Avir At Texarkana
Inspection history, citations, penalties and survey trends for this long-term care facility in Texarkana, Texas.
- Location
- 4925 Elizabeth St, Texarkana, Texas 75503
- CMS Provider Number
- 676069
- Inspections on file
- 33
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 7 (3 serious)
Citation history
Health deficiencies cited at Avir At Texarkana during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of combative behavior during care was being assisted by two CNAs with incontinence care when the resident became resistive and kicked one CNA in the leg. Instead of following the care plan directive to stop care and return later when the resident was physically abusive, the CNA immediately retaliated by open-handedly slapping the resident hard in the face, causing visible redness and leaving the resident appearing stunned and fearful. The second CNA, who witnessed the slap, briefly left the room to report the incident to the nurse, leaving the resident alone with the CNA who had just abused him, thereby failing to ensure the resident’s immediate protection from further abuse.
A resident with chronic back and neck pain, cognitively intact and on scheduled Hydrocodone-Acetaminophen TID, went without multiple ordered doses when the medication was repeatedly documented as unavailable or "on order" on the MAR. Staff, including CMAs and an LVN, were aware the drug was not in the building and that the resident was distraught and reporting uncontrolled, excruciating pain, but there was no timely or documented notification to the MD or NP, no effective follow-up with the pharmacy, and no alternative pain management offered. Pharmacy records showed minimal documented requests from the facility, while the ADON and charge nurse acknowledged knowing about missed doses yet not documenting calls or reassessments. As a result, the resident experienced days without his prescribed pain medication and significant uncontrolled pain, constituting a failure to manage pain according to professional standards.
Two residents did not receive critical ordered medications when the facility failed to ensure timely acquisition, follow‑up, and administration of an anticonvulsant and a scheduled opioid analgesic. One resident with epilepsy missed multiple doses of Topamax 25 mg PO TID over several days when the drug was not available in the building, staff did not secure it from the pharmacy, pyxis, or a local source, and the MD/NP were not consistently or clearly notified despite MAR entries showing non‑administration. Another resident with chronic pain missed numerous doses of hydrocodone‑acetaminophen 10‑325 mg PO TID, with MAR notes repeatedly indicating the medication was “on order” or “waiting on arrival,” but there was no documented contact with the MD, NP, or pharmacy to resolve the lack of supply, and the resident reported severe uncontrolled pain during this period. Staff interviews revealed confusion over who was responsible for contacting the pharmacy, lack of documentation of calls and notifications, and absence of a reliable system for ordering and receiving medications after a corporate pharmacy change, leading to prolonged medication unavailability for both residents.
A resident with advanced Alzheimer's and multiple comorbidities experienced repeated falls, bruising, and behavioral changes while on hospice care. Facility staff failed to notify the resident's representative and hospice agency of these incidents and related medication changes, despite facility policy requiring such notifications. Documentation and interviews confirmed that notifications were often delayed or omitted, and staff reported confusion about when to document and communicate these events.
A nurse failed to document a fall incident involving a resident with multiple health conditions, did not notify the resident's family or physician, and did not complete an incident report as required by facility policy. The nurse stated she was told by the DON not to document the event, leading to incomplete medical records and lack of proper notification.
Staff members with facial hair were observed serving and preparing food without required hairnets or facial coverings, despite facility policy and staff acknowledgment of the need for these precautions to prevent food contamination. The deficiency was noted during kitchen observations and confirmed through staff interviews.
A deficiency occurred when only one CNA was present in a memory care unit, leaving residents unsupervised while the CNA assisted another individual. During this period, two residents with cognitive and behavioral impairments engaged in an altercation in the dining area. Staff interviews confirmed that the unit typically required two staff members due to the residents' needs, but this standard was not met at the time of the incident.
Two residents with severe cognitive impairment and behavioral issues were involved in a physical altercation, where one pulled the other's ear and was bitten in response. Staff were aware of ongoing behavioral conflicts between the two, and although interventions were in place, the incident still occurred, resulting in a minor injury.
