Avir At North Richland Hills
Inspection history, citations, penalties and survey trends for this long-term care facility in North Richland Hills, Texas.
- Location
- 5600 Davis Blvd, North Richland Hills, Texas 76180
- CMS Provider Number
- 676127
- Inspections on file
- 46
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Avir At North Richland Hills during CMS and state inspections, most recent first.
A resident with dementia and impaired cognition complained of left wrist pain and swelling after a reported fall, leading an LVN to obtain an x-ray order and document the pending result on the 24-hour report. The x-ray, completed later that day, showed acute distal radial and ulnar fractures with displacement and was available in the lab portal late that night, but the night-shift LVN did not check or pull the results or notify the practitioner, despite facility policy requiring prompt review and communication of diagnostic findings and immediate reporting of critical values. The abnormal results were only discovered by another LVN the following morning when the lab portal was checked, confirming the fracture and revealing a delay in communicating significant diagnostic findings.
A resident with pneumonitis requiring continuous O2 via nasal cannula did not have a clearly documented admission order for oxygen therapy on the TAR, and her oxygen tubing and related equipment were not changed or dated according to facility practice. The resident reported the nasal cannula had not been changed since admission, and observation confirmed undated tubing in use on a portable tank. An LVN acknowledged there was initially no oxygen order on file, that the resident was on continuous O2, and that he had not changed the tubing, despite understanding it should be changed and dated weekly. The ADON and Administrator stated that nurses were expected to check, change, and date oxygen equipment routinely, but the facility’s written policy addressed only oxygen storage and did not cover care, maintenance, labeling, or dating of oxygen tubing.
A medication aide left a cup containing nine prescribed medications and supplements unattended in a resident's room during morning medication administration, without supervising the resident to ensure the medications were taken as ordered. The resident, who had multiple complex medical conditions and had not been assessed for self-administration, was eating breakfast at the time. Facility policy and staff interviews confirmed that medications should not be left unattended in resident rooms.
A nurse failed to administer a scheduled dose of Keppra to a resident with epilepsy and instead gave lactulose, then incorrectly documented the administration. The error was discovered after reviewing the MAR, and interviews confirmed that the nurse did not follow the required medication administration verification process.
A medication aide used a reusable blood pressure cuff on two residents without sanitizing it between uses, contrary to facility policy and standard infection control practices. Multiple staff, including ADONs and the DON, confirmed that equipment should be disinfected between residents to prevent cross-contamination. The residents involved had conditions increasing their susceptibility to infection.
A resident with cognitive impairment and a history of falls was left unsupervised on the toilet by a CNA who was unfamiliar with the resident's needs and unable to communicate effectively. The resident, unable to use the call light and without access to her communication board, fell and sustained serious injuries including a hip fracture and intracerebral hemorrhage. The facility failed to ensure staff followed care plan interventions and did not promptly investigate or report the incident, resulting in a deficiency related to neglect prevention.
A resident with cognitive impairment, a history of falls, and total dependence on staff for ADLs was left unsupervised on the toilet by a CNA who did not speak the resident's primary language. The care plan required supervision and use of a communication board, but the board was missing and staff were not using it. The resident, unable to use the call light, fell and sustained fractures, a brain bleed, and skin tears. Staff interviews revealed confusion about monitoring responsibilities and a lack of familiarity with the resident's needs, contributing to the incident.
Staff did not ensure a safe and clean environment for a resident with multiple health conditions, as evidenced by an improperly positioned mattress, unmade bed, used gloves and cups left in the bathroom, dirty clothing on a shower chair, and uncovered briefs near the shower. Staff interviews confirmed lapses in routine room checks and immediate disposal of soiled items, despite facility policies requiring regular environmental rounds and sanitation.
A resident with cognitive impairment and a history of falls was left unattended in the bathroom by a CNA unfamiliar with her needs, resulting in a fall and serious injuries including a fractured hip and femur. The incident was not reported to the state agency as required, and the facility administrator did not initiate a timely investigation or collect staff statements immediately after the event.
Two residents with severe cognitive impairment had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were missing the required physician's signature and license number, making the documents invalid. Although DNR orders and care plans were in place, the incomplete documentation was not identified by the social worker responsible for monitoring advanced directives. The facility's policy required proper documentation, but the deficiency resulted from a failure to ensure the OOH-DNR forms were fully completed.
