Avir At Arbor Terrace
Inspection history, citations, penalties and survey trends for this long-term care facility in San Angelo, Texas.
- Location
- 609 Rio Concho Dr, San Angelo, Texas 76903
- CMS Provider Number
- 675932
- Inspections on file
- 36
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Avir At Arbor Terrace during CMS and state inspections, most recent first.
The facility failed to ensure accurate PASRR Level I screenings and appropriate PASRR referrals for two residents with documented mental illness diagnoses. One resident’s records showed schizoaffective disorder, depression, generalized anxiety disorder, and schizophrenia, yet the PASRR Level I from the referring hospital indicated no mental illness. Another resident had depression, vascular dementia with psychotic disturbance and anxiety, and later a new diagnosis of schizophrenia, but her PASRR Level I also showed no mental illness and she was not referred for a PASRR Level II after the new schizophrenia diagnosis. The MDS Coordinator acknowledged that the PASRR for one resident should have been positive and corrected, and that she was unaware of the other resident’s new schizophrenia diagnosis and had not notified the local authority, while the DON and Administrator confirmed the MDS Coordinator’s responsibility for PASRR accuracy and follow‑through.
The facility failed to develop and implement comprehensive, person-centered care plans addressing psychotropic medication use and key psychiatric diagnoses for three cognitively intact residents with conditions such as schizophrenia, schizoaffective disorder, PTSD, depression, and anxiety, despite these being documented in their MDS assessments and medication orders. Each resident was receiving multiple psychotropic agents, including antipsychotics, antidepressants, and antianxiety medications, yet their care plans contained no measurable objectives or timeframes related to these medications or mental health conditions. The Interim DON, MDS Coordinator, and Administrator acknowledged that diagnoses and medications were expected to be care planned, and attributed incomplete and non-individualized care plans in part to a change in electronic health record systems and limited MDS staffing.
Surveyors found that the facility failed to maintain a safe, functional, and comfortable environment in multiple halls, with several resident restrooms showing significant lint buildup on exhaust fan vents and one restroom exhibiting holes in walls, loose baseboards, deteriorating sheetrock, and exposed areas around plumbing pipes. These conditions occurred in areas accessible to residents and were inconsistent with the Maintenance Director’s job description, which requires maintaining interior structures in good repair. The Maintenance Director and the Administrator acknowledged that these environmental issues did not appear homelike and could negatively affect residents’ quality of life.
A resident admitted with CKD stage 5 on dialysis, neuromuscular bladder dysfunction, and anxiety did not have a baseline care plan developed within 48 hours of admission, as confirmed by record review and staff interviews. The Interim DON acknowledged that the baseline care plan was only started several days after admission and stated that her expectation was for an RN to complete it within the first 48 hours. The Administrator similarly reported that nursing was expected to complete the baseline care plan upon admission and recognized that failure to do so could affect quality of care by leaving staff without needed care instructions. When surveyors requested the facility’s baseline care plan policy, no policy was provided before exit.
A resident with Alzheimer’s disease, weakness, moderate cognitive impairment, and documented oxygen therapy had their oxygen nasal cannula tubing observed wrapped around the back of an oxygen tank on a wheelchair without a protective cover or bag after staff removed it during a transfer. The resident reported that staff placed the cannula on the oxygen tank after moving them from wheelchair to bed. The Administrator stated that staff were expected to store cannulas in bags when not in use and acknowledged that failing to do so could possibly lead to respiratory infections, and no facility policy on oxygen administration or nasal cannula storage was provided.
Two residents with severe cognitive impairment were involved in an incident where one inappropriately touched the other in a common area. The event was witnessed by two other residents and reported to an LVN, who removed the alleged perpetrator and assessed the alleged victim for injury but failed to document or report the incident to administration as required by policy.
Staff failed to report an allegation of inappropriate touching between two severely cognitively impaired residents within the required 24-hour period. The incident, witnessed by two other residents and reported to an LVN, was not documented or communicated to facility leadership as required by policy, resulting in a deficiency for not following mandated abuse reporting protocols.
A resident with multiple medical conditions and intact cognition repeatedly requested to be sent to the hospital due to feeling unwell. Despite informing a CNA, who relayed the request to an LVN, no nursing assessment or documentation occurred, and the resident ultimately arranged for her own transport to the ER, where she was diagnosed and treated for a UTI and airway inflammation.
A resident with multiple medical conditions repeatedly requested to be sent to the hospital due to feeling unwell, but staff did not promptly assess her or arrange for her transfer. The resident ultimately arranged her own transport to the ER, where she was diagnosed and treated for a UTI and airway inflammation. Staff interviews and record reviews showed a lack of documentation and follow-through regarding the resident's requests.
