Avir At Lubbock
Inspection history, citations, penalties and survey trends for this long-term care facility in Lubbock, Texas.
- Location
- 4710 Slide Rd, Lubbock, Texas 79414
- CMS Provider Number
- 455940
- Inspections on file
- 56
- Latest survey
- May 15, 2026
- Citations (last 12 mo.)
- 16 (3 serious)
Citation history
Health deficiencies cited at Avir At Lubbock during CMS and state inspections, most recent first.
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.
Two residents experienced a failure in protection from abuse when a resident with a known history of inappropriate sexual behaviors was not properly supervised or care planned upon admission, leading to an incident where she placed her hand inside another resident's panties. Staff were unaware of the resident's behavioral history, and there was a lapse in 1:1 supervision due to poor communication and shift change issues, resulting in the incident of sexual abuse.
A facility failed to implement and communicate abuse prevention policies, resulting in a resident with a known history of inappropriate sexual behavior being left unsupervised and able to inappropriately touch another resident. Staff did not review admission records thoroughly, were unaware of the resident's behavioral risks, and did not maintain required 1:1 supervision, leading to the incident.
Two residents with severe cognitive impairment and behavioral issues were not properly supervised, resulting in one resident with a history of sexual behaviors inappropriately touching another. Staff failed to maintain required 1:1 observation, were unaware of behavioral risks, and did not follow facility policies for supervision and communication, leading to an incident of sexual contact.
A resident with severe cognitive impairment and multiple medical conditions had a physician order for PRN hydrocodone-acetaminophen. Staff failed to perform the required narcotic count at shift change, resulting in the discovery of a missing blister pack of hydrocodone. Documentation in the EMR and on paper count sheets was inconsistent with the quantities of medication received and administered, and the facility was unable to account for a significant number of hydrocodone tablets.
Surveyors found that liquid Lorazepam requiring refrigeration was stored on medication carts instead of in a refrigerator, and at least one medication label was illegible, making it impossible to verify key information. Staff interviews confirmed awareness of storage and labeling requirements, but the deficiencies were not detected during routine audits, and some medications were received in improper condition.
A resident with severe cognitive and psychiatric conditions exhibited aggressive behaviors toward others on two occasions, but the care plan was not updated by the IDT to reflect new interventions or address these incidents. Although staff discussed the events and implemented one-to-one supervision, the formal care plan remained unchanged, and staff interviews revealed confusion about responsibility for care plan revisions.
Two residents with severe cognitive impairment received PRN Lorazepam orders that were not limited to 14 days, and the required physician rationale for extending these orders was not consistently documented. Medication administration records and care plans lacked proper documentation, and staff interviews revealed a lack of awareness and formal training regarding the 14-day stop date requirement for PRN psychotropic medications.
A facility failed to provide scheduled showers for three residents, leading to a deficiency in ADL care. One resident, cognitively intact, was denied a shower despite requesting it, while another, moderately impaired, was told it wasn't her shower day. A third resident was overlooked after moving rooms. Staff interviews revealed a lack of coordination and communication regarding the shower schedule, resulting in missed showers and inadequate documentation.
A facility failed to maintain a medication error rate below 5%, resulting in a 9.38% error rate due to three errors involving two residents. An LVN administered medications late and in incorrect dosages, affecting residents with conditions like neuropathy and metabolic encephalopathy. The errors were attributed to the LVN not verifying dosages and being asked to take over medication pass duties unexpectedly.
The facility failed to provide palatable and properly heated meals, affecting all food forms served. Residents reported dissatisfaction with cold and bland meals, confirmed by surveyors' observations. Staff interviews revealed a lack of training and oversight in maintaining food temperature from kitchen to service.
A long-term care facility failed to maintain an effective infection prevention and control program, as evidenced by staff not sanitizing equipment between resident use, neglecting hand hygiene during medication administration, and not adhering to enhanced barrier precautions during wound care. These actions were contrary to the facility's policies and could lead to cross-contamination and infection spread.
The facility failed to obtain consent for the administration of Lorazepam to two residents with severe cognitive impairments. Despite having protocols in place, the necessary consent forms were not signed by the residents or their legal representatives, leading to the administration of the medication without informed consent. Interviews with the DON and ADM highlighted the oversight in ensuring compliance with consent procedures.
The facility failed to limit PRN orders for psychotropic drugs to 14 days for two residents, leading to a deficiency in medication management. A resident with paranoid schizophrenia and another with dementia had PRN orders for Lorazepam without a stop date, extending beyond the 14-day limit. Interviews with the DON and ADM revealed a lack of awareness of these orders, despite the facility's policy requiring a 14-day limit unless otherwise documented by a physician.
The facility failed to properly store medications on two medication carts, resulting in loose pills being found. Staff responsible for the carts were unsure of the cause but acknowledged their responsibility for proper storage. The DON and ADM were unaware of the issue, despite regular training and audits. The facility's policy requires medications to be stored in labeled containers.
The facility failed to follow proper sanitization procedures for the puree machine in dietary services. The Dietary Manager did not allow the puree machine cannister to air dry between uses, leading to potential food contamination. Despite being trained on the correct procedure, the DM skipped this step due to time constraints, as confirmed by the Assistant Dietary Manager.
The facility failed to maintain an effective pest control program, resulting in rodent presence due to unrepaired holes. Residents reported mice-related issues, and the facility lacked a maintenance person for a period, delaying repairs. A new maintenance man was hired, and pest control visits increased to address the issue.
A resident with a history of cerebral infarction and reduced mobility was documented as receiving ADL care despite refusing it. The CNA admitted to documenting care before completion and not updating records for refusals. The DON and Administrator recognized the importance of accurate documentation, but no recent training was provided. The facility's policy requires accurate entries, but it was last revised in 2012.
The facility failed to provide routine showers for several residents, leading to frustration and dissatisfaction among them. Despite having various medical conditions, residents did not receive regular hygiene care, and shower sheets were left incomplete. Interviews revealed that residents had to repeatedly request showers, often without success, due to staff being too busy or uninterested. The facility's policy required assistance with hygiene, but the lack of adherence was evident in the documentation and resident grievances.
