Avir At Overton
Inspection history, citations, penalties and survey trends for this long-term care facility in Overton, Texas.
- Location
- 1110 Hwy 135 S, Overton, Texas 75684
- CMS Provider Number
- 675408
- Inspections on file
- 40
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 20 (2 serious)
Citation history
Health deficiencies cited at Avir At Overton during CMS and state inspections, most recent first.
RN coverage was not maintained for at least 8 consecutive hours a day, 7 days a week. Payroll and punch records showed multiple days with no RN hours worked across several months, and interviews confirmed the prior DON left the facility and RN coverage was inconsistent during that period. The facility policy stated it uses the services of an RN for at least 8 consecutive hours a day, 7 days a week.
Unsecured Ceiling Tiles on Hall A and Hall F: Ceiling tiles were observed detached on Hall A and Hall F, including a tile near a sprinkler head with an exposed attic-space gap on Hall F. Both halls were occupied by residents. The Maintenance Supervisor said he had seen ceiling tile issues since starting at the facility and would repair them as he saw them, and the Administrator said issues were reported through verbal reports, texts, and the online portal.
Unsafe and Unclean Resident Room Conditions: The facility failed to maintain a clean, safe, and comfortable environment for 3 residents. Two residents with severe cognitive impairment shared a room with missing and damaged bathroom flooring and a toilet base with a soiled appearance, while another resident with hemiplegia, DM, HTN, and intellectual disabilities had bent and broken window blinds with broken pieces on the windowsill next to the bed. Staff reported maintenance issues were supposed to be entered into TELS, but no reports had been made for these conditions.
Ineffective Pest Control Program in Kitchen: A roach was observed crawling on the kitchen wall behind the handwashing station during the lunch meal. Staff reported roaches had been seen on and off near sink areas, and pest sighting logs documented multiple roach sightings. The pest control company provided monthly service, and the DON/maintenance leadership acknowledged the ongoing kitchen pest issue and that monthly treatment was thought to be working.
Unsafe Smoking Area Maintenance and Policy Enforcement: The facility failed to enforce smoking safety policies in a smoking area outside the dining room. An observation found paper trash in ashtrays and cigarette butts in a trash can with a plastic liner. The Maintenance Supervisor and Administrator both stated trash should not be in ashtrays and cigarette butts should not be placed in the trash, and the facility policy stated ashtrays are emptied only into designated receptacles.
A resident with severe cognitive impairment and a known fall risk experienced two falls, one resulting in a nasal laceration. For both events, the incident reports completed by an LVN documented that the physician and resident representative were not notified, and nursing notes lacked any record of notification attempts. The resident’s representative later reported learning of the injury only upon visiting and seeing the wound. Interviews with staff confirmed that facility practice and written policy required notifying the MD and resident representative after accidents with injury, and that such notifications should be documented on incident reports and in progress notes.
A resident with severe cognitive impairment, a diagnosis of senile brain degeneration, and a history of falls was admitted without a baseline care plan being completed within 48 hours, as required by facility policy. Record review showed no baseline care plan in the EMR and a later comprehensive care plan that only addressed falls and behavioral symptoms, omitting ADLs, transfers, social needs, and key orders. Interviews with the MDS nurse, DON, and administrator confirmed that baseline care plans were expected within 24–48 hours and that comprehensive plans used in place of baseline plans should include all essential care instructions, but this did not occur for this resident.
Two residents involved in a transport van motor vehicle accident were not assessed for injury by facility nursing staff upon return, despite one having a history of traumatic brain injury and spinal fusion and the other having severe cognitive impairment and prior stroke. EMS documentation indicated no visible injuries at the scene, and an LPN documented that EMS had evaluated and cleared both residents, but no immediate nursing or skin assessments were completed at the facility. One resident later reported neck, back, and hip pain and had to crawl over a seat to exit the van due to a malfunctioning wheelchair ramp, while the other reported being sore for several days and stated that no one checked him at the scene or on return. Staff interviews confirmed that the LPN did not assess the residents because she believed EMS had cleared them, and that the transporter and a CNA had to manually assist one resident out of the van through a side door, contrary to facility policies requiring nursing observation and documentation when there is a change in condition.
A resident with a history of behavioral symptoms stomped on another resident's foot in the dining room, resulting in a bruise. Staff observed the incident and intervened to separate the residents, and the injured resident was assessed and found to have no pain. Both residents had cognitive and behavioral diagnoses, and interventions for monitoring and redirection were in place, but the physical altercation still occurred.