The facility failed to secure medications, leaving two medication carts unlocked and unsupervised. One cart was found on F Hall with two residents nearby, and another at the nurses' station with no staff or residents in sight. The facility's policy mandates that medication carts be locked when not in use, as confirmed by the DON.
A LTC facility failed to maintain an effective infection prevention and control program, as evidenced by improper use of PPE and inadequate infection control practices. An LVN did not wear a gown during dressing changes for residents on Enhanced Barrier Precautions, and a CNA did not change gloves after contamination during incontinent care. Additionally, the LVN did not follow proper infection control principles, such as hand hygiene and appropriate use of gauze, increasing the risk of cross-contamination.
A resident with a history of verbal aggression physically assaulted a CNA, leading to the CNA's injury and the resident's discharge. The facility failed to immediately notify the resident's physician of this significant behavioral change, only doing so the following day, contrary to policy requirements.
The facility failed to protect the confidentiality of residents' records when an LVN and a CMA left their laptops unlocked and unattended, displaying personal and medical information. LVN C's laptop was left unattended on a treatment cart for about five minutes, while CMA D's laptop was left on a medication cart for 2-3 minutes. Both staff members acknowledged the oversight, and the DON confirmed that staff were aware of the requirement to lock computers when unattended.
A resident with a history of cerebral infarction, diabetes, and anxiety disorder was discharged without proper documentation from the physician. The resident, who was cognitively intact, physically assaulted a CNA, leading to an immediate discharge decision by the facility's administrator and DON. The facility failed to document the specific needs that could not be met, efforts to meet those needs, or the services the receiving facility would provide.
The facility failed to ensure the proper disposal of expired medications in two medication carts, with expired docusate sodium and loratadine found during inspections. Staff responsible for checking expired medications did not adhere to the facility's policy, potentially risking residents' safety. The DON stated that monthly inspections are conducted by a contracted pharmacist, with random checks by the DON and ADONs.
A facility failed to notify a hospice provider of a resident's emergency transfer, resulting in a deficiency. The resident, with a history of cerebral infarction and diabetes, was discharged without prior hospice notification. The DON admitted to forgetting to contact the hospice before the resident left, leading to a lack of coordinated care and medication supply for the resident's transition.
A resident with cognitive and mobility impairments was left without access to a call light after being transferred to bed by CNAs. Despite the care plan's requirement to keep the call light within reach, it was left on the floor, violating facility policy and potentially compromising the resident's safety.
Two residents in a facility were involved in unsafe transfers due to inadequate supervision and improper use of assistance devices. A resident with severe cognitive impairment was transferred using a mechanical lift without locking the wheelchair, while another resident with paralysis was transferred using a gait belt without securing both wheelchair wheels. The CNAs involved believed the transfers were conducted correctly, despite these oversights, which were against the facility's policy.
A facility failed to provide appropriate respiratory care for a resident with COPD, who was left unsupervised during nebulizer treatments. The resident, who was cognitively intact, left the treatment area while the nebulizer was still in operation, and there was no documentation of refusal or a care plan addressing this behavior. The DON stated that nurses should remain with residents during treatments, but this was not implemented.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with multiple health conditions, as required by their policy. The resident's clinical records lacked a baseline or comprehensive care plan, and interviews with the DON and Administrator confirmed the expectation for timely completion of such plans. The facility's policy mandates a baseline care plan to be developed within 48 hours to meet immediate needs, which was not followed, leading to a deficiency.
A facility failed to maintain proper infection control during wound care for a resident. The WCN did not perform adequate hand hygiene or use a no-touch technique, risking infection. The resident, with multiple health issues, had a wound requiring specific care. The WCN admitted to skipping steps, and the DON confirmed the importance of hand hygiene. The facility's Wound Care program procedures were not followed.
A resident with COPD and other conditions was not administered physician-ordered medications due to failures in the medication ordering and delivery process. The facility staff did not ensure the availability and administration of medications, leading to the resident's hospitalization for shortness of breath and anxiety.
The facility failed to maintain proper kitchen sanitation and handwashing practices, increasing the risk of food-borne illnesses. Observations revealed unclean juice dispenser spigots and lint build-up in the ice machine filter. Additionally, a dietary aide did not follow proper handwashing protocols, potentially leading to contamination. The Dietary Manager acknowledged these lapses, attributing them to her recent absence.
Two resident rooms in the facility were found to have temperatures below the acceptable range, with one room at 69.0 degrees Fahrenheit and another at 68.5 degrees Fahrenheit. Residents reported feeling cold and had informed the Maintenance Supervisor, who did not document or adequately address the issues. The facility's policy requires maintaining temperatures between 71 and 81 degrees Fahrenheit.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, on multiple occasions. Time sheets revealed no RN coverage on specific dates, and the DON confirmed the absence of proof for these dates, potentially risking improper care for residents.