A memory care unit was left unsupervised for at least six minutes when a CNA took a bathroom break, leaving residents with cognitive impairments and a history of falls at risk. A resident was found with blood around her mouth, another engaged in unsafe behavior, and a third was at risk of falling. Staff interviews revealed that it was common for the unit to be left unattended during breaks, despite the facility's policy emphasizing the need for supervision.
The facility failed to maintain food safety and sanitation standards in the kitchen, with issues such as carbon build-up on cooking equipment, improper facial hair coverage by staff, and inadequate food labeling and storage practices. These deficiencies could lead to food contamination and potential health risks for residents.
A malfunctioning call light system in the 200 Hall Memory Care Unit resulted in a loud, continuous alarm that persisted over several days, causing discomfort for residents and staff. Despite awareness of the issue, the facility was unable to silence the alarm due to wiring problems, and repair efforts were delayed. Interviews with staff revealed that the problem had been ongoing, and the maintenance request log did not document any repair requests.
The facility failed to ensure safe mechanical lift transfers for two residents, with staff not following proper procedures for spreading lift legs, posing a risk of accidents. Additionally, a resident's smoking materials were not secured as per facility policy, creating potential hazards.
A resident was unable to call for staff assistance due to a malfunctioning call light system, which was not promptly repaired. The resident had to wait for staff to enter her room, leading to unmet needs. The facility's policy on maintaining a functioning call light system was not adequately followed.
A resident with multiple health issues was found with a call light device on the floor, out of reach, while in bed. The resident was unaware the device was functional, as it had not been communicated to him. The facility failed to ensure the call light was accessible, posing a risk to the resident's ability to request assistance.
A resident's wheelchair had a malfunctioning right brake, which was not properly addressed by the facility. Despite being informed of the issue, the facility continued to use the wheelchair, posing a risk of falls. The resident had a history of falls and mobility issues, and the facility's policy on equipment maintenance was not followed.
A facility failed to protect a resident from verbal abuse when a CNA raised her voice and used inappropriate language. The incident was witnessed by another staff member, who reported it through a note. The resident, with a history of cognitive impairment, denied the abuse, but the DON noted the resident might not accurately report the incident.
A resident with cognitive impairment was verbally abused by a CNA, and the incident was not reported to the Administrator within the required 2-hour timeframe. The Activity Director and Business Office Manager failed to follow the facility's policy, leaving the resident at risk. The Administrator only became aware of the incident the following day through an anonymous note.
Resident Physically Abused by CNA and Left Unprotected After Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to ensure immediate protection from further abuse once an incident occurred. An elderly male resident with heart failure, unspecified dementia with agitation and other behaviors, and Alzheimer’s disease was admitted to the facility and had a BIMS score of 0, indicating severe cognitive impairment. His care plan documented impaired cognitive function and a history of becoming combative with staff at times, with interventions directing staff not to attempt care when he was physically abusive and to allow time and revisit the task later. Despite these documented needs and interventions, the resident was subjected to physical abuse by a CNA during routine care. On the day of the incident, two CNAs entered the resident’s room to perform routine rounds and provide incontinence care while he was in bed. According to statements and interviews, the resident was awakened, his clothing and brief were removed, and as care proceeded he became resistive and combative. The resident swung and kicked, striking one CNA on the leg. In response, that CNA immediately and open-handedly slapped the resident in the face/forehead. The slap was described by the witnessing CNA as very hard, leaving the left side of the resident’s face a little red and causing the resident to appear stunned, frozen, and nervous, as if afraid to move. The CNA who slapped the resident admitted in her written and verbal statements that she hit him back after he kicked her leg, characterizing it as a reaction. The facility also failed to ensure the resident was protected from further abuse at the time of the incident. After witnessing the slap, the second CNA briefly left the room to notify the nurse, leaving the resident alone with the CNA who had just physically abused him. During this interval, the abusive CNA remained in the room with the resident, and there is no indication that the resident was immediately removed from the abuser or that the abuser was immediately removed from the resident’s presence before the witness left to report the event. This sequence of actions and inactions—failure to follow the resident’s care plan for managing combative behavior, the CNA’s retaliatory slap, and the witness CNA’s decision to leave the resident alone with the abuser—constituted the failure to ensure the resident was free from abuse and protected from further abuse.
