Avir At Arlington
Inspection history, citations, penalties and survey trends for this long-term care facility in Arlington, Texas.
- Location
- 301 W Randol Mill Rd, Arlington, Texas 76011
- CMS Provider Number
- 675877
- Inspections on file
- 45
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 13 (3 serious)
Citation history
Health deficiencies cited at Avir At Arlington during CMS and state inspections, most recent first.
Two residents with significant wounds did not receive care consistent with comprehensive, person-centered care plans. One resident with an unstageable coccyx pressure ulcer had a care plan and physician orders directing wound monitoring, infection surveillance, and specific treatments, but staff missed at least one treatment, did not consistently assess the wound, and did not notify the physician of changes or suspected infection. The resident was described as stable and sent out with family, whose later observation of a large, foul-smelling coccyx wound led to emergency evaluation and a diagnosis of sepsis possibly related to the wound, followed by the resident’s death. Another resident with a Stage III pressure ulcer and bilateral leg ulcers had a care plan only for a right leg ulcer, with no care plan for the left leg ulcer or sacral pressure ulcer, and was not listed on the facility’s wound report despite active wound orders and ongoing treatments. These failures to create and follow complete wound care plans and to accurately track wound status resulted in an Immediate Jeopardy finding and demonstrated noncompliance with the facility’s own comprehensive care plan policy.
Two residents with pressure ulcers did not receive care consistent with physician orders and professional standards. One resident, who had multiple serious diagnoses, developed an unstageable coccyx pressure ulcer after admission; staff missed at least one ordered treatment, failed to consistently measure and document the wound, and did not notify the physician or wound NP as the wound changed. CNAs and LPNs reported seeing the wound enlarge from the size of a dime to a tangerine, while the DON never assessed it and the physician was not updated beyond the initial notification. The resident’s family later discovered a large, necrotic coccyx ulcer and an additional Stage II buttock ulcer and took the resident to the hospital, where an ED physician documented an unstageable decubitus with foul odor and necrotic tissue. A second resident with a Stage III sacral ulcer received wound care in which the WCN left wound cleanser in the ulcer bed, did not re-clean the wound after the buttock contacted it, and only fully cleansed the ulcer after being prompted, despite facility policy requiring proper cleansing of the wound and surrounding tissue.
A resident with multiple comorbidities and cognitive impairment developed a coccyx pressure ulcer that progressed from a small open area to a larger, unstageable wound with malodor, necrotic tissue, and drainage. CNAs and nurses observed changes in the wound over several days, and a wound care NP later documented a deep, malodorous unstageable ulcer and ordered specialized treatments. However, after the initial notification, the attending physician was not informed of the wound’s worsening condition or suspected infection, despite facility policy requiring MD notification for significant changes in condition, including skin changes. Nursing documentation showed missed treatments and incomplete or undocumented communication, and the resident was later taken to the ED by family, where the ulcer was described as an unstageable decubitus with foul odor and necrotic tissue. This failure to promptly consult the physician regarding the significant change in wound status resulted in an Immediate Jeopardy deficiency.
A resident with multiple diagnoses, including paraplegia, malnutrition, chronic bone infection, and a Stage III pressure ulcer, was admitted with additional leg wounds documented in the care plan and wound care report, but these wounds were not recorded on the MDS assessment. The MDS listed only the Stage III pressure ulcer, despite documentation of a non-pressure chronic ulcer and atypical lesions on both legs. The MDS was completed by the MDS Coordinator and signed by a Corporate Nurse, while the DON reported not signing it and being unsure who was responsible for ensuring MDS accuracy, contrary to facility policy requiring comprehensive assessment via the MDS by the interdisciplinary team.
A resident with advanced cognitive and mobility impairments, care planned for two-person assist during transfers, was routinely transferred by a single staff member using a 'bear hug' technique. Staff and family interviews confirmed that transfers were performed alone, despite documentation requiring two-person assistance. Inconsistencies in care plan updates and staff practices led to a failure to provide adequate supervision and assistance devices to prevent incidents.
The facility's kitchen failed to meet food safety standards, as Cook G was observed prepping food without a beard guard, risking contamination. Additionally, food items in the refrigerator were improperly stored, with a block of Swiss cheese and a container of green beans not labeled or dated, contrary to the facility's policy and FDA guidelines.