Staff failed to immediately report an incident in which one resident stomped or kicked another resident's foot, resulting in a bruise. Although the incident was witnessed and reported to a nurse, it was not reported to the administrator as required, leading to a delay in notifying proper authorities. Both residents involved had significant cognitive and behavioral health diagnoses, and staff training records indicated that required abuse reporting training had been completed.
A CNA failed to provide privacy for a resident with severe cognitive impairment during incontinent care, leaving the individual exposed and visible from the hallway when the CNA left the room to get supplies. Staff interviews and facility policy confirmed that privacy measures, such as closing curtains and covering the resident, were required but not followed in this instance.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
The facility failed to maintain RN coverage for at least eight consecutive hours daily, seven days a week, during July and August 2024. There was no RN coverage on specific days, as confirmed by the RN punch detail hour report and CMS PBJ report. Staffing issues and turnover contributed to the deficiency, with the ADON responsible for scheduling and the DON's hours not counting towards the required RN hours. The facility's policy requires RN presence to ensure resident safety.
The facility failed to maintain sanitary conditions in the kitchen, with issues in dish machine sanitation and improper thawing of raw foods. The dish machine's sanitizer was not registering due to unattached tubing, and frozen foods were thawed inappropriately in the sink. These deficiencies could risk foodborne illnesses among residents.
The facility failed to maintain a safe and sanitary environment, with issues in the Women's and Men's locked units, and the main dining room. A resident's room had a stained mattress and smeared walls, while hallways had damaged doors and floors. The dining room had a sagging ceiling and dirty vents. Staff interviews revealed a lack of maintenance action, with the administrator citing funding delays for repairs.
A facility failed to remove a worn and damaged mechanical lift sling from service, posing a risk to a resident with significant medical conditions. The resident, dependent on staff for transfers, was observed using a faded sling over two days. Staff interviews revealed a lack of awareness and adherence to inspection and maintenance policies, with the DON and Administrator unaware of the sling's condition and washing procedures.
The facility failed to post daily nurse staffing information in a prominent location, as required. Observations on two consecutive days revealed that the postings were partially blocked by medication carts and not clearly visible. Interviews with the ADON, DON, and Administrator highlighted a lack of awareness regarding the visibility of the postings, which were later moved to a more accessible location.
A resident with a full code status was found unresponsive, but the RN did not initiate CPR or call 911 immediately, assuming the resident was already deceased. Emergency services were called 29 minutes later, but the resident was pronounced deceased after CPR was initiated by emergency personnel. The facility's policy required CPR for full code residents unless there were signs of irreversible death.
A resident with a full code status was found unresponsive, but CPR was not initiated by the attending RN, who believed the resident was already deceased. The facility's policy required CPR unless a DNR order was present or there were signs of irreversible death. Emergency services initiated CPR upon arrival, highlighting a failure to follow protocol.
The facility failed to protect residents from abuse, resulting in incidents where a resident with severe cognitive impairment slapped another resident, and another resident pulled the first resident by her shirt collar. Despite interventions in place, such as serving meals first to prevent altercations, the measures were inadequate. Staff interviews highlighted insufficient supervision on the secured unit, contributing to the incidents.
A facility failed to report a resident's allegation of verbal abuse involving racial slurs by a CNA and an LVN. Despite conflicting accounts from staff and the resident's history of making false accusations, the administrator did not consider the incident as verbal abuse and did not report it to the state agency, leading to a racially discriminatory environment.
RN Coverage Not Maintained 7 Days a Week
Penalty
Summary
The facility failed to use the services of an RN for at least 8 consecutive hours a day, 7 days a week during 3 of 3 months reviewed for Quarter 1 of fiscal year 2026. Record review of the RN punch detail hour reports and the CMS Payroll Based Journal report showed no RN hours worked on multiple dates in October, November, and December 2025, including October 12, October 25, and October 26; November 8, November 9, November 26, and November 27; and December 1, December 2, December 5, December 6, and December 7. During interviews, the Administrator and HR stated the previous DON’s last day worked was 11/23/2025 and she was terminated on 11/24/2025. The Administrator and ADON stated the facility did not have consistent RN coverage from October 2025 through December 2025, and the ADON said RN coverage should be 8 hours each day with the DON present Monday through Friday and another RN working weekends. The Administrator also stated the facility hired a new full-time DON in December 2025, and the facility policy stated the center provides sufficient nursing staff and utilizes the services of an RN for at least 8 consecutive hours a day, 7 days a week.