Failure to Provide Ordered Pain Medication and Notify Provider of Uncontrolled Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate, and consistent pain management to a cognitively intact male resident with chronic pain who was admitted with diagnoses including age-related physical disability, hypertension, schizophrenia, and major depressive disorder. His MDS showed he was able to make himself understood, understood others, and was on scheduled pain medication. He had a physician’s order for Hydrocodone-Acetaminophen 10-325 mg by mouth three times daily, and his care plan directed staff to give pain medication and evaluate his pain so that he would remain free from pain. Despite these orders, the Medication Administration Record (MAR) for two consecutive months showed multiple scheduled doses at 7:00 AM, 12:00 PM, and 5:00 PM documented as not administered, with reasons such as “other/see progress note,” and repeated administration notes stating the hydrocodone was “waiting on arrival,” “on order,” or “N/A.” During the period when the medication was unavailable, there was no documentation in the resident’s progress notes that the physician, nurse practitioner, or pharmacy had been notified that the resident was out of his ordered hydrocodone. A Triplicate Request form for the hydrocodone contained an undated, unsigned handwritten note indicating a new triplicate was required because the facility had changed pharmacies, but there was no corresponding documentation of timely follow-up or communication with the prescriber. The resident reported that he had gone without his pain medication for about five days, that he was told his pain medication was not in the building, and that he was not informed why he could not have it. He described excruciating back and neck pain, inability to sleep or rest, numbness in his hands and fingers, and rated his pain as greater than 10 on a 1–10 scale. He stated he was not offered any other pain medication and that non-pharmacologic measures such as repositioning and pillow adjustment were offered but refused because he wanted his prescribed pain medication. Multiple staff interviews revealed awareness that the resident’s hydrocodone was not available and that doses were being missed, but there was a lack of effective action and documentation to resolve the issue. An anonymous staff member and a medication aide stated they had informed charge nurses and the ADON that the resident’s pain medication was unavailable and that the resident was frustrated and distraught due to uncontrolled pain, yet the nurse practitioner reported she was never notified of the missed doses or change in the resident’s condition until weeks later. The ADON acknowledged knowing the resident had missed doses, stated she had called and faxed the pharmacy and contacted the nurse practitioner about triplicates, but admitted she had not documented any of these efforts or any notification to the physician or nurse practitioner about the missed medications. The charge nurse (LVN) on duty during part of the period admitted she knew the resident did not have his ordered hydrocodone, did not reassess his pain, did not offer alternative pain-relieving medications, and could not recall notifying the nurse practitioner. Pharmacy records showed only one facility request for hydrocodone and a subsequent supply, with no further logged activity until much later, indicating a lack of documented follow-up from the facility. These combined inactions and communication failures led to the resident going without his ordered scheduled pain medication and experiencing uncontrolled, excruciating pain with behavioral changes, while the facility failed to manage his pain consistent with professional standards of practice.
