 15, 2025 · Athens, TX · 121 Commons Drive
Citations 3
CMS Rating 1/5
Beds 120
Provider ID 675424
Healthcare Facility
Advanced Rehabilitation And Healthcare Of Athens
Athens, TX  ·  View full profile →
Inspection Summary

Advanced Rehabilitation and Healthcare of Athens in Athens, TX — inspection on August 15, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0550
Resident Rights Deficiencies
Actual Harm

During an interview on 8/13/25 at 1:10 p.m., Resident #6 said she witnessed the lack of briefs over the weekend and witnessed her roommate's anxiety and frustration at the situation.

During an interview on 8/13/25 at 5:54 p.m., CNA F said she worked this weekend, and they did not have any large briefs.

She said she had one resident on the hall that required bariatric briefs, and that was Resident #5.

She said she worked on 8/9/25 and 8/10/25, and they could only find one bariatric brief on her hall.

She stated she used two medium briefs, layered them, and had to pull the resident's pants up to hold them in place.

She said Resident #5 wanted to get up every day about 11:00 a.m., and she explained that there were no briefs. CNA F said Resident #5 said she could not lay in bed all day. CNA F said Resident #5 said it was uncomfortable, but better than lying in bed all day

Record review of Resident #4's quarterly MDS dated [DATE] indicated he was cognitively stable with a BIMS of 15.

During an interview on 8/13/25 at 3:35 p.m. Resident #4 said she had on a brief at the current time, but it was not the right size, and it was cutting into her skin.

She said over the weekend they had found a couple of briefs that kind of fit her, but she did not have any problems getting up. Resident #4 said hopefully they would have some more briefs today because the ones they had were too tight for her.

She said she was fine just a little uncomfortable.

She said she did not know what size it was, but it was a size to small.

During an interview and observation on 8/13/25 at 1:20 p.m. of CNA B and two other staff were placing briefs in a room as an overflow.

They said that they had got 3 1/2 pallets of supplies and they had plenty of large, extra-large, and bariatric briefs that had arrived today.

During an interview on 8/13/25 at 3:40 p.m., LVN G said she worked at over the weekend on 8/9/25 and 8/10/25 and they did not have large briefs.

She said some of those residents could not get up because they did not have briefs to fit them.

Review of a purchase order dated 8/7/25 indicated the facility had order 22 boxes of briefs in different sizes and 21 boxes of wipes.

The order indicated it was approved for purchase on 8/8/25.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Rehabilitation and Healthcare of Athens

121 Commons Drive Athens, TX 75751

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 8/15/25 at 11:45 a.m., the RNC said the facility's census was 103 today and they did 101 skin assessments.

She said one resident was up and 1 resident refused, and they are going to try and get them later.

She said they did the in services and had a return demonstration test for the nurses.

They were not able to have all nurses do the testing because they had called some on the phone.

She said they would do their testing later.

The RNC said they had done chart audits and had the monitoring tool in place.

She stated they were currently doing everything on paper due to the current computer system being down and they were transitioning to another system.

During an interview on 8/15/25 at 12:10 p.m., the DON said she in-serviced nurses on change in condition, when to notify the doctor, and the steps to take upon admission.

The staff were given a test to determine if they knew what to do for a new admission and when to follow up.

She said one resident had surgery and did not have any orders when he was admitted on how to treat the wound, the physician was contacted, and new orders were obtained.

The DON said another resident had a tiny area on her bottom and they got an order for the treatment of the wound.

She had in-serviced 20 nurses.

She had 12 full time nurses and 8 PRN nurses.

The DON said, on today, they had the ADON, who was acting as treatment nurse, and 3 charge nurses, in the building.

She said Resident #2 had gone back to the hospital.

They were doing paper charting on today.

During an interview on 8/15/25 at 3:00 p.m., the Administrator said he would admit some mistakes were made with Resident #1. He said he did not agree with the IJ level of severity. He said however the interventions they had put into place with staff training, ensuring the physician was notified, and making sure documentation was in place, had fixed many issues. He said the morning oversight meetings should bring issues to the attention of administration, and they would be able to put systems in place to prevent future problems. He said they would form a habit of doing things the right way.

Interviews conducted with nurses the following shift nurses on 8/15/25 between 12:15 p.m. and 2:15 p.m. determined staff were knowledge about the in-services and education provided. At 12:15 p.m. LVN I worked 6p to 6aAt 12:20 p.m. LVN J /ADON worked all shiftsAt 1:15 p.m. LVN L worked 6p to 6aAt 1:30 p.m. LVN M worked 6a to 6pAt 1:34 LVN G worked 6a to 6pAt 1:45 p.m. LVN N worked 6a to 6pAt 1:50 p.m. LVN C/treatment nurse worked all shiftsAt 1:57 LVN K- PRN worked all shiftsAt 2:10 p.m. LVN O worked PRN weekends At 2:15 p.m. LVN A worked 6a to 2p The Administrator, DON, and RNS were informed the IJ was removed on 8/15/25 at 3:35 p.m.

The facility remained out of compliance at a severity level of potential harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/15/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Advanced Rehabilitation and Healthcare of Athens

121 Commons Drive Athens, TX 75751

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 8/15/25 at 12:10 p.m., the DON said she in-serviced nurses on change in condition, when to notify the doctor, and the steps to take upon admission.

The staff were given a test to determine if they knew what to do for a new admission and when to follow up.

She said one resident had surgery and did not have any orders when he was admitted on how to treat the wound, the physician was contacted, and new orders were obtained.

The DON said another resident had a tiny area on her bottom and they got an order for the treatment of the wound.

She had in-serviced 20 nurses.

She had 12 full time nurses and 8 PRN nurses.

The DON said, on today, they had the ADON, who was acting as treatment nurse, and 3 charge nurses, in the building.

She said Resident #2 had gone back to the hospital.

They were doing paper charting on today.

During an interview on 8/15/25 at 3:00 p.m., the Administrator said he would admit some mistakes were made with Resident #1. He said he did not agree with the IJ level of severity. He said however the interventions they had put into place with staff training, ensuring the physician was notified, and making sure documentation was in place, had fixed many issues. He said the morning oversight meetings should bring issues to the attention of administration, and they would be able to put systems in place to prevent future problems. He said they would form a habit of doing things the right way.

Interviews conducted with nurses the following shift nurses on 8/15/25 between 12:15 p.m. and 2:15 p.m. determined staff were knowledge about the in-services and education provided. At 12:15 p.m. LVN I worked 6p to 6aAt 12:20 p.m. LVN J /ADON worked all shiftsAt 1:15 p.m. LVN L worked 6p to 6aAt 1:30 p.m. LVN M worked 6a to 6pAt 1:34 LVN G worked 6a to 6pAt 1:45 p.m. LVN N worked 6a to 6pAt 1:50 p.m.

LVN C/treatment nurse worked all shiftsAt 1:57 LVN K- PRN worked all shiftsAt 2:10 p.m. LVN O worked PRN weekends At 2:15 p.m. LVN A worked 6a to 2p The Administrator, DON, and RNS were informed the IJ was removed on 8/15/25 at 3:35 p.m.

The facility remained out of compliance at a severity level of potential harm with a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Athens, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Advanced Rehabilitation and Healthcare of Athens or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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