Avir At Stephenville
Inspection history, citations, penalties and survey trends for this long-term care facility in Stephenville, Texas.
- Location
- 1670 Lingleville Rd, Stephenville, Texas 76401
- CMS Provider Number
- 455744
- Inspections on file
- 34
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Avir At Stephenville during CMS and state inspections, most recent first.
A cognitively intact male resident with bipolar disorder was prescribed medroxyprogesterone acetate (Provera) 5 mg daily by an NP for sexual behaviors, despite no sexual behaviors being addressed in his care plan. The MAR showed he received two doses, and a nursing note documented he was started on Provera and paroxetine with general medication education, but there was no signed consent for Provera on file. The resident later reported he learned from an outside case manager that he had been prescribed a hormone without his knowledge, stated he had not signed consent and did not want medication for his sex drive, and interviews confirmed the psych physician had not ordered Provera and that the facility had no written consent policy available. The DON and ADON acknowledged responsibility for obtaining consents lay with the prescriber or the nurse taking the order, yet no consent form for Provera could be produced.
A deficiency was cited when a resident's care plan did not include all necessary needs, lacked measurable timetables, and failed to specify actions, resulting in incomplete planning and documentation for the resident's care.
A resident with severe cognitive impairment and multiple diagnoses was admitted to hospice care, but the facility failed to document hospice services in the care plan and did not maintain required hospice forms, such as the certificate of terminal illness and hospice election form. Communication between hospice and facility staff was verbal, with no documented evidence as required by policy.
Staff failed to follow infection control protocols during perineal care for two male residents with incontinence and complex medical histories. Observed deficiencies included reusing wipes, not retracting the foreskin for cleaning, and wiping from back to front, all contrary to facility policy and recent staff training. These actions placed residents at risk for infection.
Two residents reported unsanitary conditions in their rooms and bathrooms, including the presence of roaches and unsafe bathroom fixtures. One resident's bathroom had an unsteady sink and toilet, and both residents expressed distress over the roach infestation. The facility's pest control measures were documented, but issues persisted, and the administrator was unaware of the specific bathroom fixture problems.
The facility failed to ensure a safe environment by allowing the DON to bring a dog that bit a resident and acted aggressively towards another. The incidents were not reported, and the facility lacked a clear policy on staff pets, contributing to the deficiency.
The facility failed to protect two residents from verbal abuse by a CNA, who was witnessed yelling and slamming doors. Despite initial denials from the residents, they later confirmed the abuse, indicating a failure in the facility's abuse prevention measures. The facility did not follow its policies for reporting and investigating the incident, as the DON did not document interviews or conduct an investigation, and the incident was not reported to the state agency.
A facility failed to report an alleged verbal abuse incident involving two residents to state authorities within the required timeframe. An RN witnessed a CNA yelling and slamming a door on the residents, but the incident was not documented or thoroughly investigated by the DON. The residents, both with significant medical conditions, denied the allegations, and the CNA continued working without suspension, contrary to facility policy.
The facility failed to investigate allegations of verbal abuse by a CNA towards two residents, despite a report by an RN. The residents, both with moderate cognitive impairments, denied the allegations when interviewed by the DON. The facility did not follow its abuse investigation policy, which requires thorough documentation and suspension of the accused employee during the investigation.
A resident in a LTC facility did not receive IV antibiotics as ordered due to a failure to mix the medication properly. The central line dressing was not changed as required, and weekly lab tests were not conducted. These deficiencies in care placed the resident at risk of infection relapse and complications.
Two residents in a LTC facility experienced significant medication errors. One resident did not receive IV antibiotics as ordered due to improper mixing and labeling, while another missed multiple doses of Insulin Glargine. These errors were attributed to misunderstandings and poor adherence to protocols, placing residents at risk of complications.
The facility failed to develop comprehensive care plans for residents, leading to missed PASRR services and lack of ADL goals. Insulin was not administered as ordered for a resident, and central line dressings were not changed as documented, highlighting significant lapses in care and communication.