Failure to Obtain and Administer Ordered Anticonvulsant and Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for residents, specifically seizure and pain medications. One cognitively intact male resident with epilepsy had an active order for Topamax 25 mg PO three times daily for seizure prevention. His February MAR showed multiple doses not administered beginning on 02/10/2026, with entries marked as “other/see progress note,” and documentation that the medication was not available. The resident’s care plan required seizure medications to be given as ordered and for staff to monitor effectiveness and side effects, but the ordered Topamax was not on hand from 02/10/2026–02/15/2026, and the facility did not obtain the drug from the pharmacy, pyxis, or a local pharmacy during that period. Staff interviews revealed inconsistent and incomplete follow‑up on the missing Topamax. Medication aides reported notifying charge nurses and the ADON that the resident was out of Topamax and that the medication had not arrived after being ordered, but some nurses did not follow through with the pharmacy. The ADON stated she had called and faxed the pharmacy multiple times and believed the Nurse Practitioner had been informed that the resident had missed multiple doses, but she acknowledged she did not document any of these contacts or the missed doses. The Nurse Practitioner, however, stated she had no knowledge that the resident was without Topamax prior to 02/15/2026 and only learned on that date that the resident had missed five days of doses. The physician also reported he was not notified that the resident had missed Topamax doses, had seizure‑like episodes, or had been transported to the hospital, and pharmacy records showed no refill activity between 01/26/2026 and 02/15/2026 despite the facility’s claims of repeated contacts. A second cognitively intact male resident with chronic pain and an order for scheduled hydrocodone‑acetaminophen 10‑325 mg PO three times daily also experienced prolonged unavailability of his medication. His MAR and administration notes from late January through early February documented repeated missed doses with notations such as “waiting on arrival,” “on order,” and “N/A,” indicating the drug was not in the building. Progress notes for this period did not show that the physician, NP, or pharmacy were notified that the resident was out of hydrocodone. A triplicate request form for the hydrocodone dated 01/05/2026 contained an undated, unsigned handwritten note stating a new triplicate was required because the pharmacy had changed, but there was no evidence of follow‑up to secure the medication. The resident reported he went without his pain medication for about five days, experienced excruciating back and neck pain with numbness in his hands and fingers, could not sleep, and became agitated and irritable, while staff only offered non‑pharmacologic measures such as repositioning and pillow adjustment. Across both cases, staff accounts showed confusion and disagreement about responsibilities for ordering, tracking, and following up on medications. Medication aides stated they were not allowed to call the pharmacy and relied on nurses, while at least one LVN stated MAs had the same access she did and should handle their own follow‑up. The ADON reported there was no clear system in place for ordering and receiving medications after a corporate pharmacy change, and that staff often did not know which pharmacy number to call. The Corporate Regional Nurse acknowledged that the facility had experienced problems after the corporate pharmacy change and that an acute review later identified missed medications due to unavailability, but maintained that the facility had notified the NP and followed up with the pharmacy. The survey identified that the facility failed to ensure timely acquisition and administration of ordered medications, failed to consistently notify the physician/NP when medications were unavailable, and failed to document and escalate these issues, resulting in missed anticonvulsant and pain medications for two residents.
Failure to Notify Resident's Representative and Hospice of Significant Changes
Penalty
Summary
The facility failed to notify a resident's representative (RP) and hospice agency of multiple significant changes in the resident's condition, including falls, bruising, behavioral changes, and medication changes. Documentation revealed that the resident, who had a history of cerebral infarction, hemiplegia, Alzheimer's disease, repeated falls, and was receiving hospice services, experienced several incidents such as sliding or rolling out of bed, developing new bruises, and exhibiting increased agitation and behavioral changes. Despite these events, there was no documentation that the RP or hospice agency were notified in a timely manner, as required by facility policy and professional standards. Nursing notes and interviews indicated that staff, including RNs and LVNs, often failed to document or communicate these incidents to the appropriate parties. In several instances, falls and new bruising were observed and assessed by nursing staff, but notifications to the RP and hospice agency were either delayed or not made at all. Medication changes ordered by the hospice physician in response to the resident's behavioral changes were also not communicated to the RP. Staff interviews revealed confusion regarding documentation and notification procedures, with some staff reporting that they were told by previous management not to document certain incidents if the resident was care planned for such events. The lack of notification was confirmed through interviews with the resident's RP and hospice representatives, who stated they were not informed of several falls, behavioral changes, or medication adjustments. The facility's own policies required prompt notification of the resident's physician, RP, and hospice agency in the event of accidents, incidents, injuries, or significant changes in condition. The failure to follow these policies resulted in the RP and hospice agency being unaware of important changes in the resident's status, as evidenced by the RP only learning of some incidents through hospice or after reviewing the resident's chart.