Unsecured Ceiling Tiles on Hall A and Hall F
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment when ceiling tiles were not secure on Hall A and Hall F. During an observation on 4/27/2026 at 10:34 a.m., Hall F had multiple ceiling tiles detached from the ceiling, including one tile located by a sprinkler head with an approximately 2-inch gap exposing the attic space. Hall F was occupied by residents, and a resident list report dated 4/27/2026 showed 13 residents on the hall. During an observation on 4/27/2026 at 10:48 a.m., Hall A also had multiple ceiling tiles detached from the ceiling, and Hall A was occupied by residents. A resident list report dated 4/27/2026 showed 14 residents on the hall. During an interview on 4/29/2026, the Maintenance Supervisor said he had seen ceiling tile issues since starting in October 2025 and would repair them as he saw them. He said a request was entered in the online portal on 4/27/2026 to repair the ceiling tiles. The Administrator said issues were reported verbally, by text, and through the online portal, and said ceiling tiles might have been moved by a contractor and not put back in place. The facility policy stated maintenance service shall be provided to all areas of the building, grounds, and equipment, and that maintenance personnel are to maintain the building in good repair and free from hazards.
Unsafe and Unclean Resident Room Conditions
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for 3 of 15 residents observed for resident environment. For Residents #9 and #13, both of whom had severe cognitive impairment with BIMS scores of 3 and were dependent on staff for transfer from chair to bed, the bathroom floor in their shared room had a missing piece of flooring at the entrance, damaged flooring under the sink, and the base of the toilet appeared soiled with a dark yellow and black appearance. Resident #9 had diagnoses including dementia, hypertension, paranoid schizophrenia, anorexia, and dysphasia, and Resident #13 had diagnoses including hypertension, generalized anxiety, repeated falls, dementia, and difficulty walking. During observation, both residents were clean and dressed appropriately, but neither was able to respond appropriately to questions about the bathroom floor. For Resident #43, who had hemiplegia and hemiparesis affecting the right dominant side, type 2 diabetes mellitus, hypertension, and intellectual disabilities, the blinds covering the window next to his bed were bent and broken, with broken pieces lying on the windowsill. The resident had severe impairment in thinking with a BIMS score of 07 and was dependent on staff for activities of daily living. He was observed lying in bed, clean and dressed appropriately, and was not able to respond appropriately to questions concerning the blinds. The Maintenance Supervisor stated all staff were responsible for reporting repairs or maintenance issues through the TELS system and that he checked the system daily. He said no reports had been made for the damaged bathroom flooring in the room shared by Residents #9 and #13 or for the damaged blinds in Resident #43's room. He stated he was made aware of the damaged flooring on 4/28/2026 and the damaged blinds on 4/29/2026. The Administrator stated she was not aware of the damaged flooring or broken blinds and said staff were supposed to report maintenance issues to the Maintenance Supervisor through TELS. The facility policy stated maintenance service shall be provided to all areas of the building, grounds, and equipment, and maintenance personnel are to maintain the building in good repair and free from hazards.
Ineffective Pest Control Program in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the kitchen free of roaches. During an observation on 4/28/2026 at 11:03 am, a roach was seen crawling on the kitchen wall behind the handwashing station during the lunch meal. A Dietary Aide stated she had not recently seen roaches in the kitchen, but in the past she reported them to the administrator, and said roaches can spread disease and are unsanitary. During interviews, staff reported that roaches had been seen on and off in the kitchen, usually near sink areas, and that they were killed and reported to the dietary manager. The pest control company service manager said the facility received monthly service and that common areas including the kitchen were treated, with staff using a log for pest sightings; he said extra visits were not made unless there were multiple sightings or an infestation. The Maintenance Supervisor and Administrator both acknowledged the pest control program, stated they were aware of roaches in the kitchen on and off, and noted that monthly treatment was thought to be working. Record review showed pest sightings documented on 1/08/2026, 2/10/2026, 4/01/2026, 4/20/2026, and 4/24/2026, along with monthly pest control invoices and a facility policy requiring an effective pest control program.