A medication aide left a laptop on a medication cart unlocked and unattended in a hallway, exposing resident information such as names and dates of birth. The incident was observed by a surveyor, and staff interviews revealed a lack of awareness and specific policy on securing clinical records, despite regular HIPAA training.
A medication cart on Station 3 was found unlocked and unattended, posing a risk of unauthorized access to medications. The Medication Aide responsible thought she had locked it before entering a resident's room. Staff interviews confirmed training on securing carts, but the incident revealed a lapse in adherence to the facility's policy.
A resident with specific dietary preferences, including a request for daily oatmeal, was not consistently accommodated by the facility. Despite communicating her preference to multiple staff members, the resident continued to receive meals that did not align with her request. Staff interviews revealed a lack of clear communication and understanding regarding the resident's ongoing preference, and the facility lacked a policy related to dietary services and resident preferences.
A resident with moderately impaired cognition and dementia was found to have a non-functioning call light system in her room, which could risk her not receiving necessary care. The call light did not activate the light above the door or alert the nurses' station. Staff were unaware of the malfunction, and it was not logged in the maintenance records, despite facility policy requiring immediate reporting and logging of defective call lights.
Failure to Develop and Implement Comprehensive Wound Care Plans and Follow Existing Wound Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for residents with wounds, and failure to follow an existing wound care plan. For one resident, a female with moderately impaired cognition and diagnoses including cancer, heart failure, and sepsis risk, the care plan identified her as at risk for skin alterations and documented an unstageable wound to the buttock. The care plan interventions included monitoring the site for signs and symptoms of infection, monitoring treatment effectiveness, notifying the physician as needed, and performing weekly skin assessments. Physician orders dated mid-month directed specific wound care to the coccyx, but the treatment administration record showed at least one missed treatment. Progress notes documented a reopened wound to the sacrum and buttocks and a weekly skin/wound note indicated an unstageable coccyx pressure injury with malodor, necrotic tissue, and detailed wound characteristics. Despite these findings, there was no evidence that the wound was consistently monitored for infection or that the physician was notified of changes in the wound’s condition. On the day of a family outing, nursing documentation reflected that the resident was described as stable and left with her responsible party for holiday celebrations with portable oxygen. The facility had previously informed the responsible party only that the resident had a “hot spot” on her bottom and was receiving treatment, without disclosing the severity of the wound. That same evening, the responsible party observed the wound at home, described it as large, dark, and unstageable with necrotic tissue and surrounding deep red tissue, and took the resident to the hospital. Emergency department documentation noted an unstageable decubitus ulcer to the coccyx with foul odor and necrotic tissue. Interviews revealed that the CNA who first saw the open wound on the resident’s buttocks notified an LVN, who estimated the wound as dime-sized but did not measure it and did not continue to visualize it after the initial date. Another CNA later reported noticing the wound appearing more open and notified a nurse. The wound care nurse practitioner evaluated the wound several days before the outing, documented an unstageable coccyx pressure ulcer with significant slough and eschar, ordered Dakin’s solution and iodoform packing, and requested a wound culture, but stated she was not notified about the wound until she arrived at the facility and that the facility should have notified her or the physician before the wound worsened. The facility physician confirmed he was only notified once about the wound and did not assess it between its identification and the resident’s transfer out. A second resident, a male with intact cognition and diagnoses including heart failure, wound infection, paraplegia, malnutrition, and chronic bone infection, had documented wounds including a Stage III pressure ulcer and chronic leg ulcers. His care plan addressed only a non-pressure chronic ulcer to the right leg, with interventions to monitor and document the wound’s location, size, and treatment, and to report abnormalities and signs of infection to the physician. There was no care plan in place for his chronic ulcer on the left leg or for the pressure ulcer on the sacrum, despite physician orders for wound care to both lower legs and the coccyx. Additionally, this resident was not listed on the facility’s wound report, even though the wound care nurse and DON acknowledged he had a pressure ulcer and two leg wounds and that the wound care nurse had already been providing wound care. The wound care nurse stated she was responsible for ensuring wound care plans were written and used them to educate staff, but could not explain why the care plan for the first resident was not followed or why the second resident lacked care plans for all of his wounds. The facility’s own policy required comprehensive, person-centered care plans with measurable objectives and timeframes that describe services to meet residents’ physical, mental, and psychosocial needs, but the documented practices for these two residents did not meet those requirements. The situation for the first resident escalated to an Immediate Jeopardy determination after it was identified that the resident’s wound site was not monitored for signs and symptoms of infection, the effectiveness of treatment was not evaluated, and the physician was not notified of wound changes, despite the presence of an unstageable coccyx pressure ulcer with necrotic tissue and malodor. The resident was taken out of the facility by her responsible party, who then sought emergency care after observing the wound. Hospital records documented an unstageable decubitus ulcer with foul odor and necrotic tissue, and the responsible party reported being told the resident had sepsis possibly due to the wound and that the resident later died. For the second resident, the absence of care plans for all documented wounds and the omission from the wound report represented additional failures to ensure that comprehensive, person-centered care plans were developed and implemented for residents with wounds, as required by facility policy and regulatory standards.