Failure to Document and Report Resident Fall
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented in accordance with accepted professional standards. Specifically, a nurse (LVN) did not document an incident in which a resident was found on the floor by a hospice aide during the early morning hours. The nurse did not record the fall in the resident's medical record, did not notify the resident's responsible party, and did not complete an incident report as required by facility policy. The nurse stated that she was instructed by the Director of Nursing (DON) not to complete an incident report or document the event, despite being aware of the facility's procedures for reporting and documenting falls. The resident involved had a complex medical history, including diagnoses of cerebral infarction, hemiplegia, hemiparesis, mood and anxiety disorders, Alzheimer's disease, weakness, lack of coordination, repeated falls, and abnormal albumin levels. The resident was receiving hospice services, was at risk for falls, and required substantial assistance with activities of daily living. On the morning of the incident, the hospice aide found the resident on the floor, attempted to seek help, and eventually located the nurse to assist in moving the resident. The nurse assessed the resident and found no injuries but did not document the incident or notify the family as required. Interviews with facility staff and review of facility policy confirmed that the nurse was expected to document the fall, notify the physician and family, and complete an incident report within 24 hours. The nurse admitted to not fulfilling these responsibilities, citing instructions from the DON. The administrator acknowledged confusion among staff regarding reporting and documentation expectations, particularly due to conflicting instructions from the previous DON. The facility's policy clearly outlined the steps to be taken following a fall, including documentation and notification requirements, which were not followed in this case.
Failure to Enforce Hair Restraint and Facial Covering Use in Food Service Areas
Penalty
Summary
The facility failed to ensure that food service staff adhered to professional standards for food safety by not requiring the use of appropriate hair restraints and facial coverings in the kitchen. Observations revealed that Dishwasher A, who had facial hair above his upper lip and on his chin, was not wearing a facial covering while serving food and washing dishes. Additionally, Dishwasher A was not wearing a hairnet or facial covering while in the dishwashing area, despite having been educated on the requirement to wear these items when serving food. Another staff member, [NAME] B, was observed preparing food without a facial covering to cover his facial hair. Both staff members acknowledged the importance of wearing hairnets and facial coverings to prevent hair from contaminating residents' food, but failed to comply with these requirements during the observed periods. Interviews with various staff, including the Assistant Dietary Manager and Interim Administrator, confirmed that all individuals entering the kitchen, including the dishwashing area, were expected to wear hairnets and facial coverings if they had facial hair. The facility's policy, revised in November 2022, also required food and nutrition services staff to wear hair restraints to prevent hair from contacting food. The lack of a current Dietary Manager and recent staffing changes were noted, but staff were aware of the facility's expectations regarding food safety practices. No specific residents were identified as being directly affected in the report.