Unsafe Smoking Area Maintenance and Policy Enforcement
Penalty
Summary
The facility failed to formulate, adopt, and enforce policies regarding smoking, smoking areas, and smoking safety that also considered non-smoking residents for 1 of 2 smoking areas reviewed, the smoking area outside the dining room. During an observation on 4/27/2026 at 11:46 a.m., three ashtrays were present in that smoking area, and two of the three ashtrays contained paper trash. The trash can in the area had a plastic liner with cigarette butts inside. During interviews, the Maintenance Supervisor stated he had worked at the facility since October 2025 and said he and housekeeping staff checked the smoking areas daily for trash and made sure trash and butts were in the right spots. He said trash should be in the trash receptacles and butts should be in the ashtray and/or in the red cans, and that butts should never be placed in the trash. He also said there should not be any trash in the ashtrays and there could be a risk of fire. The Administrator stated the smoking areas were the responsibility of housekeeping and Maintenance daily, that the smoking area outside the dining room was for everyone that smoked, and that staff should empty the ashtrays into the cans after each smoke break. She said trash should not be in the ashtrays and there was a risk of potential fires. Record review of the facility's Smoking Policy-Residents dated October 2022 stated the facility shall establish and maintain safe resident smoking practices and that ashtrays are emptied only into designated receptacles.
Failure to Notify Physician and Representative After Resident Falls With Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative and attending physician of significant changes in condition following falls. An elderly male resident with senile degeneration of the brain, severely impaired cognition, and a history of falls prior to and during his admission was identified as being at risk for falls in his comprehensive care plan dated 6/22/25. A comprehensive MDS indicated he was unable to complete the BIMS interview and had severely impaired cognition. Despite this known fall risk and cognitive impairment, required notifications were not made after two separate fall incidents. Record review showed that on 6/22/25 at 5:16 a.m., the resident sustained a witnessed fall in which he ran into a door facing and fell to the floor, resulting in a 1x0.5 cm laceration to the bridge of his nose. The incident report for this fall, completed and signed by LVN A, documented that the resident representative was not notified. The corresponding nursing progress note, entered at 5:18 a.m. by LVN A, described the fall and treatment (area cleaned and topical antibiotic applied) but contained no documentation of notification or attempted notification of the responsible party. The resident’s responsible party later reported that she was not called about this fall and only discovered the injury when she visited the facility the next day and saw the laceration on his nose. A second incident report dated 6/27/25 at 1:51 a.m. documented an unwitnessed fall for the same resident. In the notifications section of this report, also signed by LVN A, it was recorded that the attending physician was not faxed, the physician was not notified, and the resident representative was not notified. The nursing progress note for this fall, entered at 1:52 a.m. by LVN A, likewise contained no documentation of physician or responsible party notification or attempted notification. Interviews with another LVN, the DON, and the administrator confirmed that facility practice and written policy required notification of the physician and resident representative after accidents or incidents involving injury, and that the incident reports would reflect whether such notifications were made. Facility policy and resident rights documents further stated that the nurse must notify the attending physician and the resident’s representative when the resident is involved in an accident or incident resulting in injury or requiring a physician visit.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a baseline care plan within 48 hours of admission for one resident. The resident was an elderly male admitted with a diagnosis of senile degeneration of the brain, a progressive neurodegenerative disorder associated with dementia. A comprehensive MDS showed a BIMS score of 99, indicating he was unable to complete the interview and had severely impaired cognition. He had a history of falls prior to admission and had experienced falls while in the facility. Record review of the electronic medical record on 3/11/26 showed there was no baseline care plan completed for this resident. Further record review showed that a comprehensive care plan initiated on 6/22/25 for this resident addressed only falls and behavioral symptoms, and did not include other required areas such as ADLs, transfers, social needs, and orders. Interviews with the MDS nurse, DON, and administrator confirmed that baseline care plans were expected to be initiated within 24–48 hours of admission and that, if a comprehensive care plan was used instead, it should include instructions for all key care areas. The facility’s written policy on baseline care plans required development of a baseline plan within 48 hours of admission, including initial goals, physician, dietary, and therapy orders, social services, and PASARR recommendations as applicable. Despite these expectations and policy requirements, the resident’s baseline care plan was not completed within the required timeframe.
