Avir At Houston
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 2310 S Eldridge Parkway, Houston, Texas 77077
- CMS Provider Number
- 676066
- Inspections on file
- 27
- Latest survey
- May 8, 2026
- Citations (last 12 mo.)
- 17 (2 serious)
Citation history
Health deficiencies cited at Avir At Houston during CMS and state inspections, most recent first.
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.
Failure to Knock Before Entering Rooms and Exposed Urinary Bag: A CNA entered three residents' rooms without knocking, and each resident said staff should knock and that they preferred privacy. The residents had diagnoses including encephalopathy, heart failure, respiratory failure, malnutrition, and sepsis, with moderate cognitive impairment documented for three of them. In addition, a resident with a urinary catheter was observed with an exposed urine bag hanging from the bed without a privacy cover, and the urine could be seen from the hallway; interviews confirmed privacy covers were required and that exposed urine affected dignity.
Failure to Provide Resident-Centered Activities Three residents did not receive an ongoing activities program matched to their needs and preferences. A resident with severe visual impairment was bored on weekends and could not participate in bingo because he was not given a large-print card. Another resident said she was never asked about activity preferences, did not get an activity calendar until later, and was not offered in-room activities. A third resident with significant neurologic and physical impairments said preferred activities were unavailable and he was bored; the acting AD reported activities often started late and many residents could not participate.
Loose medications were found in 2 of 8 observed med carts, including five loose pills in one cart, one loose pill in another, and one loose blue pill in a third cart. A bottle of Active Liquid Protein also lacked an open date. Staff interviews confirmed that carts are checked by nurses, unit managers, DON, and pharmacy, and the facility policy requires the date opened to be recorded on multi-dose containers.
Cold food served to residents: Multiple residents reported that meals delivered to their rooms were cold, with one resident needing staff to reheat breakfast and another stating reheated food came back hard. Surveyors also tasted lunch test trays on two occasions and found items cold, while the dietary cook, DA, RD, and ADM acknowledged complaints or expectations related to serving food at proper temperatures.
Infection Control Failures During Resident Care: Staff did not follow PPE, hand hygiene, and equipment-cleaning practices during care for several residents. An RN failed to clean a glucometer and basket after blood sugar checks, a CNA and a Central Supply staff member entered rooms with enhanced barrier precautions without PPE, and an LVN did not clean the glucometer or insulin vial, and did not properly perform hand hygiene during insulin administration and after emptying a urinal. Residents involved had significant cognitive impairment, diabetes, wounds, and other serious diagnoses.
Failure to accommodate a resident with severe vision loss included staff placing breakfast on his bedside table without consistently telling him what food was on the tray, where it was located, or removing cellophane from items. The resident said he could not read the papers given to him, and the activity calendar in his room was not in large print. Staff interviews were inconsistent about whether he was routinely oriented to his meal and whether he received large print reading materials.
Incorrect PASRR Screening for Residents with Mental Health Diagnoses: The facility failed to complete PASRR screening correctly for two residents with documented MH diagnoses. One resident had bipolar disorder and psychotropic medication use, and another had bipolar disorder, MDD, schizophrenia, anxiety, and depression with psychotropic medication use. In both cases, the PASRR marked mental illness as no, and the MDS Coordinator stated both residents should have been marked positive.
Multiple residents with complex conditions, including diabetes, cardiomyopathy, COPD, Parkinson’s disease, chronic pain, dementia, and end-stage renal disease, had 8 a.m. medications such as antihypertensives, anticoagulants, antiepileptics, psychotropics, and analgesics administered well after the facility’s one-hour window, with actual administration times ranging from about 10:20 a.m. to after 11:30 a.m. A PRN MA reported starting the med pass late due to other commitments, and an LVN in charge described frequent short-staffing and task reassignments that delayed med administration despite knowing medications should be given within one hour of the scheduled time. The DON and facility policy confirmed that medications must be administered as ordered and within one hour of the prescribed time, with administration times based on resident need and benefit rather than staff convenience.
A resident with COPD and other comorbidities, receiving continuous O2 via nasal cannula, had physician orders and a care plan requiring weekly changes of nasal cannula tubing and the humidification bottle, as well as adherence to the facility’s oxygen administration policy. Surveyors observed that the resident’s O2 tubing and humidifier bottle, labeled with the last change date, had not been changed for more than a month. Staff interviews confirmed that Sunday night shift nurses were assigned to perform weekly changes but that no verification occurred to ensure the task was completed, resulting in the resident’s oxygen equipment not being changed as ordered.
A resident with severe cognitive impairment and multiple comorbidities developed several pressure ulcers, including on the sacrum, left foot, right ankle, and left hip, due to the facility's failure to provide timely pressure-reducing devices and consistent repositioning. Delays in obtaining an air mattress and heel boots, along with inconsistent wound care, led to the progression of wounds to unstageable and necrotic stages, ultimately resulting in hospital transfer for surgical intervention and a recommendation for hospice care.
A resident with severe cognitive impairment, right-sided paralysis, and dependence on staff for most ADLs was discharged to a men's homeless shelter that could not provide necessary assistance with personal care or medication management. Despite documentation and staff observations indicating the resident's ongoing need for substantial help, the facility proceeded with the discharge due to the end of a payment agreement and lack of family support, resulting in the resident struggling to manage basic needs and medication adherence at the shelter.
A resident with multiple complex medical conditions was discharged from the facility without a completed or transmitted discharge MDS assessment. The resident left against medical advice, and although an AMA form was signed, it was not promptly uploaded to the electronic record system. Staff interviews and record reviews confirmed that required documentation and transmission of the discharge MDS were not completed in accordance with facility policy.