A facility failed to change and date a resident's oxygen tubing weekly as required, leading to a deficiency in respiratory care. The resident, with chronic respiratory failure, had nebulizer tubing that was not replaced according to the schedule. The DON acknowledged the oversight and the lack of a clear policy on tubing dating, contributing to the deficiency.
The facility failed to ensure timely physician visits for several residents, with two not seen every 30 days during the first 90 days post-admission, and four not seen every 60 days thereafter. Missing documentation for specific months highlighted this deficiency. Interviews with the DON and ADMN revealed awareness of the issue, attributing it to physicians not visiting as required. The facility's policy mandates visits every 30 days initially and every 60 days thereafter, which was not followed.
The facility failed to maintain adequate nursing staff levels, as evidenced by timesheet reviews and resident interviews. On several occasions, the facility did not meet the required direct care staff hours, leading to concerns about delayed care and insufficient response to resident needs. The DON and ADMN acknowledged staffing issues due to unexpected staff resignations and absences, which were not aligned with the facility's policy of maintaining adequate staffing.
The facility failed to store medications securely and in their original containers, as observed with three medication carts containing unlabeled pill cups with various medications, including narcotics. Staff interviews revealed pre-filling of pill cups due to workload, risking incorrect medication administration. The DON acknowledged this practice was against policy, which requires medications to be stored securely and in original packaging.
A resident with a stage 4 pressure wound was treated without the privacy curtain being pulled, compromising their dignity and privacy. The LVN acknowledged the oversight, and both the DON and ADON confirmed the importance of using the curtain to prevent exposure. The facility's policy on maintaining resident dignity and privacy was not followed.
A resident's privacy was compromised when staff failed to pull the privacy curtain during peri-care and a transfer using a Hoyer Lift. The resident, who is cognitively intact and requires assistance due to incontinence and lack of coordination, was exposed to potential embarrassment. Facility policy requires maintaining resident dignity and privacy, which was not adhered to in this instance.
A resident was transferred using a Hoyer lift without locking the lift's legs in the required position, despite staff training on proper use. The resident, who was cognitively intact and dependent on staff for transfers, was at risk due to this oversight. The CNA admitted to not locking the lift previously, and the ADON confirmed the importance of locking the brakes to prevent falls.
Two staff members failed to follow proper infection control protocols during peri-care for a resident, neglecting to change gloves and perform hand hygiene between tasks. The resident, who was incontinent and had conditions such as hypertension and diarrhea, was at risk due to these lapses. The staff cited nervousness and lack of supplies, while the DON and ADON acknowledged insufficient training and monitoring.
The facility failed to store medications in locked compartments and keep them in their original containers. Observations revealed loose pills in the Hall 3 and Hall 5 medication carts. Staff acknowledged the issue, citing hurried actions and lack of attention as causes. The facility's policy requires drugs to be stored securely and in their original packaging.
A facility failed to respect a resident's right to smoke, revoking his smoking privileges without attempting other safety measures. The resident, with severe cognitive impairment and a history of elopement, was denied the only activity he enjoyed, despite being assessed as safe to smoke under supervision.
The facility failed to develop a comprehensive care plan for a resident with severe cognitive impairment, resulting in inadequate supervision and care. The care plan lacked person-centered interventions and measurable objectives, particularly concerning smoking safety and elopement. Interviews with the DON and ADMN confirmed the care plan's deficiencies.