A resident's medical information was left exposed on a computer screen at a nurse's station, unattended by an LVN, allowing other residents to potentially view the information. The resident had multiple complex medical conditions and was moderately cognitively impaired. Interviews revealed that the LVN had not received recent privacy training, and the facility's policy on safeguarding electronic medical records was not followed.
A resident with dementia exhibited aggressive behavior towards other residents and staff, leading to incidents of abuse and neglect. The facility failed to document, investigate, or implement effective interventions to manage the resident's behavior. Allegations of abuse by nighttime staff were not properly addressed, and the administration was unaware of the incidents, resulting in a lack of preventive measures. This led to an Immediate Jeopardy situation identified by state surveyors.
The facility failed to implement its abuse prevention policies, resulting in unreported incidents involving a resident with severe cognitive impairment and aggressive behavior. The ADM did not report or investigate allegations of abuse and neglect, including staff abuse and resident-to-resident altercations. Staff interviews revealed a lack of communication and documentation, placing residents at risk.
The facility failed to report alleged abuse and neglect incidents involving a resident with dementia, including an allegation of abuse by a nighttime staff member and two resident-to-resident altercations. Staff members did not follow the facility's abuse policy, citing reasons such as the incident occurring over the weekend and assuming the allegations had already been reported. The ADM was unaware of the incidents and did not report them to HHSC.
A facility failed to investigate allegations of abuse and resident-to-resident altercations involving a resident with dementia. Despite reports of abuse by nighttime staff and altercations with two other residents, no investigations were conducted. Staff were aware of the incidents but did not report them, and the Administrator was unaware, preventing protective measures from being implemented.
A facility failed to update a care plan for a resident with dementia and aggressive behaviors, despite documented incidents of aggression towards staff and other residents. The care plan did not reflect the resident's worsening behaviors, and staff changes contributed to the oversight. The facility's administrator acknowledged the failure to revise the care plan in a timely manner, which was required by policy.
A resident with a history of pain and fractures did not receive prescribed Hydrocodone due to a locked narcotics box. Despite repeated requests, staff failed to provide alternative pain relief or notify a physician. The facility's emergency kit contained the medication, but staff were unaware and did not access it, leading to unmanaged pain for the resident.
A facility failed to implement its abuse prevention policies when a resident reported that another resident was being abused by staff. The ADM did not consider the report an allegation of abuse and did not document or investigate it further, relying instead on the DON's assessment that the screaming was normal behavior. CNA A reported the incident to the ADON, but no further action was taken. This failure to follow the facility's abuse policy could place residents at risk for abuse and neglect.
A facility failed to report allegations of abuse involving two residents within the required timeframe. A resident with dementia reported witnessing staff abuse another resident, but the administrator did not consider it an allegation of abuse and did not investigate further. Additionally, a CNA reported an accusation of abuse to the ADON, but it was not reported or investigated. The facility's failure to follow its abuse policy could lead to abuse occurring without being discovered or addressed.
A resident with severe cognitive impairment was reportedly handled roughly by a CNA during a transfer, but the incident was not reported to the administration as required by the facility's abuse prevention policy. Despite being trained on reporting procedures, an LVN did not consider the report of rough handling as abuse because the term 'abuse' was not used. This failure to report prevented the facility from investigating the matter, highlighting a deficiency in the facility's abuse prevention measures.
A resident with severe cognitive impairment was reportedly handled roughly by a CNA during a transfer, but the allegation was not reported within the required timeframe. A family member informed an LVN, who did not escalate the report to the Administrator or DON, leading to a delay in investigation. The facility's abuse prevention policy requires immediate reporting of such incidents, but this protocol was not followed.
A resident with Alzheimer's and other cognitive disorders exhibited behaviors of exposing himself and urinating on the floor, which were not addressed in his care plan. Despite staff awareness of these behaviors, they were not documented or reported to the DON for monitoring and intervention, contrary to facility policy.
The facility failed to maintain adequate staffing in the memory care unit, leading to unsupervised incidents involving two residents with severe cognitive impairments. A male resident exhibited inappropriate behaviors such as urinating on the floor, while a female resident displayed aggressive actions towards others. Interviews revealed that the unit was often left with only one staff member, contrary to the facility's policy requiring two staff members at all times.
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.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision and Communication
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibited and prevented abuse and neglect for two residents reviewed for abuse and neglect. Specifically, the facility did not ensure a safe environment free from sexual abuse when a resident with a known history of inappropriate sexual behaviors placed her hand inside another resident's panties. The Director of Nursing (DON) did not implement necessary interventions upon the admission of the resident with a history of sexual behaviors, despite being informed by an LVN that the resident was masturbating and had inappropriately touched the DON during assessment. The facility's staff, including the DON, were unaware of the resident's history of inappropriate sexual behaviors prior to admission, even though documentation from the previous facility included multiple incidents of such behavior. The incident occurred when the resident with a history of sexual behaviors was found with her hand inside another resident's panties in the latter's room. Staff interviews revealed that the resident who was touched was supposed to be on 1:1 observation due to prior aggressive behavior, but there was a lapse in supervision during a shift change, and the assigned staff for 1:1 observation did not arrive on time. Other staff members were unaware of the need for close supervision of the resident with a history of sexual behaviors, and there was confusion and lack of communication regarding the assignment and implementation of 1:1 observation. The care plans for both residents did not initially address the risk of inappropriate sexual behavior or the need for specific interventions to prevent such incidents. Record reviews and staff interviews further indicated that the facility's admission process failed to identify and communicate the high-risk behaviors of the newly admitted resident. Key staff members, including the social worker, MDS coordinator, and admission coordinator, did not review or were unaware of the resident's documented history of inappropriate sexual conduct. The lack of proper review and communication led to insufficient care planning and supervision, resulting in the incident of sexual abuse between residents. The facility's policies on abuse, neglect, and supervision were not effectively implemented or followed at the time of the incident.