A resident with an indwelling catheter and total dependence for ADLs did not have urine output monitored and documented as ordered, despite a history of UTIs and physician directives. Missed documentation occurred on multiple shifts, and lab results indicated recurrent UTIs. Interviews with staff and leadership confirmed the importance of output monitoring, but the facility's policy did not address documentation requirements.
The facility failed to provide adequate weekend activities for residents, offering only self-guided options like puzzles and movies. Residents expressed dissatisfaction with the lack of structured activities on weekends, which did not align with the facility's policy of providing activities seven days a week.
A resident receiving IV antibiotic therapy had their PICC line dressing changed improperly and not according to schedule, increasing infection risk. The facility failed to change the dressing every 7 days as ordered, and LVN B did not measure the catheter length before removal, risking dislodgement. Systemic issues included unavailable dressing kits and poor communication among staff, contributing to the deficiency.
A facility experienced a 14% medication error rate due to an LVN's improper administration of medications to two residents. The LVN failed to follow professional standards for PEG tube administration and did not adhere to physician orders regarding medication timing, leading to potential drug interactions. The DON and ADON noted a lack of proper orientation for the LVN, contributing to these errors.
A facility failed to complete a resident's Annual MDS assessment within the required timeframe, resulting in a 124-day delay. The resident, an 88-year-old female with multiple diagnoses, had her assessment overdue by 26 days. Staff interviews highlighted the importance of timely MDS submissions for compliance and adequate care. The facility's policy mandates comprehensive assessments at specific intervals, and the delay could affect current care plans and interventions.
A facility failed to complete a quarterly assessment for a resident with severe cognitive impairment within the required timeframe. The resident's last MDS assessment was completed several months prior, and the subsequent assessment was overdue by 26 days. The MDS Coordinator admitted the delay, which was contrary to the facility's policy requiring timely submission of assessments to CMS.
A facility failed to complete and transmit a quarterly MDS assessment for a resident within the required timeframe. The assessment, due in February, was not uploaded until March, as confirmed by the MDS Coordinator. This delay could result in an incomplete record for the resident.
A facility failed to implement a comprehensive care plan for a resident with a PICC line, despite physician orders and the resident's medical history. The MDS Coordinator misunderstood the difference between a peripheral IV and a PICC line, leading to the omission. The DON acknowledged the risks associated with this oversight, which included potential infiltration and embolism.
A resident with a G-tube did not receive medication and water according to physician's orders, as LVN B administered 630 cc of water instead of the prescribed 140 cc. The resident complained of feeling too full, and it was revealed that LVN B had not received proper orientation on G-tube procedures. The facility's policy and Texas Administrative Code standards were not followed, leading to a deficiency in care.
Two residents in an LTC facility did not receive adequate grooming and personal care. One resident did not receive scheduled showers, resulting in dry, itchy skin, while another was left in a saturated incontinent brief, leading to skin excoriation. Staff failed to document and communicate effectively, contributing to these deficiencies.
A resident with multiple medical conditions, including a seizure disorder and dysphagia, experienced a significant medication error when an LVN failed to administer medications via a G-tube according to professional standards. The LVN did not ensure all medication was delivered, leaving some in the cups, which could affect therapeutic drug levels. The DON confirmed the LVN lacked proper orientation on G-tube administration, and the facility's policy on medication administration was not followed.
Two residents dependent on staff for ADL care did not consistently receive necessary grooming and personal hygiene services. One resident experienced ongoing dry, flaky skin that was not properly reported or addressed by staff, while another did not receive scheduled showers on multiple occasions, with missed care not documented as refused. Staff interviews revealed lapses in communication, monitoring, and documentation, resulting in unmet care needs.
A resident with severe cognitive impairment and limited mobility did not receive timely or appropriate foot care, resulting in long, thick, and deformed toenails with fungal infection. Multiple staff members observed the condition but failed to report it promptly, and the podiatrist was not notified until the administrator intervened. Facility policy requiring regular nail care was not followed, leading to a deficiency in maintaining proper foot health.
LVNs did not document the reasons for withholding a prescribed pain medication for a resident with multiple neurological conditions and a pain management care plan. The MAR showed the medication was not given, but no explanation was recorded in the progress notes, contrary to facility policy.
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.