Removal Plan
- Resident #3's care plan was updated to reflect the current state of their wound and interventions per the interdisciplinary team's discussion.
- All residents with wounds were reviewed to ensure the care plans are reflecting the residents' current wound status.
- Regional Nurse Consultant will educate Director of Nursing, Assistant Director of Nursing, Treatment Nurse, and MDSC Nurse over the care plan policy with emphasis on care planning wounds (wound location, type, stage), following physician orders, and ensuring care plans are comprehensive person-centered, consistent with resident rights, and include measurable objectives and time frames to meet medical, nursing, mental and psychosocial needs.
- All licensed nurses will be educated over the care plan policy with emphasis on care planning wounds (wound location, type, stage), following physician orders, and ensuring care plans are comprehensive person-centered, consistent with resident rights, and include measurable objectives and time frames to meet medical, nursing, mental and psychosocial needs.
- The Treatment Nurse and/or Designee will complete and update the care plans with any changes for wounds.
- The Director of Nursing or Designee will review the wound care plans to ensure they are present, accurate, and being followed.
- In Quality of Care meeting, the Director of Nursing, Assistant Director of Nursing, Treatment Nurse, and/or Designee will review residents with wounds, weekly wound report from wound care nurse practitioner, facility wound report, wound care orders, and wound care plans to ensure accurate information is present and documented.
- Ad hoc QAPI performed with Medical Director to inform them of the Immediate Jeopardy and the facility's plan to remove the immediacy.
Failure to Provide Ordered and Proper Pressure Ulcer Care for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and services, consistent with professional standards of practice, for two residents with pressure ulcers. One resident, an older female with cancer, heart failure, and sepsis, was admitted without pressure ulcers but was identified on 12/09/25 as being at risk for skin alterations with an unstageable wound to the buttock. Her care plan interventions included monitoring for signs and symptoms of infection, monitoring treatment effectiveness, notifying the physician as needed, and performing weekly skin assessments. A physician order dated 12/18/25 directed staff to cleanse the coccyx with wound cleanser or normal saline, apply collagen, and cover with a dry dressing once daily. The Treatment Administration Record showed the ordered wound treatment was not completed on 12/19/25, and although LVN C documented treatment on 12/20–12/21, the Wound Care Nurse’s (WCN) initials appeared for 12/22–12/25 without the WCN recognizing or confirming those entries. Progress notes documented that on 12/18/25 a skin check identified a reopened wound to the sacrum and open areas to the left and right buttocks, with education provided on treatment and turning every two hours. On 12/22/25, a weekly skin/wound note by the WCN stated the sacral pressure injury was assessed and treated per order, with the wound cleansed and dressing changed, but no measurements or detailed wound characteristics were documented. On 12/24/25, the Wound Care Nurse Practitioner performed a first evaluation of the coccyx pressure ulcer, describing it as an unstageable pressure ulcer measuring 4.5 cm x 4.5 cm x 3.5 cm with 40% granulation, 40% slough, and 20% eschar, malodorous drainage, fragile and ecchymotic peri-wound tissue, and non-blanchable maroon discoloration. The Nurse Practitioner ordered Dakin’s solution for cleansing, iodoform packing, and a superabsorbent dressing to be changed every other day, and noted that a sharp debridement was not performed at that time. The Nurse Practitioner reported she was not notified about the wound until she arrived on 12/24/25 and that the facility had no wound culture supplies when she requested a culture. Interviews revealed multiple failures in assessment, treatment, and communication for this resident’s wound. CNA B reported first seeing the open wound on 12/18/25 and notifying LVN A, who estimated the wound to be about the size of a dime, obtained an order from the WCN, but