Failure to Obtain Informed Consent for Hormone Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a cognitively intact male resident was fully informed of, and consented to, a hormone medication (medroxyprogesterone acetate/Provera) prescribed for sexual behaviors before it was administered. The resident, with a diagnosis of bipolar disorder and a BIMS score of 15/15, had no sexual behaviors identified or addressed in his comprehensive care plan. Nonetheless, an NP entered an order for Provera 5 mg by mouth daily for sexual behaviors, and the MAR showed the resident received two doses on consecutive evenings. Review of the electronic medical record revealed no evidence of a signed consent for Provera using the required HHSC Form 3713 prior to administration. Progress notes showed that on the same date the Provera order was initiated, the psychiatric provider evaluated the resident for worsening depression and anxiety, discontinued escitalopram (Lexapro), and started paroxetine (Paxil). A subsequent nursing note documented that the resident was started on Provera and paroxetine, and that he was educated on his medications and given printed information at his request, but there was still no documented written consent for Provera. The psychiatric physician later confirmed he did not prescribe Provera, only discussed it briefly as a medication ordered by the NP, and stated that obtaining signed consents was the facility’s responsibility. Interviews with staff and the resident further demonstrated that the resident had not been informed in advance or given the opportunity to consent in writing to Provera before receiving it. The resident reported learning from an outside case manager that he had been prescribed a hormone without his knowledge and stated he had not signed a consent and did not want medication for his sex drive. The DON and ADON each stated that the prescriber or the nurse taking the order was responsible for obtaining signed consent, but the facility was unable to produce a signed consent form for Provera or a policy on obtaining written consent for medications. This sequence of events shows the resident received Provera without the required informed, written consent.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was observed through review of the resident's records and care plans, which did not contain all necessary elements to ensure comprehensive care as required.
Failure to Coordinate and Document Hospice Services
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. Specifically, there was no evidence in the resident's comprehensive care plan that hospice services were being provided, despite the resident being admitted to hospice care. The clinical records lacked required hospice documentation, including the certificate of terminal illness, hospice election form, and documentation of communication between the facility and the hospice provider. The resident in question had severe cognitive impairment and multiple diagnoses, including Alzheimer's disease, kidney disease, and a urinary tract infection. Interviews and record reviews revealed that communication between hospice staff and facility staff was conducted verbally, and required communication forms were not being completed as per facility policy. The Director of Nursing acknowledged that the necessary documentation was missing and that it was her responsibility to ensure these documents were present. Facility policy required collaboration with hospice representatives, documentation of communication, and maintenance of specific hospice-related forms, none of which were found in the resident's records.
Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during the provision of incontinent care for three staff members observed. Specifically, staff did not follow proper perineal care procedures for two male residents who were always incontinent. During observations, one CNA reused wipes by folding them instead of using a new wipe for each stroke, and did not retract and clean the foreskin of an uncircumcised resident. Another instance involved staff cleaning from back to front rather than the required front to back method. These actions were contrary to the facility's perineal care policy, which specifies the use of the one wipe, one swipe technique and proper cleaning of the foreskin for uncircumcised males. The residents involved had significant medical histories, including severe cognitive impairment, hypertension, lack of coordination, diabetes mellitus, generalized edema, and peripheral vascular disease. Despite recent in-service training and documented competencies indicating that staff had met pericare skills, the observed failures in technique placed residents at risk for infection. Interviews with the DON confirmed that the observed practices did not align with facility policy and could have led to infection, particularly due to improper cleaning of the foreskin and incorrect wiping technique.
Deficiency in Resident Rights Due to Unsanitary Conditions
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents, leading to a deficiency in resident rights. Resident #8's bathroom was found to be unsafe and unsanitary, with a sink that was unsteady and appeared to be pulling away from the wall, and a toilet that was unsteady at its base. The bathroom floor was covered in a yellow substance with dirt and fuzz, and a dead roach was observed under the sink. Resident #8 expressed concerns about the safety of the bathroom fixtures, fearing potential injury due to their instability. Both Resident #8 and Resident #10 reported issues with roaches in their rooms and bathrooms. Resident #10 described seeing large roaches in her room and bathroom, which caused her distress due to her upbringing associating roaches with uncleanliness. Resident #8 also reported seeing cockroaches in his bathroom, particularly at night, which added to his discomfort and dissatisfaction with the living conditions. The facility's pest control service log indicated that the facility had been serviced for roaches, spiders, and beetles, but the presence of roaches persisted, as reported by the residents. The administrator was unaware of the specific issues with Resident #8's bathroom fixtures and acknowledged the need for a more secure mounting solution for the sink. The facility's policy on resident rights emphasizes treating residents with kindness, respect, and dignity, which includes maintaining a clean and safe environment.