Failure to Knock Before Entering Rooms and Exposed Urinary Bag
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity when CNA B did not knock before entering the rooms of Resident #20, Resident #59, and Resident #64. Resident #20 was a female with diagnoses including metabolic encephalopathy, hypertensive chronic kidney disease, hyperlipidemia, hypertension, weakness, and unsteadiness on feet, and her BIMS score was 08. Resident #59 was a female with diagnoses including heart failure, respiratory failure, muscle weakness, GERD without esophagitis, hypertension, and sepsis, and her BIMS score was 10. Resident #64 was a male with diagnoses including protein-calorie malnutrition, sepsis, hypertension, kidney failure, and alcohol abuse, and his BIMS score was 09. Each resident stated staff did not knock on the door and that they wanted staff to knock before entering their rooms. Observations during breakfast tray pass showed CNA B entering Resident #59's room at 7:17 a.m., Resident #64's room at 7:25 a.m., and Resident #20's room at 7:28 a.m. without knocking first. During interviews, Resident #59 said staff were supposed to knock and that staff would just walk in, including when she was being changed. Resident #64 said staff walked into his room all the time and that he got irritated when they did not knock. Resident #20 said staff never knocked on the door and that she preferred they knock, especially if the door was closed. The facility also failed to ensure Resident #102's urinary catheter had a privacy cover. Resident #102 was a female with diagnoses including hearing loss, pain, hypertension, cognitive communication deficit, and a rib fracture with pain, and her BIMS score was 99, indicating unable to complete the interview. Observations showed a urinary bag hanging from the side and bottom of her bed with no privacy cover, and the urine was visible from the hallway. Interviews with CNA B, MA F, CNA A, Central Supply, and the DON indicated privacy bags were supposed to be used for urinary bags and that exposed urine affected dignity and self-worth. The resident's care plan did not reflect anything about the catheter, and the report states the Dignity Policy required each resident to be cared for in a manner that promotes and enhances well-being, satisfaction with life, and feelings of self-worth and self-esteem.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing activities program that supported residents’ choices of facility-sponsored group activities, individual activities, and independent activities for three residents reviewed for activities. The deficiency involved Resident #27, Resident #73, and Resident #85, and the report states that the failure could place residents at risk for boredom, depression, and diminished quality of life. Resident #27 was an older male with diagnoses including blindness in both eyes and a BIMS score of 6, indicating severe cognitive impairment. His MDS reflected that vision was highly impaired and that books, newspapers, and magazines were very important to him. His care plan addressed visual impairment and legal blindness, but there was no activities focus. During interview, he said he got bored on weekends because there were not enough activities, especially activities that accommodated blindness. He also said he was taken to bingo but was not given a large-print bingo card, so he could not participate. Resident #73 was a female with diagnoses including a displaced comminuted fracture of the shaft of the right femur, atrial fibrillation, and morbid obesity, and her BIMS score was 15. Her baseline care plan had no activities focus. She stated she was not asked about activity preferences on admission, did not receive an activity calendar until later, and no one had come to her room to offer activities such as coloring materials or puzzles. Resident #85 was a male with diagnoses including central cord syndrome at C3, occlusion and stenosis of an unspecified middle cerebral artery, and a cerebral aneurysm, with a BIMS score of 9. His care plan noted dependence on staff for activities and cognitive stimulation/social interaction related to physical limitations. He said the facility had asked what activities he liked, but the toss game they used to play outside could not be located, popcorn was no longer available during movies, and he was currently bored. The acting AD stated activities did not always start on time, there was not much resident involvement because many residents lacked physical ability or stamina, and she had no training in being an activities director or direction from the facility regarding activities.
Loose medications and missing open date in medication carts
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with accepted professional principles for 2 of 8 medication carts observed. During observation on 05/07/2026, RN B’s medication cart contained five loose pills, and RN A’s medication cart contained one loose pill. LVN D’s medication cart also contained one loose, small round blue pill, and a bottle of Active Liquid Protein did not have an open date written on it. Staff interviews confirmed that loose medications were found in the carts and that the open date was not documented on the liquid protein container. During interviews, RN B stated nurses, unit managers, the DON, and pharmacy check medication carts, and that pharmacy checks them monthly. RN A stated loose pills in the medication cart could cause confusion. LVN D stated staff would not be able to identify a medication if it was loose in the cart and reported loose pills were disposed of in the pill incinerator. The DON stated nurses should clean their medication carts after each shift and that staff are expected to write the open date on medications, while the ADM stated staff should check their medication carts to ensure there are no loose pills. The facility policy stated the expiration or beyond-use date is checked before administering medications and that when opening a multi-dose container, the date opened is recorded on the container.
Cold food served to residents
Penalty
Summary
The facility failed to serve food and drink at a palatable, attractive, and safe appetizing temperature for residents in the kitchen and on meal trays delivered to resident rooms. Multiple residents reported that meals were cold when received in their rooms. Resident #63 stated that food was always cold when eaten in the room and that he had to ask staff to warm it up and bring it back because he could not eat cold food. Resident #91 stated the food was not good and was served cold, and Resident #103 stated his food usually arrived cold. Resident #75 was overheard yelling for breakfast because her plate was cold; staff reheated the plate and returned it, and she stated that every time her food was brought to her room it was cold and, after reheating, it came back hard. Resident #19 also stated the food was always cold. Surveyors observed and tasted meal trays during lunch meal sampling on two separate occasions. On one occasion, the regular test tray included beans, spinach, and a meat patty with gravy, and all of the food on the tray was cold when tasted by two state surveyors. On another occasion, the test tray included a Philly cheesesteak sandwich, mashed potatoes, red potatoes, green beans, mixed vegetables, a tossed salad, and cheesecake, and the green beans and mixed vegetables were cold when tasted by two state surveyors. The dietary cook stated he was aware of residents complaining that their food was cold and said it depended on which staff members were working on the floor because some CNAs worked faster than others. The DA stated she was responsible for putting meal trays on carts to go to the floors and that the food was hot when it came out of the kitchen, while the RD stated she was aware of some complaints about cold food and expected hot foods to be served according to standardized guidelines of 120 degrees. The ADM stated her expectation was that food would be delivered at a safe and warm temperature according to policy.