A resident with a history of hypertension and heart failure was administered Propranolol and Spironolactone outside of prescribed parameters, despite orders to hold the medications if certain blood pressure and pulse thresholds were not met. The medication aide admitted to not checking the order due to being in a hurry, and the facility's policy on medication administration was not followed.
Failure to Ensure Accurate PASRR Screenings and Required Referrals for Residents With Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure that PASRR Level I screenings accurately reflected residents’ mental health status and to coordinate necessary PASRR referrals. For one male resident, the face sheet and MDS documented diagnoses including schizoaffective disorder, depression, generalized anxiety disorder, and insomnia, with an MDS BIMS score indicating no cognitive impairment. His active diagnoses on the MDS included anxiety, depression, and schizophrenia. However, the PASRR Level I screening completed by the referring hospital indicated no primary diagnosis of dementia and no indicator of mental illness, despite the documented schizophrenia diagnosis present on admission. For a female resident, the face sheet and MDS documented diagnoses including depression, vascular dementia with psychotic disturbance, and vascular dementia with anxiety, with an MDS BIMS score indicating no cognitive impairment. Her active diagnoses on the MDS included non‑Alzheimer’s dementia, depression, and schizophrenia. The PASRR Level I screening completed by the referring hospital indicated no indicator of mental illness, and the resident reported she had not received PASRR services. The resident was newly diagnosed with schizophrenia on a later date, but this new diagnosis was not followed by a PASRR Level II referral. Interviews with facility staff confirmed that the PASRR information was inaccurate and that required follow‑up had not occurred. The MDS Coordinator acknowledged that the male resident’s mental illness diagnosis should have resulted in a positive PASRR Level I and that a corrected screening should have been completed and sent to the local authority. The MDS Coordinator also stated she was unaware of the female resident’s new schizophrenia diagnosis and had not notified the local authority as required. The DON and Administrator both stated that the MDS Coordinator was responsible for PASRR accuracy and follow‑through, and that inaccurate PASRR screenings could result in residents not receiving needed services or benefits.
Failure to Care Plan Psychotropic Use and Psychiatric Diagnoses After EHR Transition
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement comprehensive, person-centered care plans that included measurable objectives and timeframes for residents with psychotropic medication use and specific mental health diagnoses. For three residents reviewed, the care plans did not address their psychotropic medications or key psychiatric diagnoses, despite these being documented in their medical records and MDS assessments. The facility’s own policy required that comprehensive, person-centered care plans include measurable objectives and timeframes to meet residents’ highest practicable physical, mental, and psychosocial well-being, be developed within seven days of completion of required MDS assessments, and be revised as residents’ conditions change. One resident, an older female with diagnoses including depression, vascular dementia with psychotic disturbance, vascular dementia with anxiety, and schizophrenia, had a comprehensive MDS showing active diagnoses of non-Alzheimer’s dementia, depression, and schizophrenia, and documented use of antidepressant and antianxiety medications (buspirone and duloxetine). However, her care plan initiated in March did not contain any evidence of psychotropic medication usage or her schizophrenia diagnosis. A second resident, an older male with schizoaffective disorder, depression, generalized anxiety disorder, and insomnia, had an MDS reflecting active diagnoses of anxiety, depression, and schizophrenia, and documented use of antipsychotic, antianxiety, and antidepressant medications (including amitriptyline, aripiprazole, buspirone, duloxetine, and trazodone). His care plan, revised in March, also lacked any reference to psychotropic medication usage or schizophrenia. A third resident, an older male with COPD, PTSD, anxiety disorder, and suicidal ideations, had an MDS showing active diagnoses of anxiety, depression, and PTSD, and documented use of antipsychotic and antidepressant medications (duloxetine, olanzapine, and trazodone). His care plan, initiated more than a year earlier, contained no evidence of antipsychotic medication use or his PTSD diagnosis. During interviews, the Interim DON stated that her expectation was that medications and diagnoses are care planned and acknowledged that inaccurate care plans could result in resident care needs not being met. The MDS Coordinator confirmed responsibility for completing care plans with the IDT and acknowledged that some care plans were not complete, citing a change in electronic health record systems as a reason. The Administrator similarly stated that the facility had changed electronic health record programs, that only one MDS Coordinator was entering all care plans, and agreed that the MDS Coordinator needed to focus on completing care plans, acknowledging that incomplete care plans could result in needs not being met and decreased quality of life.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a safe, functional, clean, and comfortable environment in 5 of 6 halls (A, B, C, D, and F). Observations showed multiple resident restrooms with significant lint buildup on exhaust fan vents, including in rooms A-2, A-5, B-3, C-7, D-6, and F-7A/B. In room F-7A/B, additional environmental damage was observed in the restroom, including holes in the walls behind the toilet and sink, a baseboard hanging off the wall, deteriorating and crumbling sheetrock, and visible holes around plumbing pipes. These conditions were present in areas accessible to residents and were cited as placing residents at risk of living in an unsafe and uncomfortable environment. Interviews and record review further clarified the scope of the deficiency. The Maintenance Director reported that restroom exhaust vents were cleaned periodically but acknowledged they had not been cleaned recently. The Director also acknowledged understanding that the observed environmental issues did not appear homelike and could affect residents’ quality of life. The Administrator similarly acknowledged understanding that the environmental issues could lead to residents feeling sad and not having a homelike environment. Review of the Maintenance Director’s job description dated 08/2024 indicated responsibility for maintaining and repairing physical structures, including keeping the interior in good repair with tasks such as drywall repair, painting, and cleaning, which were not adequately carried out as evidenced by the observed damage and lack of cleanliness.