Failure to Implement Abuse Prevention Policies Leads to Resident-to-Resident Sexual Contact
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. Specifically, the facility did not identify or address at admission a resident's history of inappropriate sexual behavior, which resulted in an incident where this resident placed her hand inside another resident's underwear. The staff did not review the admission documents thoroughly, missing multiple documented incidents of inappropriate sexual behavior from the transferring facility. Key staff members, including the DON, social worker, MDS coordinator, and admission coordinator, were unaware of the resident's behavioral history at the time of admission, and the care plan did not initially reflect the need for interventions to address these behaviors. The incident occurred when the resident with a history of inappropriate sexual behavior was left unsupervised in another resident's room. The assigned 1:1 observation for the potential victim was not maintained due to a lapse in staff coverage during a shift change, and staff were unclear about their responsibilities regarding 1:1 supervision. Multiple CNAs and nurses reported not being informed about the need for close supervision or the specific risks posed by the resident with a history of sexual behaviors. As a result, the resident was able to enter another resident's room and engage in inappropriate contact without immediate intervention. Interviews and record reviews revealed that the facility's staff were not adequately trained or informed about the policies and procedures for preventing abuse, neglect, and exploitation, particularly in relation to residents with known behavioral risks. The lack of communication and documentation regarding supervision assignments, as well as the failure to review and act upon critical information in the admission packet, directly contributed to the incident. The facility's policies on abuse and neglect were not effectively implemented, and staff did not consistently follow procedures for monitoring and protecting residents at risk.
Failure to Provide Adequate Supervision Resulting in Resident-to-Resident Sexual Contact
Penalty
Summary
The facility failed to ensure adequate supervision and a hazard-free environment for two residents, resulting in one resident with a history of sexual behaviors inappropriately touching another resident. Both residents had severe cognitive impairment and behavioral issues, with one resident previously placed on 1:1 supervision due to aggression. Despite this, the resident was left alone in her room with another resident known for impulsive sexual behavior, leading to an incident where inappropriate contact occurred. Staff interviews and record reviews revealed that the assigned 1:1 supervision was not consistently maintained. The CNA assigned to 1:1 observation did not start her shift on time, and other staff were unaware of the need for close supervision or the specific behavioral risks of the residents involved. Communication lapses occurred during shift changes, and staff were not fully informed about the residents' histories or the requirements for 1:1 observation. Additionally, the care plans and admission documentation did not adequately reflect the residents' behavioral risks, and several staff members were unaware of the need for heightened supervision. The facility's policies required specific levels of observation and clear staff assignments for residents at risk, but these were not followed. The lack of proper hand-off procedures, incomplete staff training on observation protocols, and failure to review admission documentation for behavioral risks contributed to the incident. The deficiency was identified as Immediate Jeopardy due to the failure to provide the required supervision, which allowed the incident of inappropriate sexual contact to occur.
Failure to Account for and Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure that drug records for a resident were properly maintained and that all controlled drugs were accounted for and periodically reconciled. Specifically, there was a missing count of hydrocodone for a resident with severe cognitive impairment and multiple medical diagnoses, including muscle weakness, pneumonia, and intellectual disability. The resident had an open-ended physician order for hydrocodone-acetaminophen as needed for pain, but medication administration records and controlled drug count sheets showed discrepancies in the number of pills received, administered, and remaining. On the morning in question, the nurses responsible for the medication cart did not perform the required narcotic count at shift change. This lapse was acknowledged by the staff involved, who could not provide a reason for failing to conduct the count. Later, during the evening shift change, it was discovered that a blister pack containing 30 hydrocodone tablets was missing. The staff and management were unable to locate the missing medication or the associated count sheet, and there were inconsistencies between the electronic medical record, paper count sheets, and the actual administration of the medication. Interviews with staff revealed that the system for monitoring controlled substances relied on shift change counts, but this process was not consistently followed. Further review of records and interviews indicated that the facility had received multiple cards of hydrocodone from both the pharmacy and hospice, but the documentation did not match the quantities received, administered, or remaining. The Director of Nursing, Assistant Director of Nursing, and Administrator were unaware of the discrepancies until notified by the surveyor. The pharmacy consultant and supervisor were also not informed of the missing medication at the time of the incident. The failure to conduct required shift change counts and maintain accurate records led to an official unknown count of hydrocodone, with a significant number of pills unaccounted for.
Improper Storage and Labeling of Lorazepam on Medication Carts
Penalty
Summary
Surveyors identified that the facility failed to ensure proper storage and labeling of drugs and biologicals, specifically liquid Lorazepam, on three of five medication carts. Observations revealed that Lorazepam, which required refrigeration as indicated by pharmacy labels, was found on medication carts instead of being stored in a refrigerator. In one instance, a nurse acknowledged the medication should have been refrigerated and took steps to move it after being observed. Additionally, one medication box had a damaged and illegible label, making it impossible to verify the resident's name, dosage, or administration instructions. Interviews with facility staff, including the FNP, DON, ADM, ADON, and a nurse, confirmed that staff were aware of the requirements for proper medication storage and labeling, including the need to refrigerate certain medications and ensure labels were legible and complete. Despite this, staff could not provide reasons for the observed deficiencies, and it was noted that some medications were received from hospice in an improper condition. Staff also reported that medication cart audits were conducted, but these audits failed to identify the improperly stored and labeled Lorazepam. The facility's policy required that controlled substances needing refrigeration be stored in a locked box within the refrigerator and that all medication labels include specific identifying information. However, the observed practices did not align with these requirements, as medications requiring refrigeration were left on carts and at least one medication label was illegible. The pharmacy consultant was unaware of the improper storage and could not provide information on the potential negative outcomes of these deficiencies.
