Avir At Beeville
Inspection history, citations, penalties and survey trends for this long-term care facility in Beeville, Texas.
- Location
- 600 S Hillside Dr, Beeville, Texas 78102
- CMS Provider Number
- 455923
- Inspections on file
- 31
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Avir At Beeville during CMS and state inspections, most recent first.
A resident with schizoaffective disorder, dementia, severe cognitive impairment, and documented behavioral issues was discharged to another facility without receiving the required written notice of transfer or discharge, including reasons for the move and related rights. The DON and ADM confirmed that only verbal notice was given to the responsible party, despite acknowledging that important information can be forgotten if not provided in writing. Facility policy on transfers and discharges did not specify the need for formal written notice when health and safety concerns prompted an urgent discharge.
Multiple residents with severe cognitive impairment and behavioral issues were involved in physical altercations with each other, resulting in injuries such as abrasions and pain. Despite care plans addressing aggression and the need for supervision, staff were unable to prevent these incidents, and residents were not adequately protected from abuse by their peers.
A wound care nurse did not follow facility policy for hand hygiene, washing hands for less than the required 20 seconds before and after providing wound care to a resident with a stage four pressure injury. Interviews and policy review confirmed that staff are expected to wash hands for at least 20 seconds to prevent infection, but this standard was not met during the observed procedure.
A CNA entered the room of a COVID-19 positive resident on contact, droplet, and airborne precautions without donning required eye protection and wore an N95 respirator over a surgical mask, contrary to facility policy and training. The resident had multiple comorbidities and was on isolation, with clear signage indicating necessary precautions. Interviews and record reviews confirmed that the CNA did not follow established PPE protocols, despite available supplies and documented training.
A resident with multiple cardiac conditions did not receive several doses of a prescribed anticoagulant because the medication was unavailable and staff failed to request a refill or notify supervisory staff or the physician. Nursing staff documented the medication as unavailable but did not follow protocols for escalation, resulting in a lapse in pharmaceutical services.
A facility failed to ensure proper care for a resident with a G-tube by not verifying tube placement and checking residual before administering water and medications. The resident, with a history of dysphagia and other conditions, was observed receiving medication without these checks, which the LVN admitted to forgetting. The facility's policy requires these steps to prevent complications.
A resident with COPD was found with disconnected oxygen tubing, leading to low oxygen saturation. The LVN responsible was unaware of the issue until informed by a surveyor. After correcting the tubing, the resident's oxygen saturation improved. The DON confirmed the LVN's responsibility to check oxygen administration during care.
A facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. A resident with multiple medical conditions, including Alzheimer's and dysphagia, was administered medications via a G-Tube. Observations revealed that residual medication remained in the cups used for administration, indicating incomplete dosing. The LVN did not notice the residuals, and the DON confirmed that the facility's policy required full administration of medications, which was not followed.
The facility failed to ensure unit refrigerators were free of unlabeled and undated items, posing a risk of foodborne illness. Observations revealed unlabeled items in two unit refrigerators, and interviews with LVNs indicated a lack of awareness about how these items were stored. The DON confirmed that staff were trained on labeling and dating items, but no specific policy for unit refrigerator storage was provided.
A LTC facility failed to maintain an effective Infection Prevention and Control Program, with deficiencies observed in staff hand hygiene practices. An LVN did not change gloves after preparing insulin for a resident with diabetes, and failed to wash hands between glove changes for another resident with severe cognitive impairment. Additionally, another LVN washed hands for only 11 seconds after wound care, contrary to the facility's policy of 20 seconds.
A facility failed to protect two residents from sexual abuse, leading to a deficiency. A female resident with severe cognitive impairment was inappropriately touched by a male resident with Alzheimer's but cognitively intact. The incident was captured on video by the female resident's family and reported to the facility. Despite the female resident's inability to consent, the facility lacked measures to prevent such interactions, and staff were unaware of the incident until reported. The facility's policies on abuse prevention and staff training were insufficient.