Failure to Assess Two Residents After Transport Van Motor Vehicle Accident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that two residents involved in a motor vehicle accident (MVA) in the facility transport van were assessed for injury upon return to the facility, in accordance with professional standards of practice and facility policy. Resident #1, an older male with a history of focal traumatic brain injury with loss of consciousness, dementia with behavioral disturbance, and thoracic spine fusion, required substantial/maximal assistance with transfers and used a manual wheelchair for mobility. On the day of the accident, EMS documentation indicated no visible injuries, and the resident denied loss of consciousness, head strike, and use of blood thinners. A nursing progress note by LVN A documented that the van had been rear-ended, that police and EMS were called, that EMS evaluated and treated the resident, and that no injuries or pain were reported at that time. However, no nursing assessment or skin assessment was completed by facility staff upon the resident’s return after the accident. For Resident #1, the following day a nursing note by LVN B documented that the resident, described as alert and oriented x4, complained of back pain and bilateral hip pain following the MVA. Subsequent documentation noted continued complaints of stiffness and mild pain, and x‑rays of the cervical spine, bilateral hips, and lumbar spine were obtained, which showed no acute changes. Despite these later assessments, record review showed that a facility skin assessment was not completed after the accident. Interviews further clarified that Resident #1’s family member believed he should have been sent to the hospital after the accident and reported that, upon arrival back at the facility, the resident had to crawl out of the side of the van due to a non-functioning wheelchair ramp. The family member also reported bruising to the resident’s right index finger and left cheek and eye area the day after the accident. Resident #1 himself stated that EMS only asked from the front of the van if he was alright, that he reported feeling fine at that time, that no one asked if he wanted to go to the hospital, and that he had to crawl over a seat to exit the van when he returned to the facility. Resident #2, an older male with diagnoses including malignant neoplasm of the colon, history of transient ischemic attack and cerebral infarction, and age-related cognitive decline, had a significant change MDS showing severe cognitive impairment with a BIMS score of 3 and required supervision/touching assistance with walking. EMS documentation for Resident #2 on the day of the accident also indicated no visible injuries, denial of loss of consciousness, denial of head strike, and no use of blood thinners. A nursing progress note by LVN A documented that the van was rear-ended, that police and EMS were called, that EMS evaluated and treated the resident, and that no injuries or pain were reported, with the NP and responsible party notified. However, similar to Resident #1, there was no documented nursing assessment for injury upon return to the facility immediately after the accident. A skin assessment for Resident #2 was not completed until several days later and showed no skin issues. In interviews, Resident #2 reported that no one checked him at the scene or upon return to the facility and that he was sore for a few days after the wreck. Staff interviews confirmed that facility nursing staff did not perform post-accident assessments on the residents when they returned from the MVA. LVN A stated that she did not assess either resident for injury upon return because she believed EMS had evaluated and cleared them at the scene. The ADON reported that she received a call about the wreck, was told the residents were okay, and asked if they had been checked, but there was no documentation of an immediate post-accident assessment by facility nurses. The transporter, a CNA serving as a backup driver, stated that she was instructed by the administrator and DON to have EMS check the residents, that she was speaking with police and could not see whether EMS evaluated the residents, and that EMS told her they were free to go. She also confirmed that the back of the van would not open and that she and CNA C had to get Resident #1 out through the side door. The Administrator stated she believed the residents were evaluated at the scene and cleared with no injuries and referenced skin assessments she believed were done, though none were provided prior to surveyor exit. The facility’s policies on transportation and change in a resident’s condition required procedures for safe transportation and nursing observation and documentation when there is a change in condition, but the records showed that immediate post-accident assessments were not completed for the two residents involved in the MVA.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when another resident stomped on his foot in the dining room. The incident occurred when one resident, who had a history of behavioral symptoms directed at others and required secure unit placement, exhibited aggressive behavior by stomping or kicking another resident's foot. The affected resident had diagnoses including schizoaffective disorder, autistic disorder, and cognitive communication deficit, and was assessed as having moderately impaired cognition. The aggressor had diagnoses of intellectual disability, cognitive communication deficit, and bipolar disorder, with severely impaired cognition and a documented history of behavioral symptoms toward others. Staff observations and interviews confirmed that the aggressive resident attempted to stomp on the other resident's foot multiple times before staff could intervene and separate them. The resident who was stomped on moved his feet away and later denied pain or discomfort, with a light bruise noted on his right foot. Staff present at the time reported the incident and performed an assessment, confirming the injury. The aggressive resident admitted to stomping on the other resident's foot out of meanness and expressed emotional distress related to missing his parents and wanting to leave the facility. Review of care plans and staff interviews indicated that interventions for monitoring and redirecting the aggressive resident were in place, and staff had received training on abuse, neglect, and resident-to-resident altercations. However, despite these measures, the incident occurred, resulting in physical abuse and a bruise to the affected resident. The facility's policy prohibits and aims to prevent abuse, neglect, and exploitation, but the failure to prevent this altercation led to the deficiency.