Failure to Revise Care Plan After Resident Aggression
Penalty
Summary
The facility failed to review and revise a resident's comprehensive care plan by the interdisciplinary team after each assessment, specifically following two incidents of aggressive and physical behaviors toward other residents. The care plan for a male resident with multiple psychiatric and cognitive diagnoses, including dementia, psychotic disturbance, mood disturbance, anxiety, cognitive communication deficit, depressive episodes, and schizoaffective disorder, was not updated to reflect new or additional interventions after aggressive incidents occurred. The care plan in place included general interventions for behavioral symptoms and physical aggression, but did not address the specific incidents that took place on two separate occasions. Record review showed that after each incident, the resident was placed on one-to-one supervision and alternative placement was considered, but there was no evidence that the care plan was revised to include these interventions or to address the new behaviors. Interviews with facility staff, including the MDS Coordinator, Social Worker, DON, ADM, and ADON, revealed a lack of clarity and communication regarding responsibility for care plan updates. Staff acknowledged that care plans should be revised after incidents, but were unaware that the resident's care plan had not been updated following the aggressive events. The facility's policy required care plans to be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly assessment, as well as after incidents or changes in the resident's condition. The deficiency was identified through observation, interview, and record review, which confirmed that the care plan was not revised after the resident's aggressive behaviors. Staff interviews indicated that while incidents were discussed in meetings, the care plan was not formally updated to reflect the new interventions or changes in the resident's status. The lack of care plan revision was not attributed to any specific reason by the staff involved, and there was inconsistency in understanding who was responsible for making such updates.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, specifically regarding the use of PRN psychotropic medications. For two residents with severe cognitive impairment and diagnoses including generalized anxiety disorder and dementia, PRN orders for Lorazepam were not limited to 14 days as required, nor was there consistent documentation of a physician’s rationale for extending the orders beyond this period. In one case, a pharmacy consultant recommended a 90-day continuation, but this was not reflected in the physician’s order, and in another, there was no documented response to the pharmacy consultant’s recommendation. Record reviews showed that one resident received Lorazepam on several occasions without a 14-day stop date, and the medication administration records did not consistently align with the required documentation. Additionally, care plans did not always address the use of PRN psychotropic medications, and there was a lack of progress notes detailing the administration or monitoring of these drugs. Staff interviews revealed a lack of awareness and formal training regarding the 14-day stop date requirement, and there was no established system in place to monitor compliance with this regulation. Interviews with facility staff, including the DON, ADON, and administrative staff, confirmed that they were unaware of the missing 14-day stop dates and had not implemented a process to ensure compliance. The staff acknowledged the requirement and the facility’s policy but indicated that responsibility for ensuring the stop date was unclear, especially when medications were ordered by hospice or outside providers. The deficiency was further compounded by inconsistent communication and documentation between the facility, pharmacy consultant, and prescribing practitioners.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers for three residents, leading to a deficiency in the provision of Activities of Daily Living (ADL) care. Resident #1, a cognitively intact individual with a history of dementia, Parkinsonism, and hemiplegia, did not receive a shower on her scheduled days, despite requesting one. She was denied a shower by a CNA on 03/20/2025, and there was no documentation of her refusal or any attempt to reschedule her shower. Resident #1 expressed her dissatisfaction and confirmed she had not refused a shower. Resident #2, who is moderately cognitively impaired and requires substantial assistance, also did not receive a shower on her scheduled day. She expressed her desire for a shower and was told by a CNA that it was not her shower day. There was no documentation of her refusal, and she remained in her pajamas, indicating she had not been dressed for the day. Resident #3, slightly cognitively impaired and requiring moderate assistance, missed her scheduled showers due to being overlooked after moving to a new room. She confirmed she had not refused a shower and expressed her preference for showering on her scheduled days. Interviews with staff revealed a lack of coordination and communication regarding the shower schedule. CNAs were responsible for ensuring residents received showers, but there was confusion and neglect in fulfilling this duty. Some staff members were unaware of the residents' shower schedules, and there was a failure to document refusals or reschedule missed showers. The Director of Nursing and other staff acknowledged the importance of regular bathing to prevent infection and skin breakdown, but the deficiency occurred due to inadequate adherence to the facility's policies and procedures.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 9.38% due to three errors out of 32 opportunities. These errors involved two residents and were observed during a medication administration pass. LVN A was responsible for administering medications to the residents and made errors in timing and dosage. Specifically, Resident #6 received their Certizine medication late and was underdosed on Simethicone, while Resident #10 was underdosed on vitamin D3. Resident #6, an elderly female with neuropathy, congestive heart failure, and gastroparesis, was supposed to receive Certizine 10 mg at 7:00 AM and Simethicone 125 mg four times daily. However, during the observation, LVN A administered Certizine late and gave an incorrect dosage of Simethicone, providing only 80 mg instead of the prescribed 125 mg. Resident #10, also an elderly female with metabolic encephalopathy, protein-calorie malnutrition, and hypertension, was prescribed vitamin D3 125 mcg daily. LVN A administered only 25 mcg, failing to meet the prescribed dosage. Interviews with LVN A revealed that she was asked to take over medication pass duties unexpectedly, which contributed to the late administration of medication to Resident #6. LVN A admitted to not verifying the correct dosages before administration, leading to the underdosing of both residents. The facility's policy requires verification of the '5 Rights' of medication administration, which LVN A failed to follow, resulting in the observed deficiencies.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for residents during a meal observation. This deficiency was noted across all food forms served, including Regular, Mechanical Soft, and Pureed diets. During interviews, several residents expressed dissatisfaction with the taste and temperature of their meals, reporting that the food was often cold and lacked flavor. Observations by surveyors confirmed these complaints, with test trays showing that food items such as pork steak, mashed potatoes, and baked beans were served at inadequate temperatures and had poor taste and appearance. Interviews with staff revealed a lack of in-service training on food palatability and a disconnect between the kitchen and the serving process. A CNA mentioned regularly reheating food for residents due to complaints about cold meals, while the Dietary Manager acknowledged ongoing issues with food temperature and taste. The Administrator admitted to a lack of oversight in ensuring food remained hot from the kitchen to the residents, attributing the problem to delays in meal service. Despite having a policy on food handling, the facility failed to ensure its implementation, leading to resident dissatisfaction and potential risks of decreased food intake and weight loss.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with infection control protocols. During observations, it was noted that a medical assistant (MA A) did not sanitize a blood pressure cuff between its use on two residents, potentially facilitating cross-contamination. Additionally, a licensed vocational nurse (LVN A) failed to perform hand hygiene between administering medications to two different residents, despite being aware of the protocol. Further deficiencies were observed during wound care procedures conducted by another licensed vocational nurse (LVN B). LVN B did not adhere to enhanced barrier precautions (EBP) for residents with wounds, as required by the facility's policy. This included failing to don personal protective equipment (PPE) and neglecting to perform hand hygiene between glove changes while providing wound care to three residents. These actions were contrary to the facility's infection control policies, which emphasize the importance of hand hygiene and the use of PPE to prevent the spread of infections. Interviews with the staff, including the Director of Nursing (DON) and the Administrator (ADM), revealed gaps in training and awareness regarding infection control practices. LVN B admitted to not receiving formal training on wound care and infection control at the facility, although she had prior training in her career. The DON, who also serves as the infection preventionist, acknowledged that while staff had been trained on hand hygiene and EBP, there were lapses in compliance. The ADM was unaware of the non-compliance issues and emphasized the importance of following protocols to prevent infection spread.