Failure to Provide Adequate Supervision in Memory Care Unit Resulting in Resident Altercation
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for residents in one of its memory care units. On the date of the incident, only one CNA was present in the memory care unit while the other staff member was absent. During this time, the CNA was occupied in another resident's room assisting with morning care, leaving the remaining residents in the dining area unsupervised. As a result, two residents engaged in an altercation, during which they were observed swatting and slapping at each other's hands. The CNA intervened upon noticing the incident and separated the residents, after which a nurse assessed both individuals and found no injuries. One of the residents involved had a history of Alzheimer's disease, dementia, schizoaffective disorder, muscle weakness, impaired vision, and repeated falls. This resident was severely cognitively impaired, used a wheelchair for mobility, and was dependent on staff for most activities of daily living. The other resident had a history of cerebral infarction, schizophrenia, gait abnormalities, and lack of coordination, with moderate cognitive impairment and a documented history of physical behavioral symptoms directed toward others. Both residents were considered elopement risks and resided on the secured memory care unit due to their behavioral and safety needs. Interviews with staff, including the CNA, RN, DON, and interim administrator, confirmed that there was only one staff member present in the memory care unit at the time of the incident. Staff acknowledged that the unit typically required two staff members due to the residents' behavioral challenges and supervision needs. The facility's policy for the secured unit emphasized the importance of providing a safe and structured environment for residents at risk of elopement or harm due to cognitive impairment. However, on the day of the incident, the lack of adequate staffing and supervision directly led to the altercation between the two residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that two residents were free from physical abuse when an altercation occurred between them. On the specified date, one resident, who had a history of severe cognitive impairment, mental health conditions, and episodes of aggression, entered the main dining area and pulled another resident's ear. The second resident, also with severe cognitive impairment and a diagnosis of Alzheimer's disease, responded by biting the first resident on the right wrist. Both residents had documented histories of behavioral issues, including aggression and non-cooperation with care, as noted in their care plans and assessments. Staff interviews revealed that the two residents were known to have frequent verbal and physical altercations, with some staff reporting that such behaviors occurred almost daily. However, other staff and the DON stated that it had not been reported that these altercations happened daily. On the day of the incident, staff immediately separated the residents and assessed them for injuries. The first resident sustained a small bruise to her right wrist, while the second resident had no injuries. The incident was documented, and the appropriate parties were notified as per facility policy. The facility's policies required staff to protect residents from abuse, including abuse from other residents, and to investigate and report all altercations. The care plans for both residents included interventions such as medication administration, behavioral monitoring, psychiatric consults, and separation of residents when necessary. Despite these measures, the altercation occurred, indicating a failure to prevent resident-to-resident abuse as required by facility policy and regulatory standards.
Inadequate Supervision in Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents in one of its memory care units. On a specific occasion, a Certified Nursing Assistant (CNA) left the memory care unit unattended for at least six minutes to take a bathroom break, as observed by a state surveyor. During this time, several residents with cognitive impairments and a history of falls were left without supervision, increasing their risk of injury. Resident #1, who has a history of cerebrovascular disease, Parkinson's disease, and cognitive impairments, was found with blood around her mouth, which was not present before the CNA left the unit. Resident #2, diagnosed with severe cognitive impairment and bipolar disorder, was observed engaging in potentially unsafe behavior by putting water onto a cloth item. Resident #3, with a history of falls and moderate cognitive impairment, was seen self-propelling in a wheelchair, holding her leg up, indicating a potential fall risk. Interviews with staff revealed that it was common for the memory care unit to be left unsupervised during staff breaks, as there was only one aide assigned per unit during certain shifts. Staff members, including CNAs and Licensed Vocational Nurses (LVNs), acknowledged the risks associated with leaving residents unsupervised, particularly given the residents' high fall risk and potential for aggressive behavior. The facility's policy emphasized the importance of supervision to prevent accidents, but the practice of leaving the unit unattended contradicted this policy.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed in the kitchen. There was a significant carbon build-up on two baking sheets and one skillet, indicating inadequate cleaning practices. Additionally, male kitchen staff, including the Dietary Manager, were observed not wearing proper facial hair covers, which could lead to contamination. The Dietary Manager admitted to not cleaning the pans sufficiently and acknowledged the potential risk of contamination from uncovered facial hair. Further observations revealed improper storage practices, such as a scoop being left inside a sugar bin, which could lead to contamination. The facility also failed to date and label food items in Freezer #1, Freezer #2, and Refrigerator #1. This included various unlabeled and undated food packages, which could result in the use of expired or incorrect food items. The Dietary Manager confirmed that it was everyone's responsibility to date and label foods, but ultimately his responsibility to ensure compliance. Interviews with the Dietary Manager and the Administrator highlighted a lack of adherence to facility policies and procedures regarding food safety and sanitation. The Administrator expressed expectations for clean cooking equipment and proper storage of scoops to prevent foodborne illnesses. The facility's policies, aligned with state and federal food codes, emphasize the importance of maintaining clean kitchen facilities and proper food labeling to minimize the risk of infection and foodborne illness.