Surveyors found that food items in the kitchen's dry storage, refrigerator, and freezer were improperly stored, including unsealed containers, expired items, and dented cans. Staff were unaware of these issues despite regular in-service training and established policies requiring proper labeling, sealing, and separation of dented cans. These deficiencies were not in compliance with professional standards for food service safety.
Two staff members failed to adhere to droplet precautions for COVID-19 positive residents, with one entering a resident's room without an N95 mask or eye protection, and another relying on prescription glasses instead of a face shield. This non-compliance with the facility's infection control policy posed a risk of cross-contamination.
Failure to Promptly Review and Report Abnormal X-Ray Results
Penalty
Summary
The deficiency involves the facility’s failure to promptly review and communicate diagnostic test results to the ordering practitioner in accordance with its own policy. A female resident with non-Alzheimer’s dementia, depression, and severely impaired cognition (BIMS score of 6) was admitted with partial to supervised assistance needs for ADLs but was independent with ambulation. On the date of the incident, the resident complained of left wrist pain, and staff observed swelling and pain on palpation. An LVN documented the complaint, administered Tylenol, and obtained an order for an x-ray after the resident reported she had fallen and gotten herself up from the floor. The x-ray was completed that day, and the 24-hour report documented that the left wrist x-ray was pending. The facility’s policy required licensed nurses to review lab/diagnostic results and notify the physician, and specified that critical values must be communicated to the provider within one hour. The x-ray results, available in the lab portal at 11:06 PM, showed acute-subacute distal radial and ulnar fractures with displacement. However, the night-shift LVN responsible for two halls did not check or pull the x-ray results from the lab portal during the 10:00 PM to 6:00 AM shift and did not notify the practitioner of the abnormal findings. The results were not discovered until the following morning when another LVN arrived, checked the lab portal, and saw the fracture report. Multiple therapy staff who worked with the resident on the day of the incident reported that the resident guarded her left hand, did not want to use it, and had slight swelling, but she did not consistently complain of pain. The ADON confirmed that the x-ray results came in during the night shift but were not pulled until the next morning, and stated that charge nurses were responsible for checking the lab portal each shift and that pending x-rays should have been noted on the 24-hour report. This sequence of events led to a delay in recognizing and communicating the abnormal x-ray findings of a fractured wrist to the ordering practitioner. This failure could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition.
Failure to Ensure Ordered and Properly Maintained Oxygen Therapy Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care, including oxygen therapy, in accordance with professional standards, the care plan, and physician orders for a resident requiring such care. The resident, an older female admitted with pneumonitis due to inhalation of food and vomit, required assistance with multiple ADLs and had moderate cognitive impairment but was alert and able to communicate needs. Her baseline care plan and physician orders included evaluation and treatment by RT and an order for oxygen at 2 LPM via nasal cannula every shift for shortness of breath and to maintain oxygen saturation above 90%, as well as weekly changes of oxygen tubing, administration device, humidifier bottle, and concentrator filter checks. However, review of the Treatment Administration Record (TAR) did not initially reflect an admission order for oxygen treatment, and the facility only provided the oxygen order in the TAR prior to survey exit. During observation, the resident was seen in a wheelchair receiving oxygen via nasal cannula from a portable tank, with tubing that was not dated. The resident reported that the nasal cannula had not been changed on either the concentrator or portable tank since admission and that she was receiving oxygen for pneumonia. An LVN who had worked at the facility for two weeks confirmed he had not changed the resident’s oxygen tubing during his shift, noted there was no oxygen order on file when he reviewed the chart, and acknowledged that the resident was on continuous oxygen and that it was the nurse’s responsibility to ensure an order was in place and tubing was changed and dated weekly or as needed. The ADON, also recently employed, stated she was unaware the oxygen equipment was not dated, confirmed that standard practice was to change and date oxygen equipment weekly and each shift to check it, and stated that failing to date and change equipment placed residents at risk for infections. The Administrator stated that the ADON and DON were responsible for monitoring oxygen equipment each shift, that nurses were expected to change and date tubing weekly, and that the facility’s written policy only addressed oxygen storage and did not address care, maintenance, labeling, or dating of oxygen tubing.