Failure to Complete Timely Baseline Care Plan After Admission
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to develop a baseline care plan within 48 hours of admission for one resident. Record review showed that a male resident, identified as Resident #80, was admitted on 4/27/2026 with diagnoses including chronic kidney disease stage 5 requiring dialysis, dependence on renal dialysis, neuromuscular dysfunction of the bladder, and anxiety. Review of the electronic clinical record on 4/30/2026 revealed that no initial baseline care plan had been developed within the required 48-hour timeframe following his admission. During interviews, the Interim DON confirmed on 4/30/2026 that a baseline care plan had not been completed within 48 hours and stated she had only started the baseline care plan that day. She reported that her expectation was that baseline care plans be completed within the first 48 hours after admission by an RN and acknowledged that not completing the baseline care plan could result in staff not knowing how to care for the resident. In a separate interview, the Administrator stated her expectation that nursing complete the baseline care plan upon admission and acknowledged that failure to complete it timely could affect residents’ quality of care by staff not knowing how to care for them. When surveyors requested the facility’s baseline care plan policy from the DON on 4/30/2026, no policy was provided prior to exit.
Improper Storage of Oxygen Nasal Cannula for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards of practice when a resident’s oxygen nasal cannula was not stored appropriately when not in use. The resident, an older adult admitted with Alzheimer’s disease and weakness, had a quarterly MDS assessment indicating moderate cognitive impairment (BIMS score of 11) and use of oxygen therapy. During observation, the resident’s oxygen nasal cannula tubing was seen wrapped around the back of the oxygen tank on the back of the wheelchair without any protective cover or bag. The resident stated that staff had removed the nasal cannula after transferring him from his wheelchair to his bed and then placed it on the oxygen tank. In an interview, the Administrator acknowledged that staff were expected to store cannulas in bags when not in use and stated that failure to do so could possibly lead to residents acquiring respiratory infections. No policy regarding oxygen administration or storage of nasal cannula tubing was provided by the facility. These failures could place all residents who use respiratory equipment at risk for respiratory infections, as noted by the Administrator.
Failure to Timely Report Alleged Abuse Between Residents
Penalty
Summary
The facility failed to report an allegation of abuse involving two residents within the required 24-hour timeframe. Specifically, one resident with severe cognitive impairment and a history of sexually inappropriate behavior was observed by two other residents to have inappropriately touched another cognitively impaired resident in the dining room. The incident was witnessed by two residents, one of whom immediately reported it to an LVN present at the nurses' station. The LVN responded by removing the resident from the dining room and assessing the alleged victim for injury, finding none. Despite being aware of the allegation, the LVN did not document the incident in the progress notes or report it to the facility's Administrator or DON. The LVN stated she did not know why she failed to report the incident, despite having been previously in-serviced on recognizing, preventing, and reporting abuse, neglect, and exploitation. The Administrator and DON both confirmed they were unaware of the incident until informed by the surveyor during the investigation. Record reviews confirmed that both residents involved had severe cognitive impairment and required extensive assistance with daily activities. The facility's policy required all allegations of abuse, neglect, exploitation, or mistreatment to be reported and investigated within federal timeframes, but this process was not followed in this case. The failure to report the incident as required constituted a deficiency in the facility's abuse reporting procedures.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
Facility staff failed to report an allegation of inappropriate touching between two residents within the required 24-hour timeframe. Specifically, one resident with severe cognitive impairment and a history of sexually inappropriate behavior was observed by two other residents placing his hand between the legs, over the clothing, of another resident who was also severely cognitively impaired. The incident was witnessed by two cognitively intact residents, one of whom immediately reported it to an LVN present at the nurses' station. The LVN responded by removing the alleged perpetrator from the dining room and returning him to his room. Despite being informed of the incident, the LVN did not document the event in the progress notes, did not assess for injury beyond a brief check, and failed to report the allegation to the facility Administrator or DON as required by facility policy and federal regulations. The LVN stated she was aware of the reporting requirements and had previously received in-service training on abuse, neglect, and exploitation (ANE) reporting, but could not explain why she did not report the incident. The Administrator and DON both confirmed they were unaware of the incident until informed by surveyors during the investigation. Record reviews confirmed that both residents involved had significant cognitive impairments and behavioral care plans addressing inappropriate behaviors. The facility's policy required all allegations of abuse, neglect, exploitation, or mistreatment to be reported within 24 hours to the Administrator and to the appropriate state authorities. The failure to report this incident as required resulted in a deficiency, as it prevented timely investigation and appropriate follow-up as mandated by regulations.