The facility failed to report alleged abuse and incidents involving four residents to the appropriate authorities within the required timeframe. In one case, two residents were involved in a possible sexual abuse situation that was not reported immediately due to the belief it was consensual. Another resident experienced an unwitnessed fall resulting in a fracture, which was not reported as an injury of unknown origin in a timely manner. Additionally, an allegation of abuse was not reported to local law enforcement due to insufficient evidence, despite facility policy requiring immediate reporting of all abuse allegations.
Failure to Provide Required Written Discharge Notice to Resident and Responsible Party
Penalty
Summary
The deficiency involves the facility’s failure to provide required written notice of transfer or discharge to a resident and his responsible party (RP). A male resident with schizoaffective disorder and dementia, who had an initial admission date of 06/14/25 and a discharge date of 03/25/26, was discharged to another facility without receiving written notice of the discharge, the reasons for the move, or related rights. His Discharge MDS showed a BIMS score of 3, indicating severe cognitive impairment, and his care plan documented behavior problems related to dementia, including physical aggression, yelling, swinging at staff, urinating in inappropriate areas, and episodes of sexual inappropriateness toward staff. The Discharge Summary indicated he was discharged early in the morning, released to a different facility, his RP was notified, and he was not expected to return. During interviews, the DON acknowledged that no formal written discharge notice was given to the RP, explaining that the transfer had been agreed upon by the RP and that no one disputed the discharge. The DON stated she verbally informed the RP the day before the discharge and that the facility had been searching for a new facility for the resident due to ongoing issues, describing the discharge as urgent because the resident posed a safety risk to himself and others. The ADM also confirmed that, to her knowledge, no written discharge notice was provided, and stated she was usually responsible for sending discharge notices when appropriate. Both the DON and ADM recognized that important information not written down and provided to the RP could be forgotten after a meeting. Review of the facility’s transfer and discharge policy showed it did not specify that a formal written discharge notice must be given to the RP when health and safety of others are at risk.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, resulting in several altercations. In one incident, a male resident with severe cognitive impairment and a history of physical and verbal behaviors was involved in a physical altercation with another male resident, also with severely impaired cognition and a history of aggression. The altercation occurred when one resident attempted to assist the other, leading to both residents striking each other. Staff attempted to redirect and separate the residents, but the altercation still occurred, and both residents were assessed afterward. Another incident involved two female residents, both with dementia and significant cognitive impairment. One resident, who had a history of aggressive behaviors and delusions, initiated a physical altercation in the hallway by grabbing and hitting another resident after a verbal exchange. The second resident sustained a superficial abrasion and complained of elbow pain. Staff responded by separating the residents and assessing for injuries. Both residents had documented behavioral issues and required supervision and monitoring, but the altercation still took place. In both cases, the residents involved had known behavioral and cognitive challenges, including histories of aggression, delusions, and difficulty with redirection. Care plans for these residents included interventions such as monitoring for danger to self or others, analyzing triggers, and providing cues to alleviate anxiety. Despite these interventions, the facility did not prevent the physical altercations, and residents were not adequately protected from abuse by other residents.
Failure to Perform Proper Hand Hygiene During Wound Care
Penalty
Summary
A deficiency was identified when a wound care nurse (WCN) failed to perform proper hand hygiene before and after providing wound care to a resident. Specifically, the WCN washed her hands for approximately 9 seconds prior to wound care and for about 18 seconds after completing the procedure, both of which were less than the facility's policy requirement of at least 20 seconds. The resident involved was an elderly female with multiple diagnoses, including Alzheimer's disease, dementia, cerebral infarction, chronic atrial fibrillation, and hypertension, and had a stage four pressure injury to the coccyx requiring daily wound care as ordered by her physician. Interviews with the WCN, Director of Nursing (DON), and Staff Development Nurse confirmed that staff are expected to perform hand hygiene for a minimum of 20 seconds, using methods such as singing "Happy Birthday" twice or counting to 20 seconds to ensure thorough cleaning. The facility's hand hygiene policy and procedure forms also specify a minimum of 20 seconds for handwashing. Despite recent competency checks indicating no concerns, the WCN did not meet the required hand hygiene duration during the observed wound care procedure.