Infection Control Failures During Resident Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for multiple residents during observed care and record review. Resident #7 had a diagnosis of type 2 diabetes mellitus and a BIMS score of 4, indicating severely impaired cognition. During an observation, RN A used a small amount of hand sanitizer for only a few seconds, checked the resident’s blood sugar, and did not clean the glucometer before placing it in the medication cart. RN A also used a purple basket to carry glucometer supplies into the resident’s room, placed it on the bedside table, and did not clean the basket before returning it to the medication cart. RN A stated the glucometer should be sanitized before and after each use and that not doing so could put the resident at risk of infection. Resident #32 had severe cognitive impairment and multiple injuries, including intracerebral hemorrhage, subarachnoid hemorrhage, fractured rib, fractured lower leg, fractured spine, and surgical and traumatic wounds. The care plan included enhanced barrier precautions. During observation, the resident’s room had an enhanced barrier precautions sign and the PPE station outside the door had only one glove and one gown. CNA A assisted with removing a brace from the resident’s right arm without using any PPE. CNA A stated that any time there was a PPE station, staff were supposed to use the PPE and that failing to do so could transfer something to another resident. Resident #95 had diagnoses including breast cancer, Asperger’s syndrome, protein-calorie malnutrition, anxiety, and hypokalemia, and the care plan directed staff to use gown and gloves during high-contact care activities that could transfer MDROs. During observation, the resident’s door had an enhanced barrier precautions sign, but staff entered the room without PPE while Central Supply assisted with pulling the resident up in bed. Central Supply stated PPE was required any time patient care was provided to the resident. Resident #101 had type 2 diabetes mellitus and an insulin order for lispro before meals for high blood sugars. During observation, LVN D did not perform hand hygiene before putting on gloves, did not clean the glucometer before checking the resident’s blood sugar, did not clean the top of the insulin vial before withdrawing insulin, performed hand hygiene for less than 5 seconds and did not cover the backs of her hands, and did not properly perform hand hygiene after emptying the resident’s urinal. LVN D also did not clean the glucometer or tray before placing them in the medication cart.
Failure to Accommodate a Visually Impaired Resident’s Meal and Reading Needs
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not provided for a resident with severe visual impairment and severe cognitive impairment. The resident’s face sheet reflected diagnoses including blindness in the right eye and blindness in the left eye. The MDS documented that he was highly visually impaired and could see large print but not regular print in newspapers or books, and that reading books, newspapers, and magazines was very important to him. His care plan addressed visual impairment related to glaucoma and eye pressure, but there was no focus area addressing activities. During observation, the resident’s breakfast tray was placed on his bedside table while he sat on the edge of his bed. The tray contained grits, scrambled eggs, toast, a plastic cup of juice covered in cellophane, and a closed plastic container of grape jelly. The resident stated staff brought his tray, left the room, and did not tell him what food was on the tray or where it was located. He said he did not know he had juice and requested help removing the plastic. He also stated he was trying to eat because he did not want to lose any more weight and asked the surveyor to tell him where his food was on the tray. The resident further stated that the facility did not do anything to facilitate blind people and that papers dropped off for resident council were not in large print and he could not read them. Observation of the activity calendar in his room showed it was not in large print and he was unable to read it. Staff interviews were inconsistent: one OT said aides had been dropping off food without orienting him to it, while other staff said they told him what food was on his plate and where it was located. The ADM was not sure whether he received large print reading materials, and the VPC stated the activity calendar should be in large print so he could read it.
Incorrect PASRR Screening for Residents with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that PASRR screening was completed correctly for two newly admitted residents with mental health diagnoses. Resident #35 was admitted with diagnoses including bipolar disorder, stroke, dysphagia, hypertension, and need for assistance with personal care. His admission MDS documented a BIMS score of 99, indicating the interview could not be completed, and also listed bipolar disorder as an active diagnosis. His care plan noted use of psychotropic medications related to behavior management for bipolar disorder and psychosis. However, the PASRR dated 03/13/2026 marked mental illness as no. Resident #65 was admitted with diagnoses including bipolar disorder, major depressive disorder, schizophrenia, dysphagia, hypertension, and stroke. His admission MDS documented a BIMS score of 13 and listed bipolar disorder, schizophrenia, anxiety disorder, and depression as active diagnoses. His care plan also noted use of psychotropic medications related to schizophrenia and bipolar disorder. Despite these documented mental health diagnoses, the PASRR dated 04/09/2026 marked mental illness as no. During interviews, the MDS Coordinator stated she was responsible for ensuring PASRRs were correct and said both residents should have been marked positive for mental illness. She also stated the DON and ADM monitored PASRR accuracy, and the ADM said the MDS Nurse was responsible for ensuring the PASRR was correct and sending referrals to the state designated authority. The facility’s PASRR policy stated the program is intended to identify residents with mental illness, intellectual disability, or developmental disability and ensure they receive the services they require.
Untimely Morning Medication Administration Across Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely administration of medications, as required by physician orders and facility policy, for six of ten residents reviewed. Facility records showed that multiple residents with complex medical conditions, including diabetes, hypertension, cardiomyopathy, COPD, Parkinson’s disease, chronic pain, dementia, and end-stage renal disease, had morning medications scheduled for 8:00 a.m. but actually received them well beyond the facility’s one-hour before/after window. For example, one cognitively intact resident with type 2 diabetes, orthostatic hypotension, peripheral vascular disease, anxiety, muscle weakness, and hypertension had 8:00 a.m. medications such as amlodipine, linagliptin, metoprolol, and acetaminophen documented as administered at 11:03 a.m. Another cognitively intact resident with a history of femur fracture, type 2 diabetes, cardiomyopathy, embolism, thrombosis, and pain had 8:00 a.m. medications including aspirin, carvedilol, furosemide, lisinopril, and pantoprazole given at 11:20 a.m. Additional residents experienced similar delays. A cognitively intact male resident with cerebral infarction, obesity, epilepsy, anxiety, hypertension, and abdominal pain had 8:00 a.m. and 9:00 a.m. medications such as losartan, isosorbide mononitrate ER, nifedipine ER, sertraline, spironolactone, carvedilol, levetiracetam, and hydralazine administered at 10:20 a.m. A resident with severe cognitive impairment, Parkinson’s disease, diabetes, anxiety, hypertension, dementia, depression, and seizure disorder had multiple 8:00 a.m. medications, including amlodipine, amantadine, memantine, metoprolol, risperidone, valproic acid, venlafaxine, and clonazepam, documented as given at 11:07 a.m. Another severely cognitively impaired resident with cauda equina syndrome, malignant neoplasm, COPD, chronic pain, anxiety, and major depressive disorder had 8:00 a.m. medications such as amlodipine, baclofen, apixaban, gabapentin, hydrocodone-acetaminophen, and Pepcid administered at 10:35 a.m. A severely cognitively impaired male resident with end-stage renal disease, COPD, chronic kidney disease, bipolar disorder, liver disease, restlessness, agitation, and dementia had 8:00 a.m. medications including amlodipine, benztropine, divalproex, memantine, and olanzapine given at 11:35 a.m. Staff interviews and policy review further described the circumstances leading to these delays. The medication aide who administered the late morning medications stated she understood that 8:00 a.m. medications should be given between 7:00 a.m. and 9:00 a.m., but acknowledged that several residents received medications after 9:00 a.m. because she had other commitments and began the medication pass later than expected. The LVN in charge reported that the hall was often short-staffed and that MAs and LVNs were frequently assigned tasks other than medication administration, which negatively affected timely medication administration; she also stated she was aware of the one-hour window and that delays had occurred on many days in the past. The DON confirmed that medications should be administered as ordered and within one hour of the prescribed time per facility policy, and that delays could affect dosing intervals and therapeutic effects. The facility’s written policy on administering medications specified that medications are to be administered in a safe and timely manner, that administration times are determined by resident need and benefit rather than staff convenience, and that medications are to be administered within one hour of the prescribed time unless otherwise specified.