did not personally treat or subsequently visualize the wound, assuming the WCN would do so. CNA C, who bathed the resident, noticed the wound looked more open on 12/21/25 and notified a nurse, stating that each time he saw the wound it had cream on it. LVN D, who performed wound care on 12/20–12/21, described the wound as about the size of a quarter, not very deep, and without drainage, and reported using calcium alginate and a dry dressing. The WCN stated she saw the wound on 12/22/25 and 12/24/25, described it on 12/22/25 as about the size of a tangerine and curved in but did not measure or document its size, and acknowledged she did not notify the facility physician of the wound and did not document her phone contact with the Nurse Practitioner on 12/22/25. The DON stated she never looked at the wound, and the facility physician confirmed he was only notified about the wound on 12/18/25 and was not informed of any subsequent changes or suspected infection. The resident’s responsible party reported the facility had described the area only as a “hot spot,” did not disclose the severity, and that when the resident was taken home for a holiday dinner on 12/25/25, the responsible party observed a large, dark, unstageable coccyx ulcer with necrotic tissue and a separate Stage II ulcer on the right lower buttock, then took the resident to the hospital, where the emergency department physician documented an unstageable decubitus ulcer with foul odor and necrotic tissue. The deficiency also includes improper wound care technique for a second resident with a Stage III sacral pressure ulcer and diabetes. This resident’s care plan required assessment and documentation of wound appearance, including size, depth, exudate, tissue type, odor, and location during dressing changes, and a physician order directed daily cleansing with wound cleanser, application of medical grade honey, and a bordered dressing. During an observed wound care procedure, the WCN sprayed wound cleanser on and around the ulcer, then used gauze to clean only the skin around the wound, leaving wound cleanser in the ulcer itself. After measuring the wound length, the WCN changed gloves while the DON held the resident’s left buttock away from the ulcer; when the DON briefly released the buttock, it fell onto the ulcer. The WCN then resumed care without re-cleansing the wound until prompted by a question about whether she would clean the wound, at which point she sprayed cleanser again but initially still did not remove it from the ulcer bed. Only after further questioning did the WCN use gauze to clean the wound cleanser off the ulcer and surrounding skin before applying the ordered treatment and dressing. Both the DON and the WCN later acknowledged in interviews that it was important to cleanse the ulcer and surrounding skin, and to re-clean the wound if the buttock touched it, and to remove wound cleanser from the ulcer to avoid transferring bacteria into the wound.
Removal Plan
- Assess all residents with wounds and communicate the current condition of each wound with the resident's physician and the wound care nurse practitioner to ensure proper treatments are in place to treat and heal the wounds.
- Provide education to the Director of Nursing, Treatment Nurse, and Assistant Director of Nursing on the Change in Condition policy as it relates to physician notification, following orders that promote healing and prevention of pressure ulcers, and documenting all characteristics of wounds, including measurements.
- Provide education to all nurses on the Change in Condition policy as it relates to physician notification.
- Provide education to all nurses, including the treatment nurse, on documenting all characteristics of wounds, including measurements, and following physician orders related to healing and preventing pressure ulcers.
- Complete a competency test with nurses related to physician notification, following orders that promote healing and prevention of pressure ulcers, and changes in skin.
- Designate the Treatment Nurse to complete wound care and assign coverage by the Assistant Director of Nursing, Director of Nursing, or a designated nurse when the Treatment Nurse is unavailable, with weekend wound care completed by the weekend supervisor or assigned charge nurse.
