Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Azalea Heights during CMS and state inspections, most recent first.
A cognitively intact female resident with Guillain-Barre Syndrome, depression, muscle weakness, and dependence on staff for toileting received incontinent care from two CNAs while her roommate was present in the room, and the privacy curtain was not pulled at any time. The resident’s care plan documented a self-care deficit and need for assisted incontinent care, and facility policies on perineal care and resident rights required staff to provide privacy, including use of doors, curtains, and blinds. In post-incident interviews, both CNAs acknowledged that privacy should have been provided during the care and recognized that doing so is part of respecting resident rights and dignity, while the DON and Administrator confirmed their expectation that staff follow these privacy practices.
A CNA provided incontinent care to a resident with assistance from another CNA and failed to perform hand hygiene between multiple glove changes during perineal and brief care, only using alcohol-based hand rub before entering and after exiting the room. The CNA acknowledged that hand hygiene should occur between glove changes but cited the location of hand sanitizer dispensers in the hallway and uncertainty about portable sanitizer as reasons for noncompliance. The DON and Administrator both described expectations that staff perform hand hygiene before and after care and in conjunction with glove use, and the facility’s hand hygiene policy required hand hygiene immediately before resident contact and after glove removal, which was not followed during the observed care.
Controlled Substance Count Sheets Signed Incorrectly: The facility failed to ensure controlled medications were handled in a way that prevented medication errors when an LPN and an MA were observed signing the controlled substance count sheets for both the start and end of their shifts at the same time on two medication carts. Both staff members stated they knew they should not sign both sections at once, and the ADON, Treatment Nurse, and DON stated staff were required to sign the count record when coming on duty and again when going off duty. The facility policy required the oncoming and offgoing staff to make the count together and document any discrepancies.
MDS Assessments Not Accurately Coded for Active Diagnoses: A resident’s admission and quarterly MDS assessments did not accurately code active diagnoses including TBI, seizures, and schizophrenia. Records showed the resident had these diagnoses on hospital and facility documentation, and the MDS Coordinator acknowledged the coding error while the DON stated MDS accuracy was expected.
Incorrect PASRR Screening for a Resident with Mental Health Diagnoses: A resident admitted with depression and mood disorder had an inaccurate PASRR Level I that stated there was no evidence of mental illness, even though hospital records, the admission MDS, the care plan, and MAR documented mental health diagnoses and psychotropic medications. The MDS Coordinator said the error was missed, the resident did not receive a Level II PASRR screening, and the DON stated the facility should have caught the incorrect PASRR.
Failure to Complete Baseline Care Plan After Admission: A resident admitted for rehab after a fall with dx including a R femur fracture, seizures, HTN, and GERD did not have a baseline care plan completed within 48 hours of admission, and no written summary was documented as provided to the resident or responsible party. The ADON and DON confirmed the baseline care plan was not in the record and had not been done, despite facility policy requiring initiation on admission, review with the resident/representative, and documentation in the chart.
Incomplete care plan for resident’s finger-food eating and nail care needs. A resident with dementia, total ADL dependence, and a regular diet was observed repeatedly with dried food under both fingernails while eating with her fingers and being partially spoon fed by staff. Her care plan and CNA task sheet did not reflect her preference for finger foods or her need for nail care after meals, and staff interviews confirmed the resident needed her hands and fingernails cleaned after eating.
Failure to provide nail care and hygiene assistance for a resident with dementia and total ADL dependence. A resident who ate finger foods was repeatedly observed with dried brown substance under both fingernails over several days, including during meals and while sitting in the dining room and bed. The ADON confirmed the nails needed cleaning, and CNA staff stated the resident needed her hands and fingernails cleaned after every meal, but this was not consistently done.
A resident with a history of ESBL/VRE, a wound, and orders for EBP received incontinent care from a CNA who wore gloves only and did not don a gown during direct care. The CNA was observed multiple times providing toileting and brief care without the required PPE, despite EBP signage in the room and the DON confirming that gown and gloves were required for this type of care.
Incomplete Discharge Summary for a Resident: The facility failed to provide a completed discharge summary when a resident was discharged to another nursing home. The resident’s record did not contain a discharge summary, and the DON later provided an incomplete discharge summary form that was missing multiple required sections, including routine, cognitive, psychosocial, continence, dental, and discharge planning information. The ADON, SW, and ADM were unable to identify the facility policy or responsibility for completing discharge summaries.