Failure to Honor Resident's Request for Hospital Evaluation
Penalty
Summary
A deficiency occurred when the facility failed to honor a resident's request to be sent to the hospital for evaluation. The resident, who had diagnoses including acute recurrent sinusitis, shortness of breath, hemiplegia, and hemiparesis, and was assessed as having intact cognition, reported feeling unwell and requested to go to the hospital. The resident used her call light multiple times to communicate her request to CNA A, who relayed the information to LVN B. Despite these repeated requests, there was no documented assessment, vital signs, or progress notes regarding the resident's condition or her request to be sent to the hospital on the date in question. The resident ultimately contacted her significant other to take her to the hospital after several hours without nursing intervention. Interviews revealed that the DON was unaware of the resident's initial request and believed that staff should have evaluated the resident, obtained vital signs, and contacted the physician. LVN B did not recall being informed of the resident's request and stated she would typically assess and obtain vital signs if a resident was unwell. The facility's policy affirms the resident's right to request treatment or care. The lack of timely nursing assessment and response to the resident's repeated requests resulted in the resident leaving the facility to seek care independently, where she was diagnosed and treated for a urinary tract infection and acute airway inflammation.
Failure to Respond to Resident's Request for Hospital Transfer
Penalty
Summary
A deficiency occurred when a resident with a history of acute recurrent sinusitis, shortness of breath, hemiplegia, and hemiparesis requested to be sent to the hospital due to not feeling well. The resident, who had intact cognition as indicated by a BIMS score of 12, used her call light multiple times to inform a CNA of her request to go to the hospital. The CNA reported the request to the LVN on duty, but the LVN did not promptly assess the resident or arrange for her transfer. The resident continued to request assistance over several hours, but no nurse evaluated her or addressed her concerns during that time. There was no documentation in the progress notes or vital sign log regarding the resident's request or any assessment on the day in question. The resident ultimately contacted her significant other to take her to the hospital after several hours without nursing intervention. Upon evaluation at the hospital, she was diagnosed with a urinary tract infection and acute inflammation of the air passages and was prescribed antibiotics. Interviews with staff revealed a lack of awareness and follow-through regarding the resident's repeated requests, and the DON was not aware that the resident had initially asked staff to be sent to the hospital. Facility policy states that residents have the right to request treatment or care, but in this instance, the resident's request was not addressed according to professional standards or her expressed wishes.
Medication Security Lapse in Facility
Penalty
Summary
The facility failed to ensure the security and inaccessibility of medications for unauthorized staff and residents, as observed with two of the three medication carts reviewed. On one occasion, an unlocked and unsupervised medication cart was found on F Hall, with two residents in sight of the cart and no staff present. On another occasion, a second unlocked and unsupervised medication cart was noted at the nurses' station, with no staff, residents, or visitors in sight. The facility's policy requires that compartments containing drugs and biologicals be locked when not in use, and the Director of Nursing (DON) confirmed the expectation that medication carts should be locked when not in use.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper use of personal protective equipment (PPE) and inadequate infection control practices. Licensed Vocational Nurse (LVN) C did not wear a gown during dressing changes for residents on Enhanced Barrier Precautions (EBP), including Residents #30, #64, and #331. This oversight occurred despite visible EBP signage and available PPE stations outside the residents' rooms, indicating a lack of adherence to established protocols for preventing the spread of infections. Additionally, Certified Nursing Assistant (CNA) G did not change gloves after they became contaminated during incontinent care for Resident #63. CNA G continued to perform personal care tasks without changing gloves, which could lead to cross-contamination. This failure to follow proper glove-changing procedures during high-contact activities further highlights the facility's deficiency in maintaining infection control standards. The report also notes that LVN C did not follow appropriate infection control principles while performing dressing changes for Resident #331. LVN C failed to wash hands or use hand sanitizer between glove changes and used the same surface area of gauze multiple times on wounds, increasing the risk of cross-contamination. Despite being aware of the facility's policies, LVN C demonstrated a lack of understanding of EBP and infection control practices, as confirmed in interviews. The Director of Nursing (DON) acknowledged that staff had been trained on infection prevention but did not ensure compliance with these protocols.