Failure to Immediately Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours, as required. Specifically, an incident occurred in which one resident stomped or kicked another resident's foot, resulting in a bruise. The incident was witnessed by a CNA, who reported it to an RN, but neither the CNA nor the RN reported the incident to the Administrator (ADM) immediately. The ADM was not notified of the incident until the following day, well beyond the required reporting timeframe. The resident who was the victim of the incident had a history of schizoaffective disorder, autism, and cognitive communication deficits, with moderately impaired cognition. The resident who committed the act had a history of intellectual disability, cognitive communication deficit, and bipolar disorder, with severely impaired cognition and a documented history of behavioral symptoms directed at other residents. The incident was documented in event reports by the RN, and the victim was assessed and found to have a bruise but denied pain or discomfort. The perpetrator admitted to the act during an interview, stating it was done out of meanness. Interviews with staff revealed that the CNA and RN involved were aware of the requirement to report abuse but did not notify the ADM as required. The RN stated she had not received training on abuse reporting at the time of hire and was unaware of the requirement to notify the ADM. However, training records indicated that required abuse and neglect training had been completed by the staff involved. Facility policy required immediate reporting of suspected abuse to the administrator and other officials according to state law and guidelines.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide privacy for a male resident with severe cognitive impairment and significant self-care deficits during incontinent care. The resident, who required maximal assistance with toileting and hygiene due to dementia and muscle atrophy, was left exposed on his bed, naked from the waist down, with the privacy curtain open and the door to the hallway left ajar. This allowed the resident to be visible from the hallway when the CNA exited the room to retrieve additional supplies. Interviews with the CNA, Assistant Director of Nursing (ADON), and Administrator (ADM) confirmed that facility policy and staff training require privacy to be maintained during personal care by closing curtains, doors, and covering the resident if the caregiver must leave the room. The CNA acknowledged forgetting to provide privacy in this instance, despite having completed annual skills checks and being aware of the expectations. Facility documentation and policy also supported the requirement for privacy during such care.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, during July and August 2024. Specifically, there was no RN coverage on four days in July and one day in August. This deficiency was identified through a review of the RN punch detail hour report and the CMS Payroll Based Journal (PBJ) report, which confirmed the absence of RN hours on specific dates. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility had been experiencing staffing issues, and the ADON was responsible for scheduling nurses and nurse aides. The DON acknowledged that her hours worked as a nurse aide or charge nurse did not count towards the required RN hours. The Administrator was aware of the staffing challenges and the missed RN hours during the fourth quarter of 2024, attributing the issue to staff turnover. The facility's policy, revised in September 2023, mandates the use of a registered nurse for at least eight consecutive hours daily, seven days a week, to ensure resident safety. Despite this policy, the facility did not meet the requirement, potentially leaving staff without supervisory coverage for RN-specific nursing activities and coordination of emergency care and disasters.