A resident with severe cognitive impairment and a history of falls was not provided with the required bed bolsters as outlined in her care plan. Instead, a CNA used a different positioning device, and the bed was left in a high position. The resident was later found on the floor with injuries, including a fractured femur, after falling from bed. Staff interviews confirmed knowledge of the care plan requirements, but the prescribed interventions were not followed.
The facility's kitchen operations were found to be unsanitary, with issues such as empty paper towel dispensers, improper storage of food items, and inadequate sanitizing procedures. Logs for sanitizing were pre-filled inaccurately, and the ice machine had black debris. An opened juice container was not labeled with the open date, violating food safety standards.
A facility failed to document a resident's enteral feeding orders in the EHR, resulting in a lack of recorded administration of liquid nutrition for four days. The oversight occurred when an LVN did not enter the order after receiving a verbal report from an agency nurse, despite the facility's policy requiring accurate documentation during admissions.
The facility failed to provide necessary hygiene services for two residents, one of whom did not receive a bath for five days after admission, and another who did not receive a bath or shower for four weeks. Documentation inconsistencies and staff interviews highlighted a lack of adherence to proper hygiene protocols.
The facility failed to ensure adequate supervision for a resident with dementia who had a history of elopement. The resident was admitted without proper assessment, leading to an elopement incident the following day. Staff were unaware of her elopement history, and the admission assessment was inaccurately completed.
A resident with multiple diagnoses, including Alzheimer's and anxiety disorder, was prescribed Lorazepam. The facility failed to consistently document monitoring for adverse side effects of the medication, particularly during changes in dosage. Interviews with staff revealed awareness of the importance of monitoring, but documentation was inconsistent. The DON acknowledged the lapse and stated there was no specific system in place for consistent monitoring prior to 4/19/24.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
Surveyors identified a failure to provide personal privacy during incontinent care for 1 of 7 residents reviewed. The resident was an adult female with Guillain-Barre Syndrome, anxiety, major depressive disorder, muscle weakness, and a need for assistance with personal care. Her MDS showed she was cognitively intact with a BIMS score of 15, usually understood and was understood by others, and was dependent on staff for toileting. Her care plan, revised 1/3/26, documented a self-care deficit related to impaired physical mobility and called for incontinent care with one-person staff assist. On 4/29/26 at 1:16 p.m., CNA A, with assistance from CNA B, provided incontinent care to the resident while her roommate was lying in bed with eyes closed. During this care, the CNAs did not pull the privacy curtain at any time. In interviews, CNA B acknowledged that the privacy curtain should have been pulled and admitted the resident had not been provided privacy, stating she forgot to ensure the curtain was pulled and recognizing privacy was needed so no one could watch and so the resident was covered. CNA A stated that during incontinent care the door should be shut or the privacy curtain pulled and believed the curtain had been shut during this care, and identified resident rights as the reason for providing privacy. The DON and Administrator both stated their expectation that staff provide privacy during personal care by closing the door, pulling the privacy curtain, and closing the blinds, consistent with the facility’s Perineal Care procedure and Resident Rights policy, which require providing privacy and treating residents with dignity and respect, including privacy and confidentiality.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene practices during incontinent care. During an observation on 4/29/26, CNA A and CNA B used alcohol-based hand rub from a dispenser outside a resident’s room, performed hand hygiene, and donned clean gloves before beginning care. Once inside the room, CNA A moved the resident’s bed, removed her gloves, and repeatedly failed to perform hand hygiene between subsequent glove changes while providing perineal and incontinent care. Specifically, CNA A opened the resident’s brief and cleansed the pelvic and vaginal area, then removed gloves without hand hygiene; later, after the resident was rolled to her side and the bottom area and soiled brief were cleaned and removed, CNA A again removed gloves without hand hygiene. CNA A continued care by handling a clean brief and chuck pad, repeatedly changing gloves without performing hand hygiene until after exiting the room and disposing of trash. In interviews, CNA A stated that hand hygiene should be performed prior to and after providing care and between glove changes, and acknowledged she did not perform hand hygiene between glove changes during the observed care. She attributed this to the placement of hand sanitizer dispensers in the hallway outside resident rooms and uncertainty about the location of small bottles of hand sanitizer within the facility. The DON stated she expected staff to perform hand hygiene before entering a room, before donning gloves, after removing gloves, during care, and when exiting a room, and the Administrator similarly stated expectations for hand hygiene before and after care, eating, using the restroom, and with glove use. Review of the facility’s Handwashing/Hand Hygiene policy, updated 1/2025, indicated that hand hygiene is considered the primary means to prevent the spread of healthcare-associated infections, that hand hygiene products are to be readily accessible, and that hand hygiene is indicated immediately before touching a resident, after contact with blood, body fluids, or contaminated surfaces, after touching a resident or the resident’s environment, and immediately after glove removal. The observed practice by CNA A did not align with these stated expectations and policy requirements.