Failure to Ensure Proper PPE Use for Resident on Transmission-Based Precautions
Penalty
Summary
A certified nursing assistant (CNA) failed to properly don the required personal protective equipment (PPE) before entering the room of a resident who was COVID-19 positive and on contact, droplet, and airborne precautions. The CNA entered the resident's room wearing gloves, a gown, and an N95 respirator over a surgical mask, but did not wear any eye protection or face shield as required by facility policy and CDC guidelines. The CNA remained in the resident's room for approximately ten minutes without the appropriate eye protection. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertensive heart disease, and was confirmed COVID-19 positive at the time of the incident. Facility records indicated that the resident was on isolation precautions, and signage on the resident's door specified the need for contact, droplet, and airborne precautions. The CNA stated she was trained to use an N95 mask but was not specifically instructed about not wearing a surgical mask underneath, and she was unaware of the need for eye protection, despite competency validation records indicating she had been trained in proper PPE use. Interviews with the infection preventionist and the director of nursing confirmed that the CNA did not follow facility policy regarding PPE use, specifically the requirement for eye protection and the correct use of the N95 respirator. Both staff members stated that appropriate PPE, including N95 masks and eye protection, was available and that staff had been trained on these procedures. The facility's policy required adherence to CDC-recommended infection prevention and control practices, including the use of appropriate PPE for residents on transmission-based precautions.
Failure to Administer Prescribed Anticoagulant Due to Medication Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering the prescribed anticoagulant medication, Eliquis 5mg BID, over a four-day period. The medication was not given from 01/03/2025 to 01/06/2025 because it was unavailable, and no refill was requested by the clinical staff. Both the LVN and RN involved documented the medication as unavailable but did not notify the Director of Nursing (DON) or the physician about the missed doses or the need for a refill. The DON was only made aware of the missed doses after being informed by a federal government agent during a record review on 01/17/2025. The resident involved had significant medical conditions, including paroxysmal atrial fibrillation, atherosclerosis, venous insufficiency, and chronic heart failure, and was dependent on staff for activities of daily living with severe cognitive impairment. The resident's care plan and physician orders specifically required the administration of Eliquis to manage the risk of blood clots associated with his cardiac conditions. Despite clear protocols for medication administration and refills, the staff did not follow procedures to ensure the resident received his prescribed medication, nor did they escalate the issue when the medication was not available. Interviews with the involved nursing staff revealed that neither took steps to notify supervisory staff or the physician about the medication shortage, and both relied on documentation or informal communication with colleagues rather than following established protocols. The DON confirmed that she was not notified of the issue and that the facility had procedures in place for medication refills and emergency medication access, which were not utilized. The failure to administer the prescribed anticoagulant as ordered constituted a deficiency in pharmaceutical services for the resident.
Failure to Verify G-tube Placement and Residual
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding received appropriate care and services to prevent complications. Specifically, the facility did not verify the placement and check the residual of the resident's G-tube before administering water and medications. This oversight was observed during a medication administration session where the LVN did not check the placement or residual of the G-tube prior to flushing it with water and administering medications. The LVN admitted to forgetting this crucial step, acknowledging that it is necessary to ensure the G-tube is correctly positioned to prevent medications from being delivered to the wrong location in the body. The resident involved was an elderly female with a history of dysphagia, aphasia, cerebral infarction, Alzheimer's, dementia, hemiplegia, and gastrostomy status. Her care plan included the use of a feeding tube, and physician orders specified an NPO diet with enteral feed orders to flush the tube with water before and after medications. The Director of Nursing confirmed that the procedure for administering medications through an enteral tube includes checking the residual to ensure the tube is patent. The facility's policy on administering medications through an enteral tube also emphasizes verifying the placement of the feeding tube to prevent improper administration.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care to a resident who required oxygen therapy, as observed during a survey. The resident, who had a history of Chronic Obstructive Pulmonary Disease (COPD), cerebral infarction, severe vascular dementia, and generalized muscle weakness, was found with her oxygen tubing not connected to the concentrator. The nasal prongs were incorrectly positioned on her cheek instead of her nostrils, and the oxygen concentrator was on but not delivering oxygen. This oversight was discovered while a Licensed Vocational Nurse (LVN) was administering medications through the resident's feeding tube. The LVN, responsible for the resident's care, was unaware of the disconnection until informed by the surveyor. Upon checking, the resident's oxygen saturation was at 89%, which is considered low. After correcting the tubing placement and connection, the saturation improved to 97%. The LVN admitted to not recalling the last time he received in-service training on respiratory care. The Director of Nursing (DON) confirmed that the LVN was responsible for checking oxygen administration during each shift and while providing care, acknowledging that failure to do so could lead to hypoxia and respiratory distress.