Sanitation and Thawing Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed under sanitary conditions in the kitchen. During an observation, the dish machine was found to have a wash temperature of 120 degrees Fahrenheit and a rinse temperature of 125 degrees Fahrenheit, but the sanitizer did not register on the test strip. The Dietary Aide, who was trained on sanitizer testing, did not always use the test strips and relied on visual confirmation of the solution. The Dietary Manager confirmed that she had tested the machine earlier and found no issues, but the sanitizer tubing was later found unattached, preventing proper sanitation. Additionally, the facility did not ensure that raw foods were thawed appropriately. Bags of frozen food items, including peas and carrots, mashed potatoes, gravy mix, and chicken breast, were observed thawing in the kitchen sink. The proper method of thawing, which involves using a refrigerator or cold running water, was not followed. The Dietary Manager acknowledged seeing the food thawing improperly and admitted that the cook had been trained on the correct process. These lapses in food handling could potentially lead to foodborne illnesses among residents.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, clean, and sanitary environment for residents, particularly in the Women's locked unit and the Men's locked unit, as well as in the main dining room and its patio. Specifically, Resident #8's room in the Women's locked unit was found to have a stained mattress and walls smeared with substances, with exposed sheetrock in the bathroom and a non-working soap dispenser. The resident, who has severe cognitive impairment and ambulated independently, reported vomiting at night and wiping it on the wall, which had not been cleaned regularly. Observations revealed that the hallways in both the Women's and Men's locked units had gouged and marred doors and doorways, with missing paint and exposed sheetrock. The Men's unit also had vinyl flooring that was torn and pulling apart, creating a trip hazard. The main dining room had a sagging ceiling with old water damage, dirty vents, and missing tiles on the patio, posing a risk of falls. Staff interviews indicated a lack of awareness and action regarding the maintenance and cleanliness of these areas, with maintenance requests not being logged or addressed. The facility's policy emphasized maintaining a clean, sanitary, and homelike environment, but the observations and interviews highlighted significant lapses in adhering to this policy. The maintenance man and staff acknowledged the issues but cited a lack of funds and unclear responsibilities for addressing the deficiencies. The administrator confirmed the policy's intent but noted that corporate funding was awaited for necessary repairs, indicating systemic issues in maintaining the facility's environment.
Failure to Remove Damaged Mechanical Lift Sling
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards by not removing a worn and damaged mechanical lift sling from service, which was used for a resident with significant medical conditions. The resident, who had a history of traumatic brain injury, hemiplegia, hemiparesis, and aphasia, was dependent on staff for transfers using a Hoyer lift. Observations over two days showed the resident sitting on a faded mechanical lift sling, which was not removed from use despite its condition. Interviews with staff revealed a lack of awareness and adherence to the facility's policy regarding the inspection and maintenance of lift slings. The CNA and Laundry Supervisor noted the sling's faded color and frayed tag, indicating it had been bleached against manufacturer instructions, which could lead to tears and potential hazards. The DON and Administrator were unaware of the sling's condition and the washing procedures, highlighting a gap in communication and oversight. The facility's policy required regular inspections and adherence to manufacturer guidelines, which were not followed, leading to the deficiency.
Failure to Post Nurse Staffing Information in a Prominent Location
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a location that was readily accessible to residents and visitors. On two consecutive days, the staffing information was not posted in a prominent place, as required. Instead, the postings were located on a wall by the nurse station, partially blocked by medication carts, making them not clearly visible. This was observed on 2/17/2025 and 2/18/2025, with the postings dated accordingly. The facility's policy requires that staffing levels for direct care be updated each shift and posted in a public area, which was not adhered to in this instance. Interviews with facility staff revealed a lack of awareness regarding the visibility and accessibility of the staffing postings. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both acknowledged the responsibility of the night charge nurse to post the staffing information. However, they did not recognize the inadequacy of the current posting location. The Administrator admitted that the location was not suitable for visitors to easily access the information and stated that it had been moved to the front entrance on the day of the interview. This oversight could potentially prevent residents, families, and visitors from being informed about the staffing levels and census each day.
Failure to Provide Timely CPR to Full Code Resident
Penalty
Summary
The facility failed to ensure that all residents were free from neglect, as evidenced by the case of a resident who was not provided with necessary life-saving measures. The resident, a male with a history of Parkinson's Disease, hypertension, and atrial fibrillation, was found unresponsive in his room. Despite being identified as a full code, meaning CPR should be initiated in the event of cardiac arrest, the registered nurse (RN A) did not initiate CPR or call 911 immediately upon discovering the resident's condition. RN A found the resident unresponsive at approximately 9:00 PM, noting that he had no pulse or respirations, and his pupils were fixed and dilated. Instead of initiating CPR, RN A contacted the facility's administration for guidance on funeral home notification, assuming the resident was already deceased. It was not until 9:29 PM, after speaking with a nurse practitioner, that RN A was directed to call 911. Emergency services arrived at 9:50 PM and began CPR, but the resident was pronounced deceased at 10:27 PM. The facility's policy required CPR to be initiated for any resident who is a full code unless there are obvious signs of irreversible death, such as rigor mortis. RN A, who was responsible for updating the resident code status book, was aware of the resident's full code status but did not follow the facility's emergency procedures. The facility's failure to provide timely life-saving measures resulted in the identification of an Immediate Jeopardy situation.