Controlled Substance Count Sheets Signed Incorrectly
Penalty
Summary
The facility failed to ensure controlled medications were prepared and administered in a manner that prevented medication errors for 1 of 2 MA medication carts and 1 of 2 licensed nurse medication carts observed for controlled medication storage. During observation, LVN A and MA B were seen signing the controlled substance count sheets for the end of their shifts at the beginning of their shifts on LN Cart #1 and MA Cart #1. Record review showed the controlled drug count sheet required staff to acknowledge that they had counted the controlled drugs on hand and confirmed the quantity matched the controlled medication count. During interview, LVN A stated he always signed both the coming and going slots at the same time so he would not forget at the end of his shift, and he acknowledged he knew he should not do that because he would be responsible if something happened during his shift. MA B stated she also signed both the nurse on and nurse off slots at the same time so she would not forget to sign off, and she said she knew she should not do it that way because if the count was wrong, she would be responsible if something happened during her shift. The ADON, Treatment Nurse, and DON stated that each nurse and MA were to sign the controlled drug count record when coming on duty and again when going off duty. The DON also stated she had in-serviced all nurses and MAs on the procedure and was responsible for monitoring compliance. The facility policy titled Controlled Substances stated that nursing staff coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the DON.
MDS Assessments Not Accurately Coded for Active Diagnoses
Penalty
Summary
The facility failed to ensure Resident #5’s assessments accurately reflected his status on an admission MDS and two quarterly MDS assessments. Record review showed the resident was a [AGE] year-old male admitted with diagnoses that included TBI, seizures, recurrent depressive disorder, and mood disorder. Hospital records dated 03/07/2025 also listed major depressive disorder, history of traumatic brain injury, and seizure disorder. The resident’s care plan identified concerns related to antipsychotic medication for mood disturbances associated with depression and schizophrenia, and difficulty expressing needs and potential misunderstanding of others related to cognitive communication deficits from his history of traumatic brain injury. The admission MDS reflected a BIMS score of 14 and indicated the resident was non-ambulatory, continent, and able to self-transfer, but Section I: Active Diagnoses was not correctly coded to include TBI, seizures, and schizophrenia. A quarterly MDS was also not correctly coded to include TBI and schizophrenia, and the 07/03/2025 quarterly MDS was not correctly coded to include TBI. During interview, the MDS Coordinator stated it was her responsibility to correctly code the MDS and acknowledged the coding of Resident #5’s diagnoses was her mistake. The DON stated she expected the MDS assessments to be coded correctly and that it was a team effort to ensure accuracy.
Incorrect PASRR Screening for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure an accurate PASRR Level I screening was completed for Resident #5, a male admitted with diagnoses that included recurrent depressive disorder and mood (affective) disorder. The admission MDS showed a BIMS score of 14, indicating intact cognition, and also reflected that he was non-ambulatory, continent, and able to self-transfer. Hospital records sent to the facility before admission listed major depressive disorder among his diagnoses, and the admission comprehensive MDS also identified depression and mood disorder in Section I: Active Diagnoses. The PASRR Level I screening completed by the referring entity on 03/11/2025 stated in Section C0100 that there was no evidence of mental illness, despite the resident’s documented depression, mood disorder, and use of psychotropic medications including sertraline, bupropion, and quetiapine. The care plan identified mood disturbances related to depression and schizophrenia, and the MDS Coordinator stated she was responsible for ensuring PASRR accuracy but missed that the Level I screening was incorrect. She said Resident #5 did not receive a Level II PASRR screening because the incorrect Level I was not identified. The SW stated she was responsible for notifying the LA of an incorrect PASRR, and the DON stated the facility should have caught the error and that correct PASRR screenings were important to ensure residents were referred for Level II evaluations.