Failure to Follow Weekly Oxygen Equipment Change Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders and professional standards for a resident receiving continuous oxygen therapy via nasal cannula. The resident, an elderly female with COPD, obstructive sleep apnea, acute bronchiolitis, chronic kidney disease, dementia, major depressive disorder, and dysphagia, had a care plan and physician orders specifying continuous and PRN oxygen therapy, with oxygen saturation checks every shift and weekly changes of the nasal cannula tubing and humidification bottle on the Sunday night shift. Record review and observation on 04/14/26 showed that the labels on the resident’s nasal cannula and humidification bottle indicated they were last changed on 02/23/26, despite the weekly change order. The resident, who had a severely impaired BIMS score of 01, was unable to provide information about the oxygen equipment. During interviews, an LVN stated that Sunday night shift nurses were responsible for changing the nasal cannula and humidifier weekly per the physician’s order and acknowledged that the equipment had not been changed for over a month. She explained that no one verified whether the Sunday night shift had completed the changes. Another RN, working on a different hall, confirmed that her own oxygen-dependent resident’s cannula had been changed on 04/10/26 and stated that protocol required weekly changes or changes when soiled or nonfunctional. The DON, who had recently started in her role, stated that oxygen humidifier bottles, nasal cannulas, and masks should be dated and changed weekly and PRN if empty or soiled, and that everyone was responsible for ensuring orders were followed. Review of the facility’s “Oxygen Administration” policy, revised October 2010, reflected that oxygen/nebulizer tubing and masks were to be changed weekly by nursing and documented in the electronic record, which was not done for this resident.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
A resident with multiple medical diagnoses, including a lumbar fracture, subdural hemorrhage, and severe cognitive impairment, was admitted to the facility and identified as being at risk for pressure ulcers. Despite this, the facility failed to implement and maintain necessary interventions to prevent the development of pressure ulcers. The resident required total assistance with all activities of daily living and was noted to be chairfast and incontinent, further increasing the risk for skin breakdown. Initial assessments documented some redness and bruising, but subsequent weekly skin assessments repeatedly indicated intact skin until a significant change was noted, including the development of blisters and open wounds on the sacrum and lower extremities. The facility did not provide a pressure-reducing mattress for 15 days after it was ordered, nor did it supply pressure-reducing heel boots for 11 days, despite the resident's high risk and the presence of developing wounds. During this period, the resident developed multiple pressure ulcers, including on the left foot, right lateral ankle, left hip, and sacrum. Documentation and interviews revealed delays in obtaining and applying essential support surfaces and offloading devices, as well as inconsistent implementation of repositioning and pressure relief measures. The resident's wounds progressed to unstageable and deep tissue injuries, with the sacral ulcer eventually becoming necrotic and infected. The lack of timely and consistent interventions led to the resident's transfer to an acute care hospital for surgical debridement of the sacral ulcer. Interviews with facility staff confirmed that there were delays in receiving ordered equipment and that staff education on wound care and repositioning was reactive rather than proactive. The resident's condition deteriorated, resulting in a recommendation for hospice care due to the severity of the wounds and overall poor prognosis.
Inappropriate Discharge to Homeless Shelter Without Adequate Support
Penalty
Summary
The facility failed to ensure that a resident was discharged to an appropriate setting that could meet his needs and preferences. The resident, a male with a history of stroke resulting in right-sided hemiplegia and hemiparesis, severe cognitive impairment, bowel and bladder incontinence, and a history of falls, was discharged to a men's homeless shelter. At the time of discharge, assessments indicated that he required substantial to maximal assistance with most activities of daily living (ADLs), including bathing, dressing, toileting, and personal hygiene, and had significant communication deficits due to aphasia and dysarthria. The resident also had a swallowing disorder and required a mechanically altered diet while in the facility. Despite these needs, the discharge plan involved sending the resident to a homeless shelter that only provided 30 days of emergency housing and did not offer assistance with ADLs or medication management. Interviews with shelter staff revealed that the resident was unable to read, write, or speak effectively, and required explanations and assistance to understand shelter rules. The shelter did not allow staff to assist with showering, and the resident struggled with basic hygiene and medication adherence. The resident was unable to consistently take his prescribed medications, as the shelter could not store or administer them, and he had memory issues that prevented him from managing his medication independently. Facility staff, including social workers and nursing staff, indicated that the discharge was prompted by the end of a payment agreement with the hospital and the lack of available family support or financial resources for continued care. Although some staff believed the resident could perform his own ADLs, multiple interviews and documentation indicated ongoing dependence for personal care and hygiene. The resident expressed fear and difficulty functioning at the shelter, and family members reported concerns about his safety and well-being post-discharge. The facility's actions resulted in the resident being placed in an environment unable to meet his documented care needs.