Removal Plan
- Ensure staff performed CPR for Resident #1 until emergency services arrived.
- Utilize the AED when Resident #1 was found unresponsive.
- Immediately call 911 when the resident was found unresponsive.
- Charge Nurse no longer works for the facility.
- Completed a DNR and Full Code audit to ensure all are matching and correct.
- Audit staff CPR cards to ensure proper number of certified employees present each shift.
- Ensured the crash cart has an updated list of full code and DNR residents.
- Educate all nurses regarding Emergency Management Code Procedure Policy.
- Educate all direct care staff over the abuse and neglect policy.
- Perform 1 mock code drill once a shift for each Charge Nurse shift to ensure proper reaction and that staff are following protocols.
- Conduct an ad hoc QAPI with Medical Director to review the IJ Template and the facility's plan to lower the immediacy.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident identified as a full code prior to the arrival of emergency medical personnel. The resident, a male with diagnoses including Parkinson's Disease, hypertension, and atrial fibrillation, was found unresponsive by RN A. Despite the resident's full code status, CPR was not initiated, and emergency services were not called immediately. RN A assessed the resident and found no pulse or respirations, but did not start CPR, believing the resident was already deceased. RN A contacted the facility's administration for guidance on funeral home notification instead of initiating life-saving measures. The nurse was aware of the resident's full code status but had not received training on emergency procedures or CPR from the facility. The facility's policy required CPR to be initiated unless a DNR order was in place or there were obvious signs of irreversible death. However, RN A did not follow this policy, and CPR was only initiated by emergency services upon their arrival. This failure to act according to the resident's code status and facility policy resulted in an Immediate Jeopardy situation being identified.
Removal Plan
- Charge Nurse no longer works for the facility.
- Completed a DNR and Full Code audit to ensure all are matching and correct.
- Audit staff CPR cards to ensure proper number of certified employees present each shift.
- Ensured the crash cart has an updated list of full code and DNR residents.
- All Nurses educated regarding Emergency Management Code Procedure Policy.
- Mock code drill to be performed for each Charge Nurse shift to ensure proper reaction and that staff are following protocols.
- Ad hoc QAPI performed with Medical Director to review the IJ Template and the facility's plan to lower the immediacy.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents involving three residents. Resident #1, who has severe cognitive impairment and a history of inappropriate behaviors, slapped Resident #2, leaving a red handprint on her cheek. This incident was unwitnessed, and both residents were monitored for 24 hours following the event. Resident #1's care plan included interventions to manage her behavior, but these measures were insufficient to prevent the altercation. In another incident, Resident #3, who also has severe cognitive impairment, pulled Resident #1 by her shirt collar, causing scratches on Resident #1's face. This altercation occurred when Resident #1 attempted to take food from Resident #3's tray. Staff intervened to separate the residents and monitored them for 24 hours. Despite existing interventions, such as serving Resident #1 first at meals, the facility's measures were inadequate to prevent this incident. Interviews with staff revealed that supervision on the secured unit was lacking, with only one CNA assigned to each hallway. The Director of Nursing acknowledged the risks associated with insufficient supervision, including physical injury and disruption. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, yet the incidents indicate a failure to uphold this standard.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to implement their written policies and procedures to report an allegation of abuse as required for one of the residents reviewed for abuse. The resident, a male with diagnoses including Parkinson's disease, lack of coordination, reduced mobility, bipolar disorder, and generalized anxiety, alleged that a CNA and an LVN called him a racial slur. Despite the resident's clear and repeated allegations, the facility did not report the incident to the appropriate authorities as mandated by their policies. The resident's baseline care plan indicated that all accusations reported by the resident would be addressed by the administrator, DON, ADON, and social services. However, the facility's grievance form and subsequent interviews revealed that the allegations were not taken seriously. The administrator and other staff members focused on the resident's history of making false accusations and using abusive language towards staff, rather than investigating the claims of verbal abuse made by the resident. Interviews with various staff members, including the CNA and LVN involved, as well as other CNAs and the ADON, provided conflicting accounts of the events. Some staff members denied hearing or using any racial slurs, while others confirmed the resident's allegations. Despite this, the administrator did not consider the racial slur as verbal abuse and failed to report the incident to the state agency as required. This inaction led to a failure in protecting the resident from potential continued abuse and created a racially discriminatory environment, as evidenced by multiple staff members quitting in protest.
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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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