Medications Left Unattended in Resident Room During Administration
Penalty
Summary
A medication aide (MA) failed to provide proper supervision during medication administration for a resident with multiple complex medical conditions, including hypertension, diabetes mellitus, and Alzheimer's disease. The resident was cognitively intact, as indicated by a BIMS score of 13, and had not been assessed for self-administration of medications. During morning medication administration, the MA left a cup containing nine prescribed medications and supplements on the resident's bedside table while she was eating breakfast, without supervising her to ensure the medications were taken as ordered. The resident later confirmed that staff typically observed her taking medications, but on this occasion, the MA left the medications in her room because he was busy. The MA admitted to leaving medications in resident rooms when residents refused or were occupied, and acknowledged that he was not supposed to do so. The facility's policy required staff to observe residents taking medications unless a formal assessment for self-administration had been completed and approved by the care planning team and physician. Interviews with multiple facility staff, including assistant directors of nursing and the director of nursing, confirmed that leaving medications unattended in resident rooms was against facility policy and posed risks, such as residents not taking their medications or other residents accessing them. At the time of the incident, no residents had been approved for self-administration of medications, and there was no documentation supporting such an assessment for the resident involved.
Failure to Administer Anti-Epileptic Medication as Prescribed
Penalty
Summary
A deficiency occurred when a nurse failed to administer a prescribed dose of Keppra (levetiracetam), an anti-epileptic medication, to a female resident with a history of cerebral palsy, epilepsy, and severe cognitive impairment. The resident was dependent on all activities of daily living and had a care plan in place requiring seizure medication to be given as ordered. During a medication pass, the nurse administered lactulose instead of Keppra, then incorrectly documented that the Keppra had been given and failed to document the administration of lactulose. The error was discovered after the nurse reviewed the medication administration record (MAR) and realized the mistake. Interviews with the nurse and multiple members of the nursing leadership confirmed that the nurse did not follow the facility's policy requiring verification of the five rights of medication administration. The nurse acknowledged the error, stating she was unsure why it occurred and that she may have been nervous. The facility's policy required checking the medication label three times to ensure correct administration, which was not done in this instance. The incident was identified through observation, record review, and staff interviews.
Failure to Sanitize Reusable Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by the improper handling of reusable blood pressure cuffs for two residents. Specifically, a medication aide (MA A) was observed using the same reusable blood pressure cuff on two different residents without sanitizing it between uses. MA A admitted during an interview that he was not taught to clean the cuff between residents, though he acknowledged the risk of transferring bacteria. The observations were corroborated by interviews with multiple staff members, including assistant directors of nursing (ADONs), the director of nursing (DON), and the administrator-in-training, all of whom confirmed that blood pressure cuffs should be sanitized between residents to prevent cross-contamination and infection. The residents involved included one with a progressive neurological condition and hereditary motor and sensory neuropathy, who was noted to have increased susceptibility to infection due to nutritional deficiencies and dehydration, and another with non-traumatic brain dysfunction and dementia, requiring assistance with activities of daily living and having impaired cognition. Record reviews and staff interviews confirmed that the facility's policy required reusable equipment to be cleaned and reprocessed before being used on another resident, but this protocol was not followed in these instances.
Failure to Implement Abuse and Neglect Prevention Policies Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, as well as misappropriation of resident property. Specifically, the facility did not ensure that a resident with significant cognitive and physical impairments was protected from neglect, resulting in the resident sustaining serious injuries, including an intracerebral hemorrhage and a closed displaced intertrochanteric fracture of the left femur. The resident had a history of repeated falls, was dependent on staff for all activities of daily living (ADLs), and was assessed as a high fall risk. Despite these known risks, the facility did not provide effective interventions or services to address the resident's care needs. On the day of the incident, the resident, who primarily spoke Spanish and had moderate to severe cognitive impairment, was left unsupervised on the toilet by a CNA who was not familiar with the resident's clinical needs and could not communicate effectively due to the language barrier. The CNA left the resident alone after the resident gestured for privacy, and did not ensure that another staff member was monitoring the resident. The resident subsequently fell in the bathroom, resulting in significant injuries. Interviews revealed that the resident was unable to use the call light due to her cognitive status, and the communication board intended to assist with her needs was not present in her room at the time of the incident. Further review showed that the facility's administrative staff did not promptly investigate or self-report the incident as required. Staff interviews indicated a lack of awareness of the resident's fall risk and care plan interventions, and there was confusion among staff regarding who was responsible for monitoring the resident. The care plan for the resident included the use of a communication board and supervision during toileting, but these interventions were not consistently implemented. The failure to follow established protocols and ensure appropriate supervision directly contributed to the resident's injuries.