Failure to Notify Physician of Resident's Behavioral Change
Penalty
Summary
The facility failed to immediately consult a resident's physician following a significant change in the resident's behavior, which led to the resident's discharge. The resident, a cognitively intact male with a history of verbal aggression, physically assaulted a CNA, resulting in the CNA being sent to the emergency room with a chest wall contusion. Despite the severity of the incident, the resident's primary physician was not notified until the following day, after the decision to discharge the resident had already been made by the Administrator and the Director of Nursing (DON). The facility's policy requires prompt notification of a resident's physician in the event of significant changes in the resident's condition, including behavioral changes. However, the DON did not notify the physician on the day of the incident, as she believed it was unnecessary since the resident was not harmed. The resident's care plan was revised to include physical aggression, but the lack of immediate notification to the physician represents a failure to adhere to the facility's policy, potentially impacting the resident's medical care and quality of life.
Confidentiality Breach of Residents' Records
Penalty
Summary
The facility failed to protect the confidentiality of personal and medical records for two staff members, LVN C and CMA D, as observed during a survey. LVN C left her laptop unlocked and unattended on a treatment cart, displaying residents' personal and medical records. This occurred for approximately five minutes, with the cart positioned about 25 feet away from the nurse's station and not within a clear line of sight. When questioned, LVN C acknowledged the oversight and admitted that leaving the computer unlocked could allow unauthorized access to private information. Similarly, CMA D left her laptop unlocked and unattended on a medication cart while she was in a resident's room administering medication. The computer displayed a resident's medication record and was left unattended for 2-3 minutes with the screen facing the hall. CMA D admitted that leaving the computer unlocked was not acceptable practice. The Director of Nursing (DON) confirmed that staff were aware of the requirement to lock computers when unattended and stated that random rounds were conducted to ensure compliance. The facility's policy on Electronic Medical Records, revised in June 2019, emphasizes limiting the use or disclosure of protected health information to the minimum necessary.
Inadequate Documentation for Resident Discharge
Penalty
Summary
The facility failed to provide adequate documentation for the transfer or discharge of a resident, specifically lacking a documented reason from the resident's physician. The deficiency involved a male resident with a history of cerebral infarction, diabetes, hemiplegia, and anxiety disorder, who was cognitively intact. The resident exhibited verbally abusive behavior and physically assaulted a CNA, resulting in the CNA being sent to the emergency room with a chest wall contusion. Following the incident, the resident was given an immediate discharge notice and transferred to another nursing facility. The facility did not document the specific resident needs that could not be met, the efforts made to meet those needs, or the specific services the receiving facility would provide. The resident's primary physician was not notified of the incident until the day after it occurred and only provided a general discharge order without detailing the reasons for the discharge. The facility's administrator and former DON decided on the immediate discharge without the necessary documentation, placing residents at risk of not having the needed records when transferring care and services.
Expired Medications Found in Facility's Medication Carts
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the proper disposal of expired medications in two of the three medication carts inspected. During an observation, a bottle of docusate sodium and a bottle of loratadine, both with expiration dates of January 2025, were found in the medication cart assigned to an LVN. The LVN stated that nurses and medication aides attempt to check for expired medications monthly. In another observation, a bottle of loratadine with the same expiration date was found in a medication cart assigned to a CMA, who mentioned that LVNs and CMAs try to check for expired medications every few months. The Director of Nursing (DON) indicated that all staff assigned to a cart should check for expired medications, and the contracted pharmacist performs monthly cart inspections, with the DON and ADONs conducting random checks. The facility's policy on the storage of medications requires that discontinued, outdated, or deteriorated drugs be returned to the dispensing pharmacy or destroyed. However, the failure to adhere to this policy resulted in expired medications being present in the medication carts, potentially placing residents at risk of receiving ineffective medications.
Failure to Notify Hospice of Resident Transfer
Penalty
Summary
The facility failed to notify the hospice provider of an emergency transfer for a resident, which resulted in a deficiency. The resident, a cognitively intact male with a history of cerebral infarction, diabetes, hemiplegia, and anxiety, was discharged from the facility without prior notification to the hospice provider. The Director of Nursing (DON) was responsible for making all necessary notifications but forgot to contact the hospice provider before the resident left the facility. This oversight was acknowledged by the DON, who admitted to notifying the hospice only after the resident was already en route to the receiving facility. The hospice Registered Nurse (RN) expressed the need for prior notification to coordinate care and ensure the resident had a sufficient supply of medications for the transition. The Nursing Facility Hospice Services Agreement required immediate notification to the hospice in the event of a resident's transfer. The failure to notify the hospice provider before the resident's discharge placed the resident at risk of not receiving necessary care and services, as the hospice could not coordinate care with the new facility in advance.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident by not ensuring the call light was within reach after a transfer. The resident, who had long and short-term memory impairment, severely impaired cognitive skills, and lower extremity impairment, was dependent on staff for chair to bed transfers. The resident's care plan specifically required that the call light be kept within reach to prevent falls and ensure safety. During an observation, CNAs transferred the resident from a wheelchair to a bed but left the call light on the floor behind the nightstand, out of the resident's reach. A subsequent observation confirmed that the call light was still not accessible to the resident. The facility's policy mandates that call lights be within easy reach to ensure timely responses to residents' needs, which was not adhered to in this instance.