Malfunctioning Call Light System Causes Discomfort in Memory Care Unit
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in the 200 Hall Memory Care Unit due to a malfunctioning call light system. A loud, continuous alarm from the call light system was observed on multiple occasions over several days, causing discomfort and difficulty in communication during medication administration. The alarm was first noted on 05/13/24 and continued to sound through 05/14/24, affecting the environment for residents and staff. Interviews with staff, including RN D, the ADON, the Maintenance Supervisor, the DON, and the Administrator, revealed that the issue with the call light system had been ongoing since at least 05/10/24. Despite awareness of the problem, the facility was unable to silence the alarm due to wiring issues, and attempts to have the system repaired were delayed as the repair company did not arrive as scheduled. The Maintenance Supervisor indicated that disabling the alarm would require removing a fuse, which would deactivate the entire system. The facility's maintenance request log did not document any request for repair of the call light alarm.
Deficiencies in Mechanical Lift Transfers and Smoking Material Security
Penalty
Summary
The facility failed to ensure safe mechanical lift transfers for two residents, leading to potential accident hazards. For Resident #15, CNA A and the DON conducted a mechanical lift transfer with the lift legs in the narrow position, which was not in accordance with the facility's training standards. Although Resident #15 reported feeling safe during transfers, the improper use of the lift could have led to instability and potential injury. Similarly, for Resident #19, CNA B and CNA C performed a mechanical lift transfer with the lift legs in the narrow position until the resident was almost over the wheelchair. Both CNAs acknowledged the importance of spreading the lift legs to ensure stability and prevent tipping, yet the procedure was not followed correctly. Despite the residents not having been injured during these transfers, the improper technique posed a risk of accidents. Additionally, the facility failed to secure Resident #201's smoking materials, which were found in her room contrary to the facility's smoking policy. The policy required that all smoking materials be stored at the nurse's station to prevent unsupervised use and potential hazards. The presence of cigarettes and a lighter in Resident #201's room indicated a lapse in adherence to this policy, posing a risk of fire or injury.
Failure to Maintain Functioning Call Light System
Penalty
Summary
The facility failed to ensure that a resident's room was adequately equipped with a functioning call light system, which is essential for residents to call for staff assistance. Specifically, Resident #201, an elderly female with intact cognition and requiring supervision for various activities, reported that her call light was not working. Upon inspection, the surveyor confirmed that the call light system in Resident #201's room was malfunctioning, as the light above her door did not turn on when the button was pressed. The resident mentioned that she had been unable to call for help and had to wait for staff to enter her room, which could lead to unmet needs and potential risks for the resident. The issue was reportedly fixed the following day, but the resident had been without a functioning call light for at least a week prior to the repair. Interviews with the Maintenance Supervisor, Administrator, and Director of Nursing (DON) revealed that the call light system had been experiencing intermittent problems, particularly in the 300 hall. The Maintenance Supervisor had reached out to the service company, but repairs were delayed due to staffing issues. The Administrator and DON were aware of the problem and had provided bells to residents as a temporary measure, although Resident #201 did not receive one. The facility's policy mandates maintaining a functioning call light system and reporting any failures to maintenance and the administrator for prompt action, which was not adequately followed in this case.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to ensure that a resident had reasonable accommodation of needs, specifically regarding the accessibility of a call light. The resident, an elderly male with a history of pressure ulcers, protein-calorie malnutrition, and a urinary tract infection, was found to have a touch pad call device on the floor, out of reach, while he was lying in bed. The bed was in a high position, making it impossible for the resident, who was dependent on assistance for most activities of daily living, to reach the call device. Despite the call light being functional, the resident was unaware of this as he had not been informed that it was working again. During the survey, it was observed that the resident's call light was not within reach, and the resident confirmed that he could not use it to request assistance. The resident's care plan indicated that he was provided with a touch system call device, but it was not accessible to him at the time of observation. Interviews with the Director of Nursing and the Administrator highlighted the risk posed to residents who are unable to signal for help, emphasizing the importance of ensuring that call devices are accessible and that residents are informed about their functionality.