Resident Left Unattended on Toilet Resulting in Serious Fall and Injuries
Penalty
Summary
A deficiency occurred when a resident with a history of repeated falls, cognitive impairment, and significant physical limitations was left unattended on the toilet by staff, resulting in a fall that caused serious injuries, including fractures to the femur and left hip, intracerebral hemorrhage, and skin tears. The resident was dependent on staff for all activities of daily living (ADLs), had a BIMS score indicating moderate to severe cognitive impairment, and was frequently incontinent, requiring substantial to maximal assistance. The care plan specifically indicated that the resident should not be left unattended in the bathroom and required the use of a communication board due to language and cognitive barriers. However, the communication board was not present in the room at the time of the incident, and staff were not observed using it to communicate with the resident. On the day of the incident, a CNA who did not speak the resident's primary language assisted her to the toilet and left her alone after the resident gestured for privacy. The CNA did not ensure that another staff member was actively monitoring the resident, despite being aware of her fall risk and cognitive limitations. The resident was left unsupervised for several minutes, during which time she fell and sustained significant injuries. Interviews with staff revealed confusion and lack of clarity regarding who was responsible for monitoring the resident, and the CNA involved was not familiar with the resident's care needs or fall risk status. Additionally, the resident was unable to use the call light due to her cognitive impairment, a fact confirmed by both the resident and her family members. The facility failed to ensure that the resident received adequate supervision and assistive devices as required by her care plan and professional standards. The lack of effective communication tools, failure to follow the care plan, and inadequate staff communication and training directly contributed to the resident being left unattended and subsequently falling. The incident was not promptly investigated or self-reported to the appropriate authorities, and there was inconsistency in staff accounts of the event, further highlighting the breakdown in supervision and care.
Failure to Maintain Safe and Sanitary Resident Environment
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment for a resident with multiple medical conditions, including congestive heart failure, dementia, and a history of falls. Observations revealed that the resident's mattress was not properly positioned on the bed frame, leaving a portion of the metal frame exposed. Additionally, the bed was unmade, and pillows lacked pillowcases. A plastic cup was found under the bed, and the resident's bathroom contained several used disposable gloves in the sink, a plastic cup, and coffee mugs placed on the toilet. Dirty clothing was left on a shower chair, and briefs were found near the shower, some of which were not covered. Interviews with staff confirmed that the resident was capable of some self-care but often left soiled briefs and gloves in the bathroom. Staff acknowledged their responsibility to check rooms for environmental issues and to dispose of used items immediately to maintain sanitation. However, they were unable to account for the presence of dirty clothing and coffee cups in the bathroom. The staff also noted that the mattress may have been moved by the resident, resulting in the exposed bed frame, and that coffee cups should have been returned to the kitchen after use. Facility policy required regular environmental rounds and immediate disposal of soiled items to prevent contamination. Despite these policies, the observed conditions in the resident's room and bathroom did not meet the standards for cleanliness and safety. The resident, when interviewed, expressed satisfaction with her living conditions and denied noticing any unsanitary items, but further observation revealed improperly stored food items in her room. The facility's failure to adhere to its own policies and maintain a sanitary environment was documented through direct observation and staff interviews.
Failure to Timely Report Suspected Neglect After Resident Fall Resulting in Serious Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the state agency as required. Specifically, a resident with a history of repeated falls, cognitive impairment, and significant physical limitations was left unattended in the bathroom by a CNA who was unfamiliar with the resident's care needs and could not communicate effectively due to a language barrier. The resident, who was dependent on staff for all activities of daily living and identified as a fall risk, fell while left alone and sustained a fractured femur and hip. The incident occurred when the CNA, after assisting the resident to the toilet, left the resident alone at her request for privacy and notified another CNA to check on her. However, the second CNA did not receive this instruction, and the resident was left unsupervised for several minutes. The resident attempted to transfer herself and fell, resulting in serious injuries. The care plan for the resident specifically indicated that she should not be left unattended in the bathroom due to her fall risk and cognitive deficits. Additionally, the resident had a communication board care planned to assist with her language and cognitive barriers, but it was not present in her room at the time of the incident. Despite the severity of the injuries and the circumstances indicating neglect, the facility administrator did not report the incident to the state agency as required by regulation. The administrator also did not initiate a timely investigation or collect staff statements immediately following the event. Interviews with staff revealed inconsistencies in the account of the incident, and the administrator ultimately determined internally that the event did not meet the criteria for state reporting, despite regulatory requirements to report such incidents involving serious injury and potential neglect.