Unsafe Environment Due to Staff Pet in LTC Facility
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, as evidenced by the Director of Nursing (DON) bringing a dog to the facility, which resulted in incidents involving two residents. The dog bit one resident on the ankle and exhibited aggressive behavior towards another resident. These incidents were not reported immediately, and the facility lacked a clear policy regarding staff bringing pets to work, contributing to the deficiency. Resident #7, a female with a history of major depressive disorder, chronic obstructive pulmonary disease, and dysphagia, was bitten on the ankle by the DON's dog. The bite broke the skin, but the resident did not report the incident to avoid causing trouble. Resident #8, a male with a history of acute upper respiratory infection, spinal cord injury, and heart failure, experienced aggressive behavior from the dog while sitting on his scooter. He was not afraid of dogs but was concerned about the safety of other residents. Interviews with staff and residents revealed that the dog had been brought to the facility multiple times and had interacted with residents and staff, sometimes aggressively. The facility's existing dog policy did not adequately address situations involving staff pets, and there was no signed agreement from the DON regarding the facility's dog policy. The lack of a comprehensive policy and failure to report incidents contributed to the unsafe environment.
Failure to Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to protect two residents from verbal abuse by a Certified Nursing Assistant (CNA), identified as CNA D. The incident occurred on July 4, 2024, when CNA D was witnessed by a Registered Nurse (RN C) yelling, screaming, and slamming the door in the presence of the residents. Despite the allegations, the Director of Nursing (DON) did not report the incident to the Health and Human Services Commission (HHSC) Regulatory because the residents denied the abuse when interviewed by the DON. However, the residents later expressed nervousness and confirmed that CNA D yelled at them, indicating a failure in the facility's abuse prevention measures. The residents involved were both females with significant medical conditions. Resident #4, a female with ataxic cerebral palsy, anxiety disorder, and dysphagia, had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. Resident #5, also a female, had cerebral palsy and Parkinsonism, with a BIMS score reflecting moderate cognitive impairment as well. During interviews, both residents expressed fear and nervousness about being yelled at by CNA D, although they initially denied the allegations to the DON. The facility's response to the incident was inadequate, as the DON did not document interviews with the residents or witnesses, nor was an investigation conducted. The facility's policies on abuse prevention and reporting were not followed, as the incident was not reported to the state agency, and the accused CNA was not removed from duty pending an investigation. The lack of documentation and failure to conduct a thorough investigation highlight significant lapses in the facility's handling of abuse allegations.
Failure to Report and Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to report alleged abuse incidents involving two residents to the appropriate authorities within the required timeframe. Specifically, an incident of verbal abuse was witnessed by an RN, who reported that a CNA yelled at and slammed the door on two residents. Despite the RN's immediate report to the Director of Nursing (DON) and the Administrator, the incident was not reported to the Health and Human Services Commission State Survey Agency or other officials as required by state law. The residents involved were both females with significant medical conditions, including cerebral palsy and cognitive impairments, as indicated by their BIMS scores. The DON conducted interviews with the residents, who denied the allegations, and with the CNA, who also denied the incident. However, the DON did not document the incident, conduct a thorough investigation, or interview the RN who reported the abuse. The CNA continued to work on the floor without suspension, contrary to the facility's policy. The facility's policies on abuse prevention and reporting were not followed, as the incident was not thoroughly investigated or reported to state agencies. The facility's policy requires immediate reporting of suspected abuse to the Administrator or DON, and the suspension of the accused employee until the investigation is complete. These procedures were not adhered to, resulting in a deficiency in handling the abuse allegation.