Inadequate Supervision and Assistance Device Use During Resident Transfers
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistance devices during transfers for two residents, leading to potential accident hazards. Resident #2, who has severe cognitive impairment and is dependent on a wheelchair due to lower extremity impairment, was not safely transferred using a mechanical lift. During the transfer, the wheelchair was not locked, causing it to move as the resident was lifted. Both CNAs involved in the transfer believed they performed the procedure correctly, despite the oversight. Resident #63, who has memory impairment and requires substantial assistance for transfers due to paralysis from a stroke, was also involved in an unsafe transfer. The CNAs did not lock both wheels of the wheelchair during a two-person gait belt transfer, which is against the facility's policy. Both CNAs believed the transfer was conducted properly, even though the wheelchair was not fully secured. The Director of Nursing (DON) confirmed that the facility's expectations for transfers were not met, as both mechanical lift and gait belt transfers require locked wheelchairs to ensure resident safety. The facility's policy on safe lifting and movement of residents emphasizes the importance of using appropriate techniques and devices to protect both staff and residents, which was not adhered to in these instances.
Failure to Provide Supervised Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #28, who required nebulizer treatments for conditions including pulmonary edema and Chronic Obstructive Pulmonary Disease (COPD). The resident, who was cognitively intact with a mental status score of 14 out of 15, was observed to have left his room while his nebulizer treatment was still in operation, indicating a lack of supervision during the treatment. There was no documentation in the nurse's notes or Medication Administration Record regarding the resident's refusal or departure from the treatment, and the facility did not have a care plan addressing the resident's tendency to walk away from treatments. The Director of Nursing (DON) stated that if a resident refused a breathing treatment three times, the facility would notify the doctor, and that the administration of breathing treatments depended on the resident's mental status. The DON acknowledged that Resident #28's cognition fluctuated and that the expectation was for nurses to remain with him during treatments if medication was still in the nebulizer. However, this was not care planned, and the facility's policy on medication administration required documentation of medication refusal and prescriber notification, which was not followed in this case.
Failure to Develop Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a newly admitted resident within 48 hours, as required by their policy. The resident, a 62-year-old male with multiple diagnoses including myopathy, insomnia, hypertension, esophageal varices with bleeding, alcoholic liver disease, and Type 2 diabetes, was admitted without a baseline care plan. The absence of this plan was confirmed through a review of the resident's clinical records, which showed no baseline or comprehensive care plan in the electronic health record system. Interviews with the Director of Nursing (DON) and the Administrator revealed that the responsibility for completing the baseline care plan within 48 hours of admission lay with the nursing staff, specifically the DON or the RN on duty. Both the DON and the Administrator acknowledged the expectation for timely completion of the care plan to ensure proper care for the resident. The facility's policy, dated July 2024, also stipulated that a baseline care plan should be developed within 48 hours of admission to meet the resident's immediate needs. However, this was not adhered to, resulting in a deficiency noted by the surveyors.
Inadequate Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the area of hand hygiene during wound care. During an observation, the Wound Care Nurse (WCN) did not perform adequate hand hygiene by scrubbing hands with soap for at least 20 seconds before and after performing wound care on a resident. The WCN also failed to use a no-touch technique and did not change gloves appropriately during the procedure. This lapse in protocol was observed during the care of a 62-year-old male resident with multiple diagnoses, including myopathy, insomnia, hypertension, esophageal varices with bleeding, alcoholic liver disease, and Type 2 diabetes. The resident had a wound on the calf of the right leg, which required specific wound care orders to be followed. The WCN admitted to forgetting to perform hand hygiene between cleaning and applying a new dressing, acknowledging that this oversight could risk infection or slow the healing process. The Director of Nursing (DON) confirmed that all staff are expected to wash hands for at least 20 seconds to maintain infection control measures. The facility's Wound Care program outlined specific steps for hand hygiene and glove use, which were not followed during the observed procedure. The absence of a Baseline Care Plan or Comprehensive Care Plan in the facility's electronic health record system for the resident was also noted.