- Have the Director of Nursing and/or designee observe wounds to ensure documentation and proper notification are charted, immediately address discrepancies or concerns with the resident's physician and wound care practitioner, provide reeducation as needed, and review the wound care nurse practitioner's notes to ensure no additional concerns are noted.
- Perform an ad hoc QAPI with the Medical Director to review the IJ template, identify the root cause of the deficient practice, and discuss the facility's plan to remove the immediacy.
Failure to Notify Physician of Significant Change in Wound Status
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a resident’s physician when there was a significant change in the resident’s condition, specifically a deterioration in wound status. The resident was an older female with a history of cancer, heart failure, and prior sepsis, cognitively moderately impaired, and at risk for pressure ulcers but initially documented as not having one. On 12/09/25, her care plan identified an unstageable wound to the buttock with interventions including monitoring for signs and symptoms of infection, monitoring treatment effectiveness, notifying the physician as needed, and performing weekly skin assessments. On 12/18/25, a skin check note documented a reopened wound to the sacrum and open areas to the left and right buttocks, and a wound care order was initiated to cleanse and dress the coccyx wound daily. Over the following days, multiple staff observed and treated the wound, but there were gaps and inconsistencies in assessment, documentation, and physician notification. The Treatment Administration Record showed the ordered wound treatment was not completed on 12/19/25, and different nurses, including the wound care nurse (WCN) and LVNs, provided care from 12/20/25 through 12/25/25. CNA staff reported first seeing the open wound on 12/18/25 and notifying nursing, describing it initially as about the size of a dime, and later noticing it appeared more open on 12/21/25 and again notifying a nurse. LVN D, who performed wound care on 12/20/25–12/21/25, described the wound as about the size of a quarter, not very deep, and without drainage. The WCN stated that when she saw the wound on 12/22/25 it was about the size of a tangerine, curved in, without drainage or odor, and that she contacted the wound care nurse practitioner by phone but did not document this contact or notify the facility physician. On 12/24/25, the wound care nurse practitioner conducted a first evaluation of the existing coccyx pressure ulcer, documenting it as an unstageable pressure ulcer/injury with malodor after cleansing, measuring 4.5 cm x 4.5 cm x 3.5 cm, with 40% granulation, 40% slough, and 20% eschar, exposed dermis and subcutaneous tissue, fragile and ecchymotic peri-wound with non-blanchable maroon discoloration, and moderate serosanguineous drainage. She ordered Dakin’s solution, iodoform packing, and superabsorbent dressings and requested a wound culture but was told the facility did not have supplies. The facility physician reported he was only notified about the wound on 12/18/25 and was not informed of any subsequent changes or suspected infection and did not assess the wound between 12/18/25 and 12/25/25. On 12/25/25, nursing documented the resident as stable when she left with her responsible party for a holiday outing. That same evening, the responsible party saw the wound at home, described having previously been told only that there was a “hot spot,” and took the resident to the hospital, where the emergency department physician documented an unstageable decubitus ulcer to the coccyx with foul odor and necrotic tissue. The facility’s failure centered on not immediately consulting the resident’s physician when the wound significantly changed and showed concerning characteristics, despite policy requiring physician notification for significant changes in condition, including changes in skin. The surveyors determined that this failure to notify the physician of the significant change in wound status constituted a deficiency and identified it as Immediate Jeopardy on 01/08/26. Interviews with the WCN, DON, facility physician, CNAs, and other nursing staff confirmed that the physician was not kept informed of the wound’s progression or potential infection after the initial notification on 12/18/25, even as the wound increased in size, became unstageable, and developed malodor and necrotic tissue. The facility’s policy on change in condition required physician notification for significant changes in physical condition, including skin changes, but this was not followed in this case, leading to the cited deficiency.
Removal Plan
- Assess all residents with wounds; communicate the current condition of each wound with the resident's physician and the wound care nurse practitioner.
- Regional Nurse Consultant will provide education to the Director of Nursing, Treatment Nurse, and Assistant Director of Nursing on the Change in Condition policy as it relates to physician notification and documenting all wound characteristics, including measurements.
- Provide education to all nurses on the Change in Condition policy as it relates to physician notification, including changes in skin.
- Provide education to all nurses, including the treatment nurse, on documenting all wound characteristics, including measurements.