Failure to Complete and Transmit Discharge MDS Assessment
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment for a resident who was discharged. The resident, a female with multiple medical diagnoses including nephrostomy catheter infection, congestive heart failure, hypertension, end stage renal disease, and anemia, was admitted and later discharged from the facility. Documentation showed that she was cognitively intact and required substantial assistance with activities of daily living, and had ongoing monitoring for nephrostomy tube output and antibiotic therapy for a urinary tract infection. Upon review, it was found that the discharge MDS assessment for this resident was not documented or transmitted as required. The resident left the facility alert, oriented, and stable, taking all her belongings. Interviews with the DON revealed uncertainty about the resident's discharge destination and indicated that the resident left against medical advice (AMA). The AMA form was signed but not immediately uploaded to the electronic record system, and the discharge order was entered after the resident had already left the facility. Further interviews with the social worker confirmed that the resident left AMA and that the AMA form was obtained but not provided to medical records staff in a timely manner. The facility's policy required documentation of the date and time of discharge, a summary of the resident's condition, and the signature of the person recording the data, but these steps were not fully completed. The lack of a completed and transmitted discharge MDS assessment was confirmed through record review and staff interviews.
Failure to Monitor Catheter Output and Prevent UTIs
Penalty
Summary
The facility failed to ensure that a resident who was incontinent of bladder and had an indwelling catheter received appropriate treatment and services to prevent urinary tract infections (UTIs) and to restore continence to the extent possible. Specifically, the resident's urine output was not monitored and documented as ordered on multiple occasions, including several missed shifts in March 2025. The resident had a history of significant medical conditions, including a traumatic spinal fracture, subdural hemorrhage, and lower extremity impairment, resulting in total dependence for activities of daily living and mobility. The care plan and physician orders required regular monitoring of urine output due to the presence of a Foley catheter and recent UTIs, but this was not consistently performed or recorded. Record reviews showed that the resident experienced recurrent UTIs, as indicated by laboratory results showing cloudy urine and elevated white blood cell counts. Interviews with nursing staff and facility leadership confirmed that urine output monitoring was essential for assessing hydration status and catheter function, and that failure to document output could prevent timely identification of changes in the resident's condition. The facility's policy on changes in resident condition did not address the need for accurate documentation in resident records, contributing to the deficiency.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide activities that meet the interests and support the physical, mental, and psychosocial well-being of residents on weekends. During a group interview, five residents expressed that there were no activities available on Saturdays and Sundays, except for church services on Sundays. The Activities Director confirmed that she only worked Monday through Friday and occasionally on weekends, leaving residents with self-guided activities such as uno, coloring books, and dominos. The facility was in the process of hiring an assistant activities director, but the current staffing did not provide adequate weekend activities. The Activities Calendar for January, February, and March 2025 showed limited activities on weekends, primarily consisting of independent activities, matinee movies, and church services. The facility's policy stated that activities should be scheduled seven days a week and tailored to meet the needs and interests of each resident. However, the lack of structured activities on weekends did not align with this policy, potentially impacting the residents' quality of life and psychosocial well-being.
Deficiency in PICC Line Management and Dressing Changes
Penalty
Summary
The facility failed to ensure the proper administration of parenteral fluids for a resident, specifically in the management of a PICC line. The resident, a female with multiple diagnoses including sepsis and pneumonia, was receiving IV antibiotic therapy. The facility did not change the resident's PICC line dressing every 7 days as ordered by the physician, which was a critical oversight in maintaining sterile conditions and preventing infections. During observations, it was noted that the dressing on the resident's PICC line had not been changed according to the schedule, with the last change documented on 03/07/25, despite the order for weekly changes. LVN B, who was responsible for the resident's care, admitted to not changing the dressing on 03/19/25 due to being busy and losing track of time. Additionally, LVN B did not measure the external catheter length before removing the old dressing, which is necessary to ensure the catheter has not dislodged. This oversight, along with improper removal techniques, increased the risk of dislodgement and infection. Further interviews revealed systemic issues, such as the unavailability of central line dressing kits and a lack of communication among staff. RN E, who worked on 03/15/25, could not find a dressing kit and failed to notify upper management, which was against protocol. The ADON, responsible for overseeing the unit, was absent due to illness, and the DON acknowledged the need for better oversight and supply management. These lapses in protocol and communication contributed to the deficiency in care for the resident with a PICC line.
Medication Administration Errors by LVN
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a 14 percent error rate. This involved five errors out of 35 opportunities, specifically concerning one staff member, LVN B, and two residents. LVN B administered medications to Resident #392 via a PEG tube without adhering to professional standards. She crushed medications into powder, dissolved them in water, and failed to ensure all medication was administered, leaving residue in the medication cups. This practice could affect the therapeutic drug levels in the resident's blood. Additionally, LVN B did not follow the physician's orders for Resident #393 by administering doxycycline monohydrate alongside antacids, vitamins, or iron without waiting the required two hours. This oversight could lead to drug interactions or reduced efficacy of the medication. LVN B admitted to not checking the medication label and acknowledged the potential for stomach upset due to the improper administration. Interviews with the DON and ADON revealed that LVN B did not receive proper orientation on G-Tube medication administration. The facility's policy requires medications to be administered according to prescriber orders and pharmaceutical recommendations, which were not followed in these instances. The lack of proper orientation and adherence to medication administration procedures contributed to the medication errors observed.