Failure to Investigate Allegations of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse involving two residents, Resident #4 and Resident #5, by a Certified Nursing Assistant (CNA D) on July 4, 2024. The incident was witnessed by a Registered Nurse (RN C), who reported that CNA D entered the residents' room, yelled at them in a loud and irritated tone, and slammed the door. Despite RN C's immediate report to the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON), no comprehensive investigation was conducted, and CNA D continued to work on the floor. Resident #4, a female with moderate cognitive impairment and multiple diagnoses including ataxic cerebral palsy and anxiety disorder, and Resident #5, a female with cerebral palsy and Parkinsonism, were both interviewed by the DON following the incident. Both residents denied the allegations of verbal abuse. The DON reported the incident to the Administrator but did not document the incident or conduct further interviews with RN C or other potential witnesses, as required by the facility's abuse investigation policy. The facility's policies on preventing resident abuse and conducting abuse investigations were not followed. The policy mandates that all reports of abuse be promptly and thoroughly investigated, including interviewing the person reporting the incident, witnesses, and other staff members. Additionally, the accused employee should be suspended pending the investigation's outcome. However, these procedures were not adhered to, as evidenced by the lack of documentation and the failure to remove CNA D from duty during the investigation.
Failure in IV Antibiotic Administration and Central Line Care
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids and antibiotics for a resident, leading to a deficiency in care. The resident, a female with a history of methicillin-resistant Staphylococcus aureus infection and recent knee surgery, was receiving IV antibiotics through a central line. The facility did not adhere to professional standards and physician orders, as evidenced by the failure to mix the antibiotic medication properly before administration. The Licensed Vocational Nurse (LVN) responsible for administering the medication did not activate the vial containing the antibiotic powder, resulting in the resident not receiving the prescribed dose. Additionally, the facility did not change the resident's central line dressing as ordered by the physician. The dressing was observed to be loose and not sealed, which compromised the sterile environment necessary to prevent infection. The Director of Nursing (DON) acknowledged that the dressing should have been changed every seven days or as needed, but it had not been changed since a specific date. This oversight was attributed to a lack of communication and verification among the nursing staff, as one nurse assumed another had completed the task. Furthermore, the facility failed to draw the required laboratory tests weekly as ordered by the physician while the resident was on IV antibiotics. The lack of lab work monitoring could have impacted the resident's treatment and recovery. The DON admitted that the facility had not performed the necessary lab draws and was unaware of the oversight until contacted by the infectious disease physician's office. This deficiency in care placed the resident at risk of infection relapse and potential complications from untreated conditions.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for two residents who were reviewed for medication errors. Resident #7 did not receive her IV antibiotics as ordered by the physician on multiple occasions. The medication, meropenem, was not properly mixed before administration, resulting in the resident not receiving the antibiotic doses as prescribed. This failure was attributed to a misunderstanding by the nursing staff, who believed the medication was pre-mixed, and a lack of proper labeling and monitoring of the IV administration process. Additionally, the central line dressing for Resident #7 was not maintained properly, which could have increased the risk of infection. Resident #51 also experienced medication errors, with multiple instances of missed Insulin Glargine doses by various nursing staff members over a two-month period. These omissions were not in accordance with the physician's orders and placed the resident at risk of diabetic complications. The report highlights the lack of adherence to medication administration protocols and the failure to ensure that treatments were performed and documented accurately. The deficiencies in medication administration and documentation were observed through interviews and record reviews, revealing a pattern of non-compliance with established protocols. The facility's staff, including the DON and various LVNs, acknowledged the errors and provided explanations for the lapses, such as being busy or assuming tasks were completed by others. However, these explanations did not mitigate the fact that the residents were placed at risk due to the facility's failure to administer medications as ordered and maintain proper documentation and monitoring practices.