Wheelchair Brake Malfunction
Penalty
Summary
The facility failed to ensure that all patient care equipment was in safe operating condition, specifically for one resident whose wheelchair had a malfunctioning right brake. This deficiency was identified through observations, interviews, and record reviews. The resident, who had a history of falls and mobility issues, was using a wheelchair with a right brake that did not lock properly, posing a risk of falls and injury. Interviews with the resident's family member and hospice nurse revealed that the facility had been informed of the wheelchair's issues, including the broken anti-tipping device and the non-functioning right brake. Despite hospice sending new wheelchairs, they were returned by the facility due to the absence of an anti-tipping device, which hospice did not provide. The facility's staff, including CNAs and a physical therapy assistant, confirmed that the right brake was not functioning properly, allowing the resident to move the wheelchair even when the brakes were engaged. The Director of Nursing (DON) and the Administrator were unaware of the brake issue until it was brought to their attention during the survey. The facility's policy on equipment maintenance requires that unsafe equipment be reported and removed from use until repaired or replaced. However, the malfunctioning wheelchair continued to be used, indicating a lapse in adherence to this policy.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure the right to be free from abuse for one resident when a CNA raised her voice and cussed at the resident. The incident occurred on the morning of 04/02/24 when the CNA was passing out breakfast trays and yelled at the resident to sit down and used inappropriate language. This was witnessed by another staff member who later reported the incident through a handwritten note slipped under the Administrator's door. The resident involved had a history of alcohol-induced dementia, traumatic brain injury, and seizures, and was noted to have moderate cognitive impairment with a BIMS score of 8. The investigation revealed conflicting accounts of the incident. The CNA denied cussing at the resident and stated that she had to speak loudly because the resident was hard of hearing. However, the Activity Director confirmed hearing the CNA yelling and cursing at the resident. The Activity Director admitted to hearing the incident but did not report it immediately to the abuse coordinator or the Administrator. The resident herself denied any abuse when interviewed, but the DON noted that the resident might not be able to accurately report the incident due to her cognitive impairment. The facility's records showed that the CNA had received customer service education following the incident, emphasizing the need for compassionate and kind communication with residents. Both the CNA and the Activity Director had previously been in-serviced on the facility's Abuse and Neglect policy. Despite these measures, the facility failed to protect the resident from verbal abuse, as evidenced by the conflicting reports and the delayed reporting of the incident by the Activity Director.
Failure to Report Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment were reported immediately or within 2 hours. This deficiency was observed in the case of a resident with alcohol-induced dementia, a history of traumatic brain injury, and seizures. The resident, who had moderate cognitive impairment and required supervision for activities of daily living, was verbally abused by a CNA. The CNA was heard yelling and using inappropriate language towards the resident during breakfast service. Despite witnessing the incident, the Activity Director and Business Office Manager did not report the abuse to the Administrator within the required timeframe. The Activity Director heard the CNA yelling and cursing at the resident but did not report the incident immediately. Instead, she reported it to the Business Office Manager after lunch, who also failed to report it to the Administrator, assuming the Activity Director would do so. The Administrator only became aware of the incident the following day when she found an anonymous note describing the abuse. The Activity Director admitted to hearing the abuse and not reporting it promptly, while the Business Office Manager confirmed that the Activity Director had informed her but did not take further action. The facility's policy requires that all alleged violations of abuse be reported to the Administrator or other officials within two hours. Signs posted in the facility indicated the Administrator's role as the Abuse/Neglect Coordinator and provided her contact information. Despite this, the staff failed to follow the policy, leaving the resident at risk. The Director of Nursing and the Administrator both expressed that the incident should have been reported immediately to prevent further harm to 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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