- Complete a competency test with nurses on physician notification related to changes in skin.
- Designate the Treatment Nurse to complete wound care; assign the Assistant Director of Nursing, Director of Nursing, or a designated nurse to complete wound care when the Treatment Nurse is unavailable; assign weekend wound care to the weekend supervisor or assigned charge nurse.
- Director of Nursing and/or designee will observe wounds to ensure documentation and proper notification are charted; immediately discuss discrepancies or concerns with the resident's physician and wound care practitioner and provide reeducation as needed.
- Director of Nursing and/or designee will review the wound care nurse practitioner's notes to ensure no additional concerns are noted.
- Conduct a QAPI meeting with the Medical Director to review the IJ template, identify root causes of the deficient practice, and implement the facility's plan to remove the immediacy.
Inaccurate MDS Assessment of Resident Wounds
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s MDS assessment accurately reflected his clinical status, specifically his skin conditions and wounds. The admission MDS for a male resident with diagnoses including heart failure, wound infection, paraplegia, malnutrition, chronic bone infection, and a Stage III pressure ulcer documented only the Stage III pressure ulcer and did not indicate any other wounds. However, the resident’s care plan identified an actual impairment to skin integrity related to a non-pressure chronic ulcer on the right leg, with interventions to monitor and document the wound and report abnormalities to the physician. Additionally, the facility’s wound care report showed that the resident had an atypical lesion on the right leg, an atypical lesion on the left leg, and a Stage III pressure ulcer on the coccyx, all present on admission. Surveyors were unable to interview the MDS Coordinator, who did not return calls. The DON stated she did not sign the MDS assessment for this resident and did not know who was responsible for ensuring MDS assessments were correct, though she acknowledged their importance for ensuring appropriate care interventions. The Corporate Nurse reported that she signed the MDS assessment to show it was completed, while the MDS Coordinator actually filled it out. Facility policy on resident assessments indicated that a comprehensive assessment includes completion of the MDS and that the interdisciplinary team uses the MDS form mandated by federal and state regulations to conduct the resident assessment. Despite this policy, the resident’s MDS did not accurately capture all existing wounds documented elsewhere in the record.
Failure to Provide Required Supervision and Assistance During Resident Transfers
Penalty
Summary
A deficiency occurred when a resident with significant physical and cognitive impairments did not receive adequate supervision and assistance during transfers. The resident, diagnosed with Alzheimer's disease, hemiplegia, generalized muscle weakness, unsteadiness, and other mobility issues, was care planned and assessed as requiring extensive assistance for bed mobility with one person and total dependence with two-person physical assist for transfers. However, interviews and record reviews revealed that staff routinely transferred the resident alone, using a 'bear hug' technique, despite documentation indicating a two-person assist was required for transfers. Multiple staff members, including CNAs, reported transferring the resident by themselves, stating that the resident was now a one-person assist. Family observations corroborated that the resident was transferred by a single staff member, contrary to the care plan and MDS documentation. There was also inconsistency among staff and administration regarding the use of a gait belt, with conflicting statements about whether it was necessary or appropriate for the resident. The facility's policy required ongoing assessment and documentation of residents' transfer needs, including input from nursing and rehabilitation staff. Despite this, the care plan and MDS were not updated consistently to reflect the resident's actual transfer status, and staff did not follow the documented requirements for assistance. This failure to provide the required level of supervision and assistance during transfers constituted a deficiency in ensuring the area was free from accident hazards and that adequate supervision was provided to prevent accidents.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Cook G was found prepping food without a beard guard properly in place, leaving his beard exposed. This was confirmed during an interview with Cook G, who acknowledged the risk of bacterial contamination due to the lack of a beard guard. Additionally, the facility's refrigerator contained improperly stored food items, including a block of Swiss cheese that was partially wrapped and exposed to air, and a plastic container of green beans that was neither labeled nor dated. Cook G confirmed these observations and acknowledged the importance of proper labeling and sealing to prevent food contamination. The facility's Food Storage policy from 2018 requires all refrigerated foods to be dated, labeled, and tightly sealed. The FDA Food Code of 2017 also mandates that food storage containers be identified with the common name of the food and that refrigerated, ready-to-eat foods be clearly marked with the date by which they should be consumed or discarded. The failure to comply with these standards could place residents at risk for foodborne illness, as the food was not adequately protected from contamination.