Medication Administration Errors via G-Tube
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. This was based on 2 errors out of 25 opportunities, involving a resident who was administered medications via a Gastrostomy tube (G-Tube). The resident, who had a history of dysphagia, aphasia, cerebral infarction, Alzheimer's, dementia, hemiplegia, pain, and gastrostomy status, was prescribed Acetaminophen-Codeine for pain and Memantine for Alzheimer's. During medication administration, it was observed that residual medication remained in the cups used for the crushed tablets, indicating that the full dose was not administered. The Licensed Vocational Nurse (LVN) responsible for administering the medications did not notice the residual medication left in the cups. The Director of Nursing (DON) confirmed that the expectation was for no residual to remain and that additional water should be used to ensure the full dose is given. The facility's policy on administering medications through an enteral tube required diluting crushed medications with at least 30ml of purified water, which was not adequately followed, leading to the medication errors.
Failure to Label and Date Items in Unit Refrigerators
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that unit refrigerators were free of unlabeled and undated items. During an observation, it was found that unit 1 contained an unlabeled and undated near-empty bottle of salad dressing, while unit 2 had three bottles of water, a hamburger bun, a hamburger patty, and a near-empty container of orange juice, all without labels or dates. This oversight could potentially expose residents to foodborne illnesses due to cross-contamination. Interviews with two LVNs revealed that the refrigerators were kept locked for patient safety, with only the nurse holding the key. Both LVNs acknowledged the importance of labeling and dating items to prevent cross-contamination and stated that they were unaware of how the unlabeled items ended up in the refrigerators. The DON confirmed that the LVNs were trained and reminded about the importance of labeling and dating items. A review of the facility's policy indicated that food brought by family or visitors should be labeled and stored properly, but there was no specific policy provided regarding food storage in unit refrigerators.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by several observed deficiencies involving staff members and residents. One incident involved an LVN who did not remove his gloves after preparing insulin medication for a resident with multiple health conditions, including diabetes and heart disease. The LVN proceeded to administer the medication without changing gloves, acknowledging that he forgot to do so, which could lead to contamination. Another deficiency was observed with the same LVN during medication administration for a resident with severe cognitive impairment and a feeding tube. The LVN failed to wash his hands or use hand sanitizer between glove changes, admitting that he forgot to perform hand hygiene. This oversight was recognized by the LVN as a potential cause of contamination and infection spread among residents. A third incident involved an LVN performing wound care on a resident with severe cognitive impairment and at risk for skin breakdown. The LVN washed her hands for only 11 seconds after removing gloves, contrary to the facility's policy of washing hands for at least 20 seconds. The LVN believed she had washed her hands long enough by singing the Happy Birthday song twice in her head, but acknowledged the importance of proper handwashing to prevent infection spread.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from sexual abuse, leading to a deficiency identified by surveyors. Resident #2, a female with severe cognitive impairment, was not adequately supervised, resulting in an incident where Resident #3, a male with Alzheimer's disease but cognitively intact, was recorded touching Resident #2 inappropriately. The incident was captured on video by Resident #2's family member, who reported it to the facility the following day. Despite Resident #2's cognitive impairment, which rendered her unable to consent to sexual activities, the facility did not have measures in place to prevent such interactions. Resident #2's care plan indicated severe cognitive impairment and a history of attention-seeking behavior from males, yet the facility did not implement specific supervision interventions to prevent inappropriate interactions. The care plan also noted Resident #2's tendency to make inappropriate sexual comments and false accusations, but there was no evidence of updated supervision strategies following the incident. The facility's staff, including the DON and Administrator, were unaware of the incident until it was reported by the family, indicating a lack of proactive monitoring and supervision. The facility's policy required immediate reporting and investigation of abuse allegations, but there was a delay in recognizing and addressing the incident. The staff were not adequately trained or prepared to handle such situations, as evidenced by the lack of in-service documentation and specific monitoring for Resident #2. The facility's failure to protect Resident #2 from potential harm and abuse highlights deficiencies in supervision, staff training, and adherence to abuse prevention policies.