Failure to Obtain Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to inform two residents, Resident #40 and Resident #32, or their responsible parties, about the risks and benefits of the proposed care and treatment involving the administration of Lorazepam, a medication used to treat anxiety disorders. Resident #40, a male with a history of paranoid schizophrenia, rhabdomyolysis, and generalized anxiety disorder, was administered Lorazepam without a signed consent form from either himself or his legal representative. Similarly, Resident #32, a female with unspecified dementia, panic disorder, and Alzheimer's disease, also received Lorazepam without the necessary consent documentation. Both residents had severe cognitive impairments, as indicated by their BIMS scores, which necessitated the involvement of their legal representatives in the consent process. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility's protocol required nurses to ensure consent forms were signed before administering psychotropic medications. The DON acknowledged that the absence of signed consent forms could lead to residents being uninformed about potential side effects, such as drowsiness, sedation, or increased risk of falls. Despite monthly and quarterly audits to monitor compliance, the facility failed to obtain the necessary consents for these residents, as confirmed by the review of the facility's policy on psychoactive medications, which mandates obtaining consent prior to administering such drugs, except in emergencies.
Failure to Limit PRN Psychotropic Drug Orders to 14 Days
Penalty
Summary
The facility failed to ensure that PRN orders for psychotropic drugs were limited to 14 days for two residents, leading to a deficiency in medication management. Resident #40, a male with a history of paranoid schizophrenia, rhabdomyolysis, and generalized anxiety disorder, had PRN orders for Lorazepam without a stop date, which extended beyond the 14-day limit. Similarly, Resident #32, a female with unspecified dementia, panic disorder, and Alzheimer's disease, also had PRN orders for Lorazepam without a stop date. Both residents were at risk for side effects due to the lack of a defined duration for their psychotropic medications. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility's nursing staff was responsible for ensuring residents were free from unnecessary medications. However, the DON was unaware of the PRN psychotropic medications without a 14-day stop date for the two residents. The facility's policy required PRN orders for psychotropic drugs to be limited to 14 days unless the attending physician documented a rationale for extending the order. The failure to adhere to this policy placed residents at risk for adverse effects from unnecessary medications.
Improper Medication Storage on Facility Carts
Penalty
Summary
The facility failed to ensure proper storage of drugs and biologicals on two of its medication carts, leading to the presence of loose pills. During an observation of the medication cart at Station 1, two loose pills were found in the bottom drawer. The Licensed Vocational Nurse (LVN) responsible for the cart was unsure why the pills were loose and acknowledged it was her responsibility to ensure proper storage. Similarly, at Station 2, four loose pills were discovered in the medication cart drawer. The Medication Aide (MA) also expressed uncertainty about the presence of loose pills and confirmed her responsibility for proper storage. Both staff members recognized the potential for drug diversion or medication errors due to loose pills. The Director of Nursing (DON) and the Administrator (ADM) were unaware of the loose pills on the medication carts. They stated that it was the responsibility of the nursing staff to check the carts for loose pills and ensure proper storage. The facility's policy on medication storage, revised in January 2018, mandates that medications be stored in containers with pharmacy labels. Despite regular training and audits conducted by nursing administration and the pharmacy consultant, the presence of loose pills on the carts indicates a lapse in adherence to these procedures.
Improper Sanitization of Puree Machine in Dietary Services
Penalty
Summary
The facility failed to adhere to professional standards for food service safety during the preparation of pureed meals. During an observation, it was noted that the Dietary Manager (DM) did not allow the puree machine cannister to air dry between uses, as required by the facility's policy. After pureeing new potatoes, the DM cleaned the processor bowl, lid, and blade but did not allow them to air dry before reassembling and using them again for pureeing bread and carrots. This resulted in the equipment being reassembled with liquid still present, which could lead to food contamination. Interviews with the DM and the Assistant Dietary Manager (ADM) revealed that the DM was aware of the proper procedure, which includes allowing the puree machine cannister to air dry completely between uses. However, the DM admitted to skipping this step because he was in a rush due to late lunch tickets. The ADM confirmed that the DM had been trained on the correct procedure and acknowledged that not following it could result in contaminated food and potential illness for residents. The facility's policy, dated 2018, clearly states the requirement for air-drying utensils and equipment to prevent re-contamination and ensure the sanitizing solution has time to work effectively.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of rodents within the building. The issue was identified when the facility did not follow the pest control company's instructions to repair multiple holes that rodents could use to access the building. These holes were identified between January 10, 2025, and February 25, 2025, but were not addressed in a timely manner, leading to continued rodent activity. Interviews with residents and their family members revealed that the presence of mice was a concern. One resident reported having papers chewed up by mice, while a family member of another resident found mouse droppings and evidence of mice in a drawer containing candy bars. These incidents indicate that the rodent problem was affecting the residents' living conditions and potentially their health. The facility was without a maintenance person for a period, which contributed to the delay in addressing the rodent issue. The previous maintenance man was reportedly not performing his duties adequately, leading to his dismissal. The facility eventually hired a new maintenance man, who began working on March 3, 2025, and started making progress in repairing the holes. The pest control company increased their visits to weekly until the problem was resolved, and the facility took additional steps to ensure cleanliness and monitor for new rodent activity.