Deficiencies in Care Planning and Medication Administration
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, which led to deficiencies in meeting their medical, nursing, and psychosocial needs. For Resident #2, the facility did not incorporate PASRR services into the care plan, despite the resident being PASRR positive. Resident #28's care plan lacked specific goals related to activities of daily living (ADL) functions, which are crucial for ensuring appropriate care and support. These omissions indicate a lack of thoroughness in the care planning process, potentially affecting the quality of care provided to these residents. Resident #51 experienced multiple instances where insulin glargine was not administered as per physician orders. Several licensed vocational nurses (LVNs) and a registered nurse (RN) failed to administer the insulin on numerous occasions over a two-month period. The nurses did not contact the physician to discuss holding or adjusting the insulin dosage, which is a critical step in ensuring proper diabetes management. This lack of communication and adherence to physician orders could have significant implications for the resident's health, particularly in managing blood glucose levels. Additionally, the facility failed to ensure that central line dressings for Resident #7 were changed as documented. LVNs B and C signed off on dressing changes that were not performed, citing distractions and assumptions that another nurse had completed the task. This oversight in documentation and execution of care tasks highlights a breakdown in the facility's processes for ensuring accurate and timely care. The failure to perform these essential tasks could lead to increased risk of infection and other complications for the resident.
Failure to Change and Date Oxygen Tubing Weekly
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in changing and dating the oxygen tubing weekly as required. Resident #70, a female with chronic respiratory failure and other health issues, was observed to have nebulizer tubing dated 05/06/2024, indicating it had not been changed in accordance with the order to replace it every Sunday. This oversight was confirmed during an observation with the Director of Nursing (DON), who acknowledged that the tubing should have been changed and that the staff should not have dated the tubing per policy. The DON admitted to not knowing who was responsible for monitoring the tubing changes and mentioned that the interdisciplinary team should have been making rounds to ensure compliance. The lack of a clear policy on dating the tubing and the failure to follow the electronic medication administration record (EMAR) contributed to the deficiency. The facility did not provide evidence of a policy requiring the dating of respiratory tubing when changed, which could potentially place residents at risk of respiratory infections.
Failure to Conduct Timely Physician Visits
Penalty
Summary
The facility failed to ensure that physician visits were conducted as required for several residents. Specifically, two residents were not seen by a physician every 30 days during the first 90 days after admission, and four residents were not seen every 60 days thereafter. This lack of compliance with physician visit schedules was identified through interviews and record reviews, which revealed missing documentation for specific months when the visits should have occurred. Resident #2, a male with multiple diagnoses including hypertension, type 2 diabetes, and paranoid schizophrenia, was not seen by a physician in April 2024, despite the requirement for monthly visits during the initial 90 days post-admission. Similarly, Resident #73, diagnosed with Alzheimer's disease and acute kidney failure, missed physician visits in March, April, and May 2024. Other residents, such as Resident #25, #46, #51, and #56, also had gaps in their required 60-day physician visits, with missing documentation for various months in 2023 and 2024. Interviews with the Director of Nursing (DON) and the Administrator (ADMN) revealed that the facility was aware of the issue with timely physician visits. The DON acknowledged the responsibility for monitoring these visits and noted that the failure was due to physicians not visiting residents as required. The ADMN also recognized the problem and stated that the DON was working on improving the tracking system for physician visits. The facility's policy mandates physician visits every 30 days for the first 90 days and every 60 days thereafter, which was not adhered to in these cases.