Removal Plan
- Resident #3 discharged from Birchwood of Beeville.
- Resident #2 was assessed and found to be in no immediate physical or mental harm safety check in place.
- 26 Interview able residents have been identified and resident safe surveys were initiated.
- Review of the F-tag 600.
- Medical Director notified.
- DON and the Administrator were in-serviced over the abuse and neglect policy and procedure by the Chief Operating Officer.
- One to one staff supervision or safety checks will be applied to any resident who alleges abuse and or causes abuse until the investigation is thoroughly completed.
- The Abuse and Neglect Policy and Procedure (identifying sexual abuse capacity) was reviewed in the facility protocol. All staff will be in-service before the start of their shift and no staff will be allowed to start work until the training has been completed.
- Walkie talkies purchased to help increase communication between the staff to assist with increased resident supervision. The nurse staff: charge nurse and certified nurse aide will use radios.
- Resident #2's care plan was updated, and it does include specific interventions for monitoring.
- Psych services to continue monthly visits with the resident to assist with her psychosocial well-being related to her ability to have needed sexual expression.
- The facility's process for determining whether residents have capability to give consent to sexual activities is BIMs, Resident Assessment and Care Plan, and Family Responsible Party Consent.
- The facility will recognize residents who lack capacity to make decisions or are making unsafe decisions by the Resident Assessment and Care Plan.
- Reviewed the facility conducted 100% review of all residents. 4 residents were identified with inappropriate sexual behaviors.
- Resident #2's care plan was updated reflecting no specific supervision interventions.
- Record review of Resident #2's 1:1 log sheet documented beginning 1:1 and maintained current during observation through review.
- Record review of the facility's What to do if you witness or suspect sexual abuse in-service had 100% clinical staff in attendance.
- Record review of the facility's in-service objective of the In-service: Free of accidents/hazards/supervision/devices, facility will provide adequate supervision to prevent sexual abuse, facility will provide interventions and monitoring to ensure residents safety from sexual abuse, freedom from abuse/neglect/ Misappropriation of property/and exploitation, facility will provide an environment free from sexual abuse-had Administrator and DON in attendance.
- Two-way walkie talkie's will be utilized in the facility to communicate with each other for the resident and staff safety. Please use same channel to communicate effectively to each other. Return radios to the charger ports after your shift. We must have radios on through your shift to communicate any behavior in the residents that maybe concern.
Failure to Report Alleged Abuse and Incidents Timely
Penalty
Summary
The facility failed to report alleged violations involving abuse to the State Survey Agency and other officials within the required timeframe for four residents. In one incident, two residents were involved in a possible sexual abuse situation that was not reported immediately. The facility's Director of Nursing (DON) and Administrator believed the interaction was consensual due to the residents' behavior and did not report it until prompted by an Ombudsman. The DON acknowledged that the resident involved had severe cognitive impairment and was unable to consent to sexual activities, yet the incident was not reported within the required two-hour window. Another incident involved a resident who experienced an unwitnessed fall resulting in an elbow fracture. The fall was initially assessed with no injuries noted, but a fracture was discovered days later. The facility did not report the incident as an injury of unknown origin to the Health and Human Services Commission (HHSC) within the required timeframe. The Administrator and DON stated that such incidents should be reported, but the delay in discovering the injury led to a failure in timely reporting. Additionally, the facility did not report an allegation of abuse involving a resident who claimed to have witnessed a staff member on top of another resident. The facility conducted an investigation and deemed the allegation unfounded due to the resident's history of hallucinations and false allegations. However, the facility did not notify local law enforcement as required by their policy, which mandates reporting all allegations of abuse immediately. The DON and Administrator concluded there was insufficient evidence to substantiate the claim, leading to a failure in following proper reporting procedures.
Latest citations in Texas
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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