Inaccurate ADL Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically in documenting Activities of Daily Living (ADL) care. The resident, a male with a history of cerebral infarction, muscle weakness, and reduced mobility, was documented as dependent on staff for showering, bathing, dressing, and toileting. However, on multiple occasions, the resident refused a bed bath, which was not accurately reflected in the documentation. Despite the resident's refusal, the Certified Nursing Assistant (CNA) documented that the resident received a shower/bath, indicating a discrepancy between the care provided and the records maintained. Interviews with the CNA revealed that she sometimes documented ADLs before completing them and did not update records if a resident refused care. The Director of Nursing (DON) and the Administrator acknowledged the importance of accurate documentation and the potential negative outcomes of inadequate ADL documentation, such as skin breakdown and infection control issues. The facility's policy on charting and documentation, last revised in 2012, requires accurate entries reflecting the date, time, and signature of the person recording the data, as well as documentation of any treatment refusals. However, there was no recent training provided to staff on proper documentation practices.
Failure to Provide Routine Showers for Residents
Penalty
Summary
The facility failed to provide routine showers for seven residents, as observed during a survey. The residents, who had various medical conditions such as transient ischemic attack, dementia, and end-stage renal disease, were not receiving regular hygiene care, including showers or bed baths. The lack of completed shower sheets and documentation indicated that the facility did not maintain records of when or if showers were provided, leading to residents expressing frustration and dissatisfaction with their care. Interviews with the residents revealed that they had not received showers for extended periods, with some residents stating they had not had a shower in weeks. The residents reported that they had to repeatedly request showers, and even then, the staff often did not follow through. The residents expressed feelings of embarrassment and frustration due to the lack of personal hygiene care, and some mentioned that the staff appeared too busy or uninterested in providing the necessary assistance. The facility's policy required that residents unable to perform activities of daily living independently receive necessary services to maintain hygiene. However, the facility's failure to adhere to this policy was evident in the incomplete and blank shower sheets and the residents' grievances. The Director of Nursing and the Administrator acknowledged the issue, noting that the facility was short-staffed and that the problem had persisted for months, as documented in resident council minutes and grievance lists.
Resident Privacy Breach Due to Unattended Computer Screen
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal medical records. An observation was made where a Licensed Vocational Nurse (LVN) left a computer screen displaying a resident's medical information open and unattended on a medication cart at the nurse's station. This occurred while the LVN was on the opposite side of the nurse's station, allowing residents to walk by and potentially view the exposed information. The resident involved was a male with multiple complex medical conditions, including end-stage renal disease, atrial fibrillation, and severe sepsis, among others. The resident was moderately cognitively impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 10. Interviews with the LVN, Director of Nursing (DON), and the Administrator revealed that the LVN acknowledged the mistake and admitted to not having recent privacy training due to new management. The DON and Administrator both expressed expectations that staff should lock or minimize screens when not in use to protect resident information. The facility's policy on electronic medical records, revised in June 2019, emphasizes the importance of safeguarding electronic protected health information (e-PHI) and limiting access to authorized personnel only. However, the incident demonstrated a lapse in adherence to these policies, resulting in a deficiency related to the privacy of resident medical records.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, as evidenced by multiple incidents involving aggressive behavior by a resident with dementia. This resident, who was severely cognitively impaired, exhibited physical aggression towards other residents and staff. Despite documented aggressive behavior, the facility did not implement effective interventions to manage the resident's actions, leading to incidents where the resident pulled another resident out of bed and grabbed a third resident by the face. These incidents were not properly documented or investigated by the facility. Additionally, there were allegations of abuse involving the same resident and nighttime staff, which were not adequately addressed. The resident and a family member reported that the resident had been hit by a staff member, but these allegations were not investigated or reported to the appropriate authorities. Staff members were aware of the allegations but failed to follow the facility's abuse reporting procedures, citing issues such as lack of access to a working phone and the absence of the abuse coordinator during weekends. The facility's administration was unaware of the incidents and allegations, resulting in a lack of preventive measures to protect the residents involved. The facility's failure to investigate and document these incidents, as well as the lack of staff training on handling aggressive behavior, contributed to the ongoing risk of harm to residents. The facility's inadequate response to these incidents led to the identification of an Immediate Jeopardy situation by state surveyors.
Removal Plan
- Develop/Implement Abuse/Neglect Policies
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse and neglect for three residents. The Administrator (ADM) did not report allegations of abuse to the Health and Human Services Commission (HHSC) and failed to document investigation and prevention measures for incidents involving Resident #1. These incidents included an allegation of abuse by an unknown nighttime staff member, an injury of unknown origin, and two resident-to-resident altercations. Additionally, the ADM did not notify family members or assess the mental and physical effects on the involved residents. Resident #1, who was severely cognitively impaired and had a history of aggressive behavior, was involved in multiple incidents. These included being hit by a staff member, sustaining injuries of unknown origin, and engaging in altercations with other residents. Despite these events, there were no investigation reports available, and the facility staff failed to report the incidents to the appropriate authorities. Interviews with staff and family members revealed a lack of communication and documentation regarding these incidents. The facility's policies required immediate investigation and reporting of abuse allegations, but these were not followed. Staff members, including CNAs and the Assistant Activity Director, did not report the allegations to the ADM or the abuse preventionist. The facility's failure to adhere to its policies placed residents at risk for abuse and neglect, as evidenced by the Immediate Jeopardy identified by surveyors.