Staffing Deficiency in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by a review of timesheets and interviews with residents and staff. On three specific days, the facility did not meet the required direct care staff hours as per their PPD budget, with significant shortfalls noted. Interviews with residents revealed concerns about long wait times for care, such as waiting an hour to be changed, insufficient showers, and fears of inadequate response in case of falls. Staff interviews indicated a reluctance to discuss staffing issues due to fear of retaliation, and some staff expressed relief at the presence of state surveyors, hoping it would lead to better staffing. The Director of Nursing (DON) and Administrator (ADMN) acknowledged the staffing issues, attributing them to unexpected staff resignations, call-ins, and no-shows. The DON outlined expectations for staffing levels, which were not met, leading to potential risks such as increased falls and delayed care. The facility's policy stated that adequate staffing should be maintained to meet residents' needs, but this was not achieved, as confirmed by the facility's own records and staff admissions.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications in locked compartments and maintain them in their original containers, as observed during a survey. Specifically, three medication carts were found with unlabeled pill cups containing various medications, including narcotics, outside of their original blister pack containers. These medications were not stored behind two locks as required, posing a risk of drug diversion. RN K was observed with seven unlabeled pill cups on top of medication cart #1, and three unlabeled pill cups containing narcotics inside an unlocked drawer. Similarly, RN J's medication cart #2 had unnamed pill cups with crushed medications, and cart #3 had an unlabeled pill cup with medication outside its original container. Interviews with staff revealed that RN J was pre-filling pill cups due to being busy and covering multiple halls, which could lead to administering the wrong medication to residents. The Director of Nursing (DON) acknowledged that pre-popping medications was against facility policy and could have detrimental effects on residents. The DON and Administrator emphasized the importance of following policies and proper medication disposal if refused by residents. The facility's policy from 2007 mandates that drugs and biologicals be stored in their original packaging and in a secure manner, which was not adhered to in this instance.
Failure to Ensure Resident Privacy During Wound Care
Penalty
Summary
The facility failed to uphold the dignity and privacy of a resident during wound care, as observed by surveyors. The incident involved a resident with a stage 4 pressure wound who was receiving treatment without the privacy curtain being pulled, despite the door being closed. This oversight was acknowledged by the LVN performing the care, who admitted that the curtain should have been closed to prevent exposure if someone entered the room. The resident expressed a preference for the curtain to be pulled to avoid embarrassment. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the privacy curtain should have been used to ensure the resident's dignity and privacy. Both the DON and ADON emphasized the importance of privacy during care and acknowledged that the failure to pull the curtain could lead to embarrassment for the resident. The facility's policy on dignity and respect, which mandates the protection of resident privacy during personal care, was not adhered to in this instance.
Privacy Breach During Resident Care
Penalty
Summary
The facility failed to protect the privacy and dignity of a resident during personal care activities. Specifically, staff did not pull the privacy curtain while performing peri-care and transferring the resident from bed to chair using a Hoyer Lift. This oversight was observed during a specific incident where another CNA entered the room without the curtain being drawn, compromising the resident's privacy. The resident involved was a cognitively intact male with a history of hypertension, lack of coordination, and incontinence. The facility's policy mandates that residents be treated with dignity and respect, including maintaining bodily privacy during personal care. Interviews with the ADON and DON confirmed that the failure to pull the privacy curtain was a breach of expected standards, potentially leading to embarrassment for the resident.
Failure to Lock Hoyer Lift During Resident Transfer
Penalty
Summary
The facility failed to ensure the resident environment was free from accident hazards and that adequate supervision and assistance devices were provided to prevent accidents. Specifically, during a transfer of a resident using a Hoyer lift, the CNA and NA did not lock the lift's legs in the maximum opened/locked position as required. This oversight occurred while transferring a cognitively intact male resident with a BIMS score of 15, who was dependent on staff for all efforts in activities such as chair/bed-to-chair transfers. The resident's diagnoses included hypertension, lack of coordination, and incontinence. During an observation, it was noted that the CNA did not lock the Hoyer lift during the transfer, and in an interview, the CNA admitted to not having locked the lift previously. The ADON confirmed that all nursing staff were trained on the use of the Hoyer lift and that the brakes should have been applied to prevent potential falls. The ADON also mentioned that the failure occurred because the CNA did not take the time to calm herself while being observed. The facility's records showed that the CNA had received training on the equipment, including the requirement to lock the wheels, but this was not adhered to during the incident.