Delayed MDS Assessment Completion
Penalty
Summary
The facility failed to complete the Annual Minimum Data Set (MDS) assessment for a resident within the required timeframe, resulting in a delay of 124 days. The resident, an 88-year-old female with multiple diagnoses including dementia, bipolar disorder, and schizophrenia, had her MDS assessment due on a specific date but it remained incomplete and overdue by 26 days. The MDS Coordinator acknowledged the delay and stated that the assessment was completed but not uploaded in a timely manner, which is crucial for compliance and ensuring adequate care. Interviews with facility staff, including the Administrator and Director of Nursing (DON), revealed awareness of the issue and the importance of timely MDS submissions. The Administrator noted that MDS assessments should be completed and submitted within required timeframes, and the DON emphasized that timely updates are essential for staff to be aware of residents' current risks and care needs. The facility's policy requires comprehensive assessments at specific intervals, and the failure to adhere to these requirements could impact the reflection of current care plans and interventions for residents.
Failure to Complete Timely Quarterly Assessment
Penalty
Summary
The facility failed to conduct a quarterly assessment for a resident, identified as Resident #1, within the required three-month timeframe. Resident #1, an 88-year-old female with severely impaired cognition as indicated by a Brief Interview of Mental Status (BIMS) score of 03, was admitted to the facility on an unspecified date. The last completed Minimum Data Set (MDS) assessment for this resident was dated 08/08/2024, and the subsequent quarterly assessment was due by 02/22/2025. However, as of 03/20/2025, the assessment was still in progress and 26 days overdue. During an interview on 03/20/2025, the MDS Coordinator acknowledged that the MDS assessment for Resident #1, due by 02/22/2025, had not been completed until 03/20/2025. The facility's policy, revised in October 2023, mandates that resident assessments be conducted and submitted in accordance with federal and state submission timeframes. The policy specifies that the assessment coordinator or designee is responsible for ensuring timely submission of assessments to CMS' internet Quality Improvement Evaluation System (iQIES). Despite these guidelines, the facility did not adhere to the required timeframe for Resident #1's assessment, potentially impacting the accuracy of the resident's care plan.
Delayed MDS Transmission for a Resident
Penalty
Summary
The facility failed to complete and transmit a quarterly Minimum Data Set (MDS) assessment for Resident #1 within the required timeframe. Resident #1, an 88-year-old female, was admitted to the facility, and her quarterly assessment was due on February 22, 2025. However, as of March 20, 2025, the assessment was still marked as 'In Progress' and had not been uploaded to the CMS System. During an interview, the MDS Coordinator acknowledged that the assessment was transmitted late, on March 20, 2025, and admitted it was her responsibility to ensure timely submission. This delay in transmission could result in an incomplete record for the resident.
Failure to Implement Comprehensive Care Plan for PICC Line
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who had a PICC line inserted. The resident, a female with a history of sepsis, hypertension, neuropathy, metabolic encephalopathy, pneumonia, and depression, was admitted to the facility and was receiving IV antibiotic medications. Despite the physician's order for a PICC line insertion, the resident's care plan did not reflect this critical aspect of her treatment. The MDS Coordinator mistakenly believed that a peripheral IV was the same as a PICC line, leading to the omission in the care plan. The Director of Nursing acknowledged the importance of individualized comprehensive care plans and recognized that the lack of proper care planning for the PICC line could result in significant risks, such as infiltration and embolism. The facility's policy on care plans emphasized the need for measurable objectives and timetables to meet residents' needs, which was not adhered to in this case. This oversight placed the resident at risk for infections and unwanted hospitalization.
Failure to Follow G-Tube Medication Administration Protocol
Penalty
Summary
The facility failed to ensure that services provided to a resident with a gastrostomy tube (G-tube) met professional standards of quality. The resident, who had multiple diagnoses including dysphagia and chronic thromboembolic pulmonary hypertension, was observed receiving medication and water through her G-tube by LVN B. The physician's orders specified that the G-tube should be flushed with 30 ml of water before and after medication administration, and with 10 cc between each medication. However, LVN B administered a total of 630 cc of water, significantly exceeding the prescribed amount. During the medication administration, the resident complained of feeling too full, indicating discomfort. LVN B admitted to not calculating the total amount of water given and acknowledged that the excessive water could lead to fluid overload and aspiration. The Director of Nursing (DON) confirmed that LVN B had not received proper orientation on G-tube procedures, which was supposed to be provided by the Assistant Director of Nursing (ADON). However, the ADON stated that another RN, who no longer worked at the facility, was responsible for LVN B's orientation. The facility's policy on administering medications through an enteral tube was not followed, as it required verification of physician's orders and proper dilution of medications. The Texas Administrative Code also mandates that nurses obtain necessary instruction and supervision when implementing nursing procedures. The lack of proper orientation and adherence to physician's orders and facility policy contributed to the deficiency in care provided to the resident.
Deficiencies in Resident Care and Hygiene
Penalty
Summary
The facility failed to provide necessary grooming and personal care services for two residents, leading to deficiencies in their care. Resident #195, a female with diabetes, hypertension, and an amputation, did not receive scheduled showers or bed baths consistently. Despite being scheduled for showers three times a week, there were no records of showers being given, and the resident reported feeling unclean and having dry, itchy skin. Staff interviews revealed a lack of communication and documentation regarding the resident's refusal or acceptance of showers, contributing to the oversight in care. Resident #192, a female with diabetes, hypertension, and atrial fibrillation, experienced a delay in receiving incontinent care. The resident was found lying in a wet hospital gown and bed linens, having been left in a saturated incontinent brief for an extended period. This resulted in redness and excoriation on her skin. Staff interviews indicated that rounds for incontinent care were not conducted as frequently as required, and there was a lack of monitoring by the nursing staff to ensure timely care. The facility's policy on Activities of Daily Living (ADL) requires that residents who cannot perform ADLs independently receive necessary services to maintain hygiene and grooming. However, the facility failed to adhere to this policy for both residents, leading to potential risks of skin breakdown and infection. The lack of proper documentation and communication among staff members further exacerbated the deficiencies in care provided to these residents.