Incomplete OOH-DNR Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that two residents' Out-of-Hospital Do Not Resuscitate (OOH-DNR) documents were properly completed, specifically lacking the required physician's signature and license number. Both residents had severe cognitive impairment, as indicated by a BIMS score of 03, and had diagnoses including Alzheimer's disease, non-Alzheimer's dementia, hypertension, and depression. Their care plans and physician orders reflected a DNR status, and the care plans included approaches to honor the DNR wishes and consult with responsible parties. Upon review, it was found that the OOH-DNR forms for both residents were signed by the residents or their medical power of attorney but were missing the physician's statement, signature, date, and license number, rendering the documents invalid. The forms were present in both the residents' electronic medical records and in a binder maintained by the social worker, but neither contained the necessary physician information. The social worker stated that while she assisted with the initiation of these documents and performed audits to ensure forms were on file, she did not always verify the completeness of documents that were initiated prior to her tenure or by outside agencies such as hospice. Interviews with the DON and Administrator confirmed that the social worker was responsible for monitoring advanced directives and that the incomplete OOH-DNR forms had not been previously identified. The facility's policy required residents to be informed of the opportunity to file advance directives upon admission and at least annually, with social services responsible for maintaining current and complete records. However, the lack of physician signatures on the OOH-DNR forms for these two residents constituted a failure to ensure that residents' end-of-life wishes were properly documented and could be honored.
Improper Food Storage and Handling Practices Identified in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an inspection of the kitchen's dry storage, refrigerator, and freezer areas, multiple food items were found to be improperly stored. Specifically, several containers and packages of cereal, oats, pasta, fish fry, rice, tortillas, marshmallows, grape jelly, and hamburger patties were unsealed and exposed to air. Additionally, some items lacked expiration dates, and expired food items were present in storage areas. Four dented cans containing various foods were also found stored alongside undamaged canned goods. Interviews with the Dietary Manager and a Dietary Aide revealed that both were unaware of the presence of expired, unsealed, and dented food items in the kitchen. Both staff members acknowledged that all kitchen staff were responsible for ensuring food items were properly sealed, labeled, and checked for expiration dates. The Dietary Manager stated that dented cans should be separated from other canned foods and placed in a designated area, and that all food items should be stored according to the facility's policy, which includes labeling, dating, sealing, and using the FIFO (First In, First Out) method. The Dietary Aide confirmed similar expectations and procedures based on regular in-service training. A review of the facility's food storage policy and relevant FDA codes confirmed that all food should be stored in tightly covered, labeled, and dated containers, with expired items discarded and dented cans separated. The observed deficiencies in food storage practices, including the presence of unsealed, expired, and dented food items, were not in compliance with these standards and procedures. No specific residents or patient medical histories were mentioned in relation to the deficiency.
Inadequate Adherence to Droplet Precautions for COVID-19 Positive Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two staff members who did not adhere to droplet precautions for residents diagnosed with COVID-19. Resident #1, a female with a BIMS score indicating no cognitive impairment, was under droplet precautions due to a positive COVID-19 test. Despite clear signage and available personal protective equipment (PPE) outside her room, PTA B entered without donning an N95 mask or eye protection, only wearing a surgical mask, gown, and gloves. This was observed during a therapy session, and PTA B admitted to being aware of the resident's COVID-19 status but misunderstood the PPE requirements. Similarly, Resident #2, a male with severe cognitive impairment and a positive COVID-19 test, was also under droplet precautions. CNA C entered his room wearing an N95 mask, gown, and gloves but failed to wear appropriate eye protection, relying instead on her prescription glasses. This was contrary to the facility's policy and the infection preventionist's (IP) instructions, which required a face shield or goggles in addition to the N95 mask. CNA C's actions were based on incorrect information allegedly provided by the IP, who denied giving such instructions. The facility's policy, aligned with CDC guidelines, mandated the use of N95 masks, gowns, gloves, and eye protection for staff entering rooms of COVID-positive residents. The IP confirmed that all necessary PPE was available and that staff had been adequately trained. However, the failure of PTA B and CNA C to comply with these precautions posed a risk of cross-contamination and infection spread within the facility.
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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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