Failure to Complete Baseline Care Plan After Admission
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission and failed to provide the resident and/or the resident representative with a written summary of that baseline care plan for Resident #93. The resident was a male admitted with diagnoses including displaced fracture of the base of the neck of the right femur, seizures, hypertension, and gastro-esophageal reflux disease. Review of the electronic record showed no documentation that a baseline care plan or written summary had been completed or provided. During observation, Resident #93 was in his room, clean, well-groomed, and in bed with the bed in a low position, with water and the call light within reach. He stated he had been recently admitted for rehabilitation following a fall at home and hoped to return soon. During interviews, the ADON and DON stated the baseline care plan was not in the clinical record and had not been done. They stated it should have been initiated on admission, completed within 48 hours, reviewed with the resident and/or responsible party, signed, and filed in the electronic clinical record. The facility policy reviewed stated that a baseline plan of care is developed within 48 hours of admission and that the resident and/or representative are provided a written summary, with documentation of provision in the medical record.
Incomplete care plan for resident’s finger-food eating and nail care needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #45 that included measurable objectives and time frames to meet her medical, nursing, mental, and psychosocial needs. Resident #45 was a female admitted with frontotemporal neurocognitive disorder, had a BIMS score of 99 on the annual MDS indicating she was not able to complete the interview, and was documented as non-ambulatory, incontinent, and dependent on staff for all activities of daily living. Her physician orders included a regular diet with regular consistency and no other specific instructions. The resident’s comprehensive care plan, initiated on 12/18/2024 and revised on 09/22/2025, identified a self-care deficit but did not address her preference for finger foods, her use of her fingers to eat, or her nail care needs. The nurse aides’ task assignment sheet for December 2025 also did not indicate any nail care needs for Resident #45. During multiple observations on 12/08/2025 through 12/10/2025, Resident #45 was seen with a dried, brownish substance under the fingernails on both hands while sitting in the dining room, after meals, and while in bed. During observation and interview, CNA-F stated that Resident #45 ate meals using her fingers and hands, preferred foods she could pick up and eat herself, and needed her fingernails and hands cleaned after every meal. CNA-F also stated the dried, brownish substance was dried food and that she should have cleaned the resident’s fingernails after assisting with lunch. The ADON observed the resident’s hands and stated her fingernails needed cleaning. The DON stated the care plan and nurse aides’ task assignment sheet should address the resident’s preference for finger foods and need for nail care after meals, and that the care plan team was responsible for ensuring the care plan addressed the specific needs of residents.
Failure to Provide Nail Care and Hygiene Assistance
Penalty
Summary
The facility failed to ensure Resident #45, a female with frontotemporal neurocognitive disorder who was dependent on staff for all activities of daily living, received the necessary hygiene care to maintain good grooming and personal hygiene. Her annual MDS indicated she was unable to complete the interview and required staff assistance for all ADLs, including showering and personal hygiene. Her care plan identified a self-care deficit and included interventions for hygiene assistance, and the nurse aides’ task assignment sheet assigned staff to assist her with hand hygiene as needed. During multiple observations in the dining room and in bed over several days, Resident #45 was repeatedly noted to have a dried, brownish substance underneath the fingernails on both hands. This was observed while she was sitting in a Geri-chair after activities, while eating meals, after meals, while waiting for meals, and while sitting upright in bed. On one occasion, she was observed eating finger foods with her hands while a staff member spoon fed her other food, and the dried substance remained under her fingernails throughout the observations. During interview and observation, the ADON confirmed that Resident #45’s fingernails needed cleaning. CNA-F stated the resident ate with her fingers, preferred finger foods, and needed her fingernails and hands cleaned after every meal, and said this should have been done after helping her eat lunch. CNA-F also stated that if a resident required special instructions like nail care after meals, it should be on the nurse aides’ task assignment sheet. The DON stated the care plan and nurse aides’ task assignment sheet should address the resident’s preference for finger foods and need for nail care after meals, and said the nurses were responsible for ensuring residents received needed hygiene care.