Medication Administration Error via G-Tube
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, a Licensed Vocational Nurse (LVN) did not administer medications via a gastrostomy tube (G-tube) in accordance with professional standards. The resident, who had a history of dysphagia, pneumonitis, hyponatremia, chronic thromboembolic pulmonary hypertension, and seizure disorder, was dependent on staff for all activities of daily living. The LVN crushed and dissolved medications, including atorvastatin, lamotrigine, and fluoxetine, but failed to ensure that all the medication was administered, leaving some in the medication cups. This action was not in line with the physician's orders, which required flushing the feeding tube with water before and after medication administration and between each medication. Interviews revealed that the LVN was aware that not all medication was administered, which could affect the therapeutic drug levels in the resident's blood. The Director of Nursing (DON) acknowledged that the LVN had not received proper orientation on G-tube medication administration, as the Assistant Director of Nursing (ADON) was responsible for the LVN's orientation. The ADON stated that another RN, who no longer worked at the facility, had provided the orientation. A review of the LVN's competency skills orientation showed no signatures on the performance objectives, indicating a lack of proper training. The facility's medication administration policy emphasized the importance of administering medications according to prescriber orders and ensuring optimal therapeutic effects, which was not adhered to in this case.
Failure to Provide Consistent ADL Care and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services to maintain grooming and personal care for two residents who were dependent on staff for activities of daily living (ADLs). One resident, a male with severely impaired cognition and multiple medical diagnoses including HIV, hypertension, and cerebral infarction, was observed to have ashy, dry, and flaky skin from below the knees to the soles of his feet. Despite being totally dependent on staff for personal hygiene and bathing, staff did not consistently report or address his dry skin. The wound care nurse, floor nurse, and CNA all acknowledged the presence of dry, flaky skin but did not communicate this to supervisory staff or document it appropriately. The wound care nurse also reported not having received skills check-off or in-service training on skin assessment at the facility. Another resident, a male with moderately impaired cognition and significant physical limitations, was dependent on staff for showers and other ADLs. He reported not receiving scheduled showers consistently, specifically missing showers on several assigned days. Documentation on shower sheets confirmed these missed showers, and there was no record of the resident refusing care. Staff interviews revealed that when showers were missed, CNAs would sometimes state they were too busy, and there was a lack of follow-up or documentation regarding refusals or reasons for missed care. The process for monitoring and ensuring completion of scheduled showers was inconsistently followed, with both nurses and the unit manager acknowledging lapses in oversight and documentation. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain grooming and hygiene. However, observations, interviews, and record reviews demonstrated that these services were not consistently provided or documented for the two residents in question. The lack of communication among staff, insufficient monitoring, and failure to document care or refusals contributed to the deficiencies in maintaining residents' personal hygiene and skin integrity.
Failure to Provide Timely and Appropriate Foot Care
Penalty
Summary
A deficiency was identified when a male resident with severe cognitive impairment, limited mobility, and multiple medical diagnoses, including HIV, hypertension, and cerebral infarction, was not provided with appropriate foot care. The resident was dependent on staff for all activities of daily living, including personal hygiene and bathing. Despite these needs, observations and record reviews revealed that the resident's toenails were long, thick, deformed, and discolored, with evidence of fungal infection and irritation. The podiatrist's assessment confirmed onychomycosis, calluses, and atherosclerosis, and noted the resident's complaints of pain due to the condition of his toenails. Staff interviews indicated a lack of timely communication and action regarding the resident's foot care needs. The wound care nurse and an LVN both observed the resident's long and discolored toenails but did not promptly report the issue to the unit manager or social worker. The wound care nurse stated that she had informed the social worker about the toenails two weeks prior, but the podiatrist only visited the facility every three months. The LVN admitted to not reporting the condition, despite having completed a skills check-off on nail care. The podiatrist was only notified after the administrator intervened, and he stated that earlier notification would have allowed for more timely care and possibly prevented the development of cracks and fungal infection. Further interviews with facility leadership, including the social worker, administrator, nurse practitioner, and DON, revealed that none were aware of the resident's foot condition until it was brought to their attention by the wound care nurse or administrator. Facility policy required regular cleaning, trimming, and infection prevention for residents' nails, but this was not followed in the resident's case. The lack of timely assessment, reporting, and intervention resulted in the resident not receiving foot care consistent with professional standards of practice.
Failure to Document Reasons for Withheld Pain Medication
Penalty
Summary
Licensed Vocational Nurses (LVN) failed to accurately document the reasons for not administering a prescribed pain medication, Tramadol HCl Oral Tablet 100 MG, to a resident on two occasions. The Medication Administration Record (MAR) indicated that the medication was held or not given, but the required explanations were not entered in the resident's progress notes as per facility policy. Interviews with staff revealed that the medication was likely withheld due to the resident's declining condition and a change in the route of administration, but no supporting documentation was found in the medical record. The resident involved was an elderly female with diagnoses including encephalitis, encephalomyelitis, dysphagia, and cognitive communication deficit, and was on a care plan for pain management. She passed away on the same day the medication was not administered. The facility's policy required that any held or omitted medication be clearly documented with reasons in the resident's record, which was not done in this case.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