Unsecured Laptop on Medication Cart Breaches Resident Confidentiality
Penalty
Summary
The facility failed to ensure the confidentiality of residents' personal and medical information when a medication aide, MA E, left a laptop on a medication cart unlocked and unattended in the hallway of Station 3. This incident was observed by a surveyor, who noted that the laptop screen displayed resident information such as names, dates of birth, and photos. At the time of the observation, there were no staff present in the hallway, and a resident was seen walking past the unsecured medication cart. MA E admitted to being responsible for securing the laptop and acknowledged the risk of unauthorized access to residents' confidential information. Interviews with other staff members, including an LVN and the DON, revealed that they were unaware of the incident but confirmed that staff were trained to keep medication carts locked and secured when unattended. The facility's policy on medication storage did not address securing clinical records, and the Administrator confirmed the absence of a specific HIPAA policy. Despite regular in-service training on HIPAA compliance, the failure to secure the laptop posed a risk of unauthorized access to sensitive resident information.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to properly secure medications in locked compartments on Station 3, as observed by a surveyor. A medication cart was found unlocked and unattended in the hallway, with a resident walking past it. The Medication Aide (MA E) responsible for the cart was inside a resident's room at the time. MA E acknowledged her responsibility to ensure the cart was locked and secure, admitting she thought she had locked it before entering the room. She recognized the risk of unauthorized access to medications, which could lead to ingestion and potential harm. Interviews with staff, including an LVN and the Director of Nursing (DON), revealed that they were unaware of the unlocked cart. Both confirmed that staff were trained to keep medication carts locked when unattended. The DON expressed her expectation that carts should always be locked and acknowledged the potential harm if medications were accessed by unauthorized individuals. The facility's policy mandates that medication carts be locked or attended by authorized personnel, highlighting a lapse in adherence to this policy.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preferences, specifically the request for daily oatmeal, which was not consistently provided. The resident, who had moderately impaired cognition and medical conditions including gastroesophageal reflux disease, diabetes, and end-stage renal disease, expressed dissatisfaction with the breakfast options, preferring oatmeal over the bacon and eggs provided. Despite communicating this preference to multiple staff members, including a nurse and a medication aide, the resident continued to receive meals that did not align with her request. Interviews with staff revealed a lack of clear communication and understanding regarding the resident's ongoing preference for oatmeal. LVN C and other staff members misunderstood the request as a one-time preference rather than a standing order. The Dietary Manager, who had recently started in her position, noted that menus were posted outside the dining room, and dietary staff followed diet orders on tickets. However, there was no established process for ensuring that resident preferences were consistently communicated and honored. The Director of Nursing (DON) and other staff acknowledged the potential risks of not honoring resident food preferences, including malnutrition and weight loss. The facility did not have a policy related to dietary services and resident preferences, which contributed to the communication breakdown and failure to meet the resident's dietary needs. The Administrator noted recent staff turnover in dietary services, which may have further impacted communication and service delivery.
Call System Malfunction in Resident's Room
Penalty
Summary
The facility failed to ensure that the call system in a resident's room was functioning properly, which could place residents at risk of not receiving necessary care and services. The resident, an elderly female with moderately impaired cognition and a diagnosis of unspecified dementia, required supervision with dressing and partial assistance with transfers. During an observation, it was noted that when the call light button was pressed, the light above the door did not function, no sound was heard at the nurses' station, and the panel near the nurses' station did not indicate the call was placed. The call light was plugged into the wall using a cord that was split with another cord for the unoccupied half of the room, and the second call light was found to be functioning appropriately. Interviews with staff revealed that the resident's call light malfunction was not previously reported or logged in the maintenance records. The Maintenance Supervisor, who was responsible for testing call lights daily, was unaware of the issue and stated that call light malfunctions could place residents at risk. The Charge Nurse was also unaware of the malfunction and emphasized the importance of checking call lights periodically. The facility's policy required that defective call lights be reported immediately and logged in the maintenance log, but there were no entries related to call light malfunctions in the log book for the relevant period.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