Inadequate Infection Control During Peri-Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper peri-care and hand hygiene practices observed among two staff members, CNA L and an NA, during the care of Resident #28. The resident, a cognitively intact male with diagnoses including hypertension, lack of coordination, and diarrhea, was always incontinent. During an observation, the staff members did not perform hand hygiene or change gloves between dirty and clean tasks while providing peri-care, which is a violation of the facility's infection control protocols. Interviews with the staff revealed that CNA L was aware of the lapse in protocol but cited nervousness and lack of supplies as reasons for the oversight. The DON and ADON acknowledged the failure in ensuring staff adherence to infection control protocols, attributing it to inadequate in-service training and monitoring. The facility's policy on standard precautions mandates frequent hand washing and glove changes to prevent contamination, which was not followed in this instance, placing residents at risk of infection.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications in locked compartments and to keep each resident's drugs in their original containers/packaging. During an observation, the Hall 3 medication cart was found to have seven loose pills in the second drawer, identified as Lisinopril, Midodrine, Furosemide, Keppra, Zoloft, and Buspirone. LVN B acknowledged the presence of loose pills and stated that staff sometimes get in a hurry, accidentally drop pills, and forget to dispose of them. LVN B also mentioned that all staff were responsible for ensuring their medication carts were clean, organized, and free from any loose pills. Similarly, the Hall 5 medication cart was observed to have three loose pills, identified as Atorvastatin, a Multi-vitamin, and Protonic. The ADON confirmed that there should not be loose pills in the medication carts and stated that every night shift was responsible for cleaning the medication carts, with every shift nurse also expected to clean the carts themselves. The ADON and DON both stated that they randomly checked medication carts at least once per week. The DON emphasized that the night shift was to check medication carts once per week and that staff should be aware and check each shift. The facility's policy on medication storage, dated April 2007, requires that all drugs and biologicals be stored in a safe, secure, and orderly manner in their original packaging or containers.
Failure to Respect Resident's Right to Smoke
Penalty
Summary
The facility failed to treat a resident with respect, dignity, and care in a manner that promotes the maintenance or enhancement of his quality of life. Specifically, the facility did not allow Resident #1 to smoke as per his request and smoking assessment. Resident #1, a male with severe cognitive impairment and a history of elopement attempts, had his smoking privileges revoked indefinitely after an elopement incident. The decision to revoke smoking privileges was made without attempting other measures to ensure his safety while allowing him to smoke, such as one-on-one supervision or allowing him to smoke in a secure courtyard. Interviews with staff and the resident's family member revealed that the facility's decision to revoke smoking privileges was intended for the resident's safety but was perceived as punitive. The family member expressed that smoking was the only activity the resident still enjoyed and that he could smoke safely. The Director of Nursing acknowledged that the care plan appeared punitive and admitted that no other measures were attempted to balance the resident's safety and his right to smoke. The facility's policy on resident rights emphasizes treating residents with respect, kindness, and dignity, which was not upheld in this case.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident that included measurable objectives and person-centered interventions specific to smoking safety and elopement. The resident, a male with severe cognitive impairment and multiple diagnoses including nicotine dependence and major depressive disorder, had a history of elopement attempts. Despite these incidents, the care plan did not include individualized and measurable goals to address these behaviors effectively. The resident's care plan was found to be lacking in person-centered approaches and measurable objectives. For instance, after an elopement incident, the care plan included general actions such as moving the resident to a different room and conducting window audits, but it did not provide specific, individualized interventions. Additionally, the care plan failed to address the resident's smoking needs adequately, as it only mentioned the revocation of smoking privileges without considering alternative solutions like nicotine patches. Interviews with the Director of Nursing (DON) and the Administrator (ADMN) revealed that the care plans were not person-centered and lacked measurable objectives. The DON acknowledged that the care plan should have included different approaches and not just the suspension of smoking privileges. The ADMN also stated that the care plans should have been person-centered and that the failure to do so could result in residents not having all their needs met. The oversight in creating a comprehensive, individualized care plan led to the deficiency in providing appropriate supervision and care for the resident.
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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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