Failure to Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, within the required timeframes. Specifically, the Administrator (ADM) did not report several incidents involving a resident with dementia who exhibited aggressive behavior. These incidents included an allegation of abuse where the resident was reportedly hit by an unknown nighttime staff member, and two resident-to-resident altercations where the resident attempted to pull another resident out of bed and grabbed a third resident in the face. Additionally, an injury of unknown origin involving the resident was not reported or investigated. Interviews and record reviews revealed that several staff members, including CNAs, an Assistant Activity Director, and an LVN, failed to follow the facility's abuse policy by not reporting the allegations of abuse and neglect to the abuse preventionist or the ADM. The staff members cited various reasons for not reporting, such as the incident occurring over the weekend, the on-call phone not being answered, and assuming that the allegations had already been reported. The ADM was unaware of the incidents and did not report them to the Health and Human Services Commission (HHSC) because he was not informed by the staff. The facility's policy requires that all alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but not later than two hours after the allegation is made. The failure to report these incidents could place residents at risk for abuse and neglect. The ADM acknowledged that the staff should have reported the incidents to him and that he was responsible for reporting to HHSC. The facility's abuse prevention program includes procedures for identifying and reporting abuse, neglect, and exploitation, but these procedures were not followed in the reported incidents.
Failure to Investigate Allegations of Abuse and Resident Altercations
Penalty
Summary
The facility failed to investigate allegations of abuse, neglect, or mistreatment for three residents. Resident #1, a male with dementia and severe cognitive impairment, reported being hit by an unknown nighttime staff member. Despite the report, there was no evidence of an investigation into this allegation. Additionally, Resident #1 was involved in two resident-to-resident altercations on the same day, where he attempted to pull Resident #2 out of bed and grabbed Resident #3 in the face. These incidents were not documented or investigated by the facility. Interviews with staff revealed that there was a lack of communication and reporting regarding these incidents. Family Member M expressed concerns about Resident #1's injuries, which were not consistent with a fall, suggesting possible abuse. Staff members were aware of the allegations but did not report them to the Administrator or conduct an investigation. The Assistant Activity Director and CNAs were aware of the incidents but did not follow the facility's policy to report and investigate allegations of abuse, neglect, or mistreatment. The facility's policies on abuse investigation and resident-to-resident altercations were not followed. The Administrator, who was responsible for investigating and implementing resident protection measures, was unaware of the incidents. This lack of awareness and failure to investigate prevented the implementation of preventive measures to protect the residents involved. The facility's failure to document and investigate these incidents could place residents at risk for further abuse and neglect.
Failure to Update Care Plan for Aggressive Resident
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. The resident, who was admitted with diagnoses including unspecified dementia and other behavioral disturbances, exhibited increasingly aggressive behaviors that were not reflected in the care plan. The care plan, dated earlier in the month, did not include any information about the resident's physical and verbal aggressive behaviors, which had worsened over time. The resident's aggressive behaviors included hitting, kicking, and other physical actions that posed risks to both the resident and others. Despite these behaviors being documented in progress notes, the care plan was not updated to address these issues. The facility's policy required care plans to be revised and accurate to meet residents' needs, but this was not done in a timely manner. The facility experienced staff changes, including the resignation of the Director of Nursing and Assistant Directors of Nursing, which contributed to the oversight in updating the care plan. Interviews with staff revealed that the resident had been involved in multiple incidents of aggression towards staff and other residents. Staff reported feeling shaken by these incidents, and there was a lack of documented training or tools for staff to manage the resident's behaviors. The facility's administrator acknowledged the oversight in updating the care plan and attributed it to the challenging circumstances of losing key clinical staff members. The administrator admitted that the care plan should have been revised within a few days of the behaviors occurring, but this was not done due to the focus on staffing and other immediate needs.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services, as evidenced by the failure to administer Hydrocodone-Acetaminophen as prescribed. The resident, a female with a history of unspecified pain, atherosclerosis, and fractures, was not given her prescribed pain medication from 6 A.M. to 1:50 P.M. on the specified date. Despite having a care plan that included administering pain medications as ordered, the resident's request for Hydrocodone was not fulfilled due to issues with accessing the medication. The deficiency arose when the lock box containing the resident's narcotics could not be opened, preventing the administration of the prescribed Hydrocodone. The Assistant Director of Nursing sent an email to the pharmacy technician about the issue, but no medication was requested from the facility's emergency kit during the time the lock box was inaccessible. Interviews with staff revealed that the resident repeatedly asked for her Hydrocodone, but the staff did not provide an alternative pain medication or notify the physician to address the issue. The facility's emergency kit contained Hydrocodone, but staff were unaware of this and did not attempt to access it. The Director of Nursing demonstrated the emergency kit's functionality, which showed that Hydrocodone was available. The facility's policies indicated that emergency pharmacy services were available, but the staff did not follow the procedures to access the medication from the emergency kit. This oversight resulted in the resident experiencing unmanaged pain for several hours.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect, as evidenced by the handling of an allegation involving two residents. Resident #1 reported to the ADM that Resident #2 was being abused by staff, including CNA A, after hearing screams from Resident #2's room. Despite Resident #1's report, the ADM did not consider it an allegation of abuse and did not document or investigate the claim further. The ADM's decision was based on a conversation with the DON, who stated that Resident #2's screaming during ADL care was normal and that Resident #1 had a history of trying to move Resident #2 into her room. The ADM and the DON both failed to follow the facility's abuse policy, which requires immediate reporting and investigation of any allegations of abuse. The ADM did not interview any other staff or residents, nor did he review any records to corroborate the DON's assessment. Similarly, CNA A reported the incident to the ADON, but no further action was taken to investigate the allegation. The ADON also failed to report the incident to the ADM, as required by the facility's policy. The lack of documentation and investigation into the reported abuse allegation highlights a significant deficiency in the facility's adherence to its abuse prevention policies. The ADM, DON, and ADON all acknowledged their familiarity with the facility's abuse policy but did not follow the required procedures. This failure to act on the reported concerns could place residents at risk for abuse and neglect, as the facility did not ensure that all allegations were properly addressed and investigated.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report allegations of abuse involving two residents within the required timeframe, as per their policy. The policy mandates that any alleged violations involving abuse, neglect, exploitation, or mistreatment must be reported immediately, but not later than two hours after the allegation is made if it involves abuse or results in serious bodily injury. In this case, the allegations were not reported to the administrator or the state agency as required, which could place residents at risk for abuse or neglect. Resident #1, who has a diagnosis of dementia and altered mental status, reported to the administrator that she witnessed staff abusing Resident #2. She described hearing Resident #2 scream and seeing staff scratching and digging into Resident #2's stomach. Despite reporting this to the administrator, no immediate action was taken, and the incident was not documented or reported as an allegation of abuse. The administrator did not consider the report as an allegation of abuse and did not investigate further, relying on the DON's assessment that Resident #2's screaming was normal during ADL care. CNA A also reported an incident to the ADON, where Resident #1 accused her and her partner of abusing Resident #2. However, the ADON did not report this as an allegation of abuse, and no further investigation was conducted. The facility's failure to follow its abuse policy and report the allegations immediately could lead to abuse occurring without being discovered or addressed, as acknowledged by the ADM and DON during interviews.