Medication Administration Failure Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, which led to the resident being transferred to the emergency department and subsequently admitted to the hospital. The resident, who had a history of chronic obstructive pulmonary disease (COPD), anxiety disorder, hypertension, hypothyroidism, type 2 diabetes, and other conditions, did not receive physician-ordered medications, including inhalers, nebulizer treatments, nasal sprays, and tablets for respiratory diseases. This lack of medication administration resulted in the resident experiencing shortness of breath and anxiety, necessitating hospital transfer. The deficiency occurred because the facility did not administer the resident's medications due to a failure in the medication ordering and delivery process. The admitting nurse and other staff members did not ensure that the medications were available and administered as ordered. The resident's medications were not delivered from the pharmacy, and the facility staff did not utilize the emergency medication dispenser (EMDS) to provide the necessary medications. Interviews with staff revealed a lack of communication and understanding of the procedures for obtaining and administering medications, particularly for new admissions. The facility's policies and procedures for medication orders were not followed, leading to the resident not receiving any of her medications for two days. The staff failed to notify the physician or administrative staff about the unavailability of medications, and there was a lack of initiative to obtain the medications from alternative sources. This oversight placed the resident at risk of significant harm, as evidenced by the exacerbation of her chronic conditions and the need for hospitalization.
Kitchen Sanitation and Handwashing Deficiencies
Penalty
Summary
The facility failed to maintain proper sanitation and hygiene standards in its kitchen, which could increase the risk of food-borne illnesses among residents. During an inspection, it was observed that the handheld multi-juice dispenser spigot had a dark slime deposit, indicating it had not been cleaned as required. The Dietary Manager (DM) acknowledged that the spigot should have been cleaned every other day but had not been maintained due to her recent absence. Additionally, the ice machine filter was found with lint build-up, which the DM admitted was supposed to be cleaned every two weeks. These oversights in cleaning practices were attributed to the DM's recent return from vacation. Furthermore, improper handwashing practices were observed among the kitchen staff. A dietary aide washed her hands for only seven seconds, turned off the faucet with her bare hands, and then handled food items, which could lead to contamination. The aide admitted to not following the facility's handwashing protocol, which requires washing hands for at least 20 seconds and using a paper towel to turn off the faucet. The DM confirmed that staff are expected to adhere to these handwashing procedures to prevent cross-contamination and the spread of germs. The facility's policies emphasize the importance of maintaining clean and sanitary kitchen facilities to minimize the risk of infection and food-borne illness.
Failure to Maintain Safe and Comfortable Temperature Levels
Penalty
Summary
The facility failed to maintain a homelike environment with comfortable and safe temperature levels for two resident rooms, F7 and F10, which were found to have ambient temperatures below the acceptable range of 71 to 81 degrees Fahrenheit. In room F7, the temperature was recorded at 69.0 degrees Fahrenheit, and the resident reported feeling cold, wearing multiple layers of clothing to stay warm. The resident had previously informed the Maintenance Supervisor about the issue, but the thermostat was reportedly only adjustable up to 72 degrees Fahrenheit. Similarly, in room F10, the temperature was 68.5 degrees Fahrenheit, and the resident also reported feeling cold, noting a draft from a window gap. This resident had also informed the Maintenance Supervisor, who acknowledged the complaints but did not follow up with the resident. The Maintenance Supervisor, who had been with the facility for a year, admitted to checking temperatures as needed but did not document them. He was unaware of the specific temperature issues in the two rooms and the draft in one of the windows. The facility's policy, dated February 2021, mandates maintaining a safe, clean, comfortable, and homelike environment with temperatures between 71 and 81 degrees Fahrenheit. The Administrator, new to the facility, was informed of the temperature issues and acknowledged the need to address them, although no corrective actions were detailed in the report.
Failure to Provide RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. Specifically, there was no RN coverage on the dates of 08/06/2023, 08/12/2023, 09/10/2023, and 09/17/2023. This deficiency was identified through a review of the facility's time sheets, which confirmed the absence of RN coverage on these specific dates. During an interview conducted on 01/04/2023 at 2:24 PM, the Director of Nurses confirmed the lack of proof of RN coverage for the aforementioned dates. This failure could potentially affect residents and put them at risk of improper care, as the presence of an RN is crucial for maintaining the standard of care required in the facility.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of medications as prescribed. The resident, a cognitively intact male with a history of essential hypertension, chronic venous hypertension, acute diastolic heart failure, and acute respiratory failure, was prescribed Propranolol and Spironolactone with specific parameters for administration. The orders indicated that Propranolol should be held if the systolic blood pressure (SBP) was less than 110, diastolic blood pressure (DBP) was less than 60, or pulse was less than 60, and Spironolactone should be held if SBP was less than 110. Despite these parameters, the medication administration record (MAR) showed that Propranolol and Spironolactone were administered on multiple occasions when the resident's vital signs were outside the prescribed limits. On one occasion, a medication aide admitted to administering Spironolactone without checking the order due to being in a hurry. Interviews with the Director of Nursing (DON) and other staff confirmed that the medications should not have been given under these conditions, as it could have led to a drop in the resident's blood pressure. The facility's policy on administering medications, which requires verification of the right resident, medication, dosage, time, and method, was not followed in these instances.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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