Failure to Report Alleged Rough Handling of Resident
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent resident abuse, as evidenced by an incident involving a resident with severe cognitive impairment. The resident, who had a history of Alzheimer's disease and other medical conditions, was reportedly handled roughly by a CNA during a transfer. This incident was observed by a family member who reported it to an LVN, but the LVN did not notify the administration as required by the facility's abuse prevention policy. The LVN, despite being trained on abuse and neglect reporting procedures, did not consider the report of rough handling as abuse and therefore did not report it to the Administrator. The facility's policy mandates immediate reporting of any allegations of abuse, but the LVN failed to act because the family member did not use the term 'abuse.' This oversight was confirmed by interviews with the Administrator and the DON, who both stated that the term 'rough' should have been considered reportable and investigated. The facility's abuse prevention policy, revised in October 2023, requires all staff to report allegations of abuse immediately. However, the LVN's failure to report the incident prevented the facility from investigating the matter and potentially placed residents at risk. The facility had conducted in-service training on abuse and neglect, emphasizing the importance of reporting, but the LVN did not adhere to these protocols, resulting in a deficiency in the facility's abuse prevention measures.
Failure to Timely Report Allegation of Rough Handling
Penalty
Summary
The facility failed to report an allegation of abuse within the required timeframe for a resident who was reportedly handled roughly by a CNA during a transfer. The incident was reported by a family member to an LVN, who did not escalate the report to the Administrator or the Director of Nursing as required by the facility's abuse prevention policy. The LVN believed that the situation did not constitute abuse because the family member did not use the word 'abuse' and did not report the incident, which led to a delay in the investigation. The resident involved was an elderly female with severe cognitive impairment, Alzheimer's disease, and other medical conditions, including a recent hospitalization for fractured ribs. The family member observed the CNA being rough with the resident and expressed concern for the resident's safety and well-being. Despite the family member's report, the LVN did not document the incident in the resident's progress notes or the facility's incident records, and the allegation was not reported to the state agency within the required timeframe. Interviews with facility staff, including the Administrator, Director of Nursing, and other CNAs, revealed that the facility had policies and training in place for reporting abuse and neglect. However, the LVN's failure to report the incident as required by the facility's policy resulted in a delay in addressing the allegation. The facility's abuse prevention policy mandates immediate reporting of such allegations to the Administrator and state agency, but this protocol was not followed in this case.
Failure to Address Resident's Inappropriate Behavior in Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with a history of exposing himself and urinating on the floor. The resident, who has Alzheimer's disease, major depressive disorder, dementia with agitation, generalized anxiety disorder, impulse disorder, and cognitive communication deficit, was admitted with severely impaired cognition and frequent urinary incontinence. Despite these issues, the resident's care plan did not address his behaviors of exposing himself and urinating in various areas of the unit, including other residents' rooms and common areas. Interviews with facility staff revealed that the resident's behavior was known but not documented in the care plan. Staff members, including a Licensed Vocational Nurse (LVN), Certified Nursing Assistant (CNA), and the Director of Nursing (DON), acknowledged the behavior but indicated that it was not addressed in the care plan. The DON was unaware of the behavior and stated that it should have been reported for monitoring and potential medical evaluation. The facility's policy requires staff to report new behaviors or changes from the resident's baseline to ensure they are included in the care plan, but this was not done in this case.
Inadequate Staffing in Memory Care Unit
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This deficiency was observed in the memory care unit, where there was inadequate supervision to assure resident safety. Specifically, the facility did not maintain the required staffing levels, as there were instances where only one staff member was present in the secure unit, leaving residents unsupervised. Two residents, a male and a female, were directly affected by this staffing deficiency. The male resident, diagnosed with Alzheimer's disease and other cognitive disorders, exhibited behaviors such as exposing himself and urinating on the floors. The female resident, also with severe cognitive impairments, displayed aggressive behaviors, including yelling, cursing, and physically aggressive actions towards other residents and staff. These behaviors were not adequately managed due to insufficient staffing, leading to unsupervised incidents and potential safety risks for all residents in the unit. Interviews with staff, including a Licensed Vocational Nurse (LVN), Certified Nursing Assistants (CNAs), and the Director of Nursing (DON), revealed that the secure unit was often left with only one staff member, especially during breaks or when someone called in sick. This lack of supervision allowed the male resident to urinate in various areas and the female resident to wander into other residents' rooms, causing distress among other residents. The facility's policy required two staff members in the secure unit at all times, but this was not consistently followed, contributing to the observed deficiencies.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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