Failure to Use EBP PPE During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for a resident who required Enhanced Barrier Precautions (EBP). Resident #2 was a female admitted to the facility with diagnoses including diabetes, dysphagia, hypertension, atrial fibrillation, chronic pain, radiculopathy, intervertebral disc degeneration, and osteoporosis. Her quarterly MDS showed a BIMS score of 15, indicating no cognitive impairment, and she required maximum assistance with most ADLs. She was incontinent of bowel and bladder, had a history of MDRO/ESBL/VRE multidrug-resistant UTI, and had a sheer wound on her right hip; her physician orders directed staff to practice EBP as indicated due to chronic wounds and history of ESBL. During observations, CNA C provided incontinent care and direct care to the resident while wearing only gloves and no gown, despite an EBP sign posted on the door and bedside wall. The CNA was observed holding the resident against her body, returning to the room to continue incontinent care, and again performing care without donning a gown. When interviewed, the CNA stated she was supposed to wear a gown for direct care and did not have a reason for not doing so. The DON stated staff had been trained that residents requiring EBP needed a gown and gloves for direct care, including when changing briefs or assisting with toileting, and the facility policy identified ESBL-producing Enterobacterales and VRE as organisms requiring EBP.
Incomplete Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to complete a required discharge summary for Resident #6 when the resident was discharged to another nursing home. Record review of the resident’s medical record accessed on 12/10/2025 did not reveal a discharge summary, and the face sheet showed the resident had been admitted and later discharged to another nursing home. During interview, the ADON stated she did not know the facility’s policy on discharge summaries and said she had been told the SW and DON complete the discharge summary. The SW also stated she did not know the facility’s policy or who was responsible for completing discharge summaries, and said that when a discharge summary was not completed it placed residents at risk for missed appointments. During interview and record review, the DON provided an incomplete document titled Discharge Summary - Planning/Instructions/Recapitulation. The document was missing Resident #6’s customary routine, cognitive patterns, vision, mood and behavior patterns, psychosocial well-being, continence, dental status, and documentation of participation in assessment, and it was also incomplete in communication, physical functioning and structural problems, nutritional status, and discharge planning. The DON verbally confirmed that this was the document used as the discharge summary and recognized that it was not complete. The ADM stated nursing staff were responsible for discharge summaries and was unaware of the facility’s policy on discharge summaries.
Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, total dependence for activities of daily living, and a history of falls was not provided with the required safety interventions as outlined in her care plan. The resident, who had diagnoses including anoxic brain damage, convulsions, aphasia, and pseudobulbar affect, was care planned to have bolsters on her bed to minimize the risk of rolling out and for the bed to be kept at an appropriate height when unattended. On the day of the incident, the resident was returned to bed by a CNA who used a black wedge positioning device instead of the prescribed bolsters, which were found stored in front of the closet rather than on the bed. The incident was discovered when a nurse heard a loud thud and found the resident on the floor beside her bed, with a laceration to her face and a right leg injury. The bed was observed to be in a higher position, typically used for mechanical lift transfers, and there were no bolsters or wedge cushions on or around the bed at the time. The resident was subsequently diagnosed with a fractured right femur and required hospitalization and surgery. Interviews with staff revealed that the CNA was aware of the care plan requirements but did not use the bolsters, instead opting for a different device that was not part of the resident's care plan. Further review indicated that the CNA did not provide a clear reason for not using the prescribed bolsters, stating only that she used what was present on the bed that morning. The facility's documentation confirmed that all staff had access to the resident's care plan and Kardex, which specified the need for bolsters and bed positioning. The failure to implement these interventions as planned directly led to the resident's fall and subsequent injury.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. The paper towel dispensers at the hand wash sink and employee restroom were found to be empty, which could hinder proper hand hygiene. Additionally, a scoop was improperly stored inside a bulk flour bin, and the utensil drawer was soiled with food debris and dried liquid. Opened bags of brown sugar and potato chips were not properly sealed, which could compromise food safety. The facility's three-compartment sink was not sanitizing properly, and the logs for the sink and dish machine were pre-filled with results for meals that had not yet occurred. This indicates a lack of proper monitoring and documentation of sanitizing conditions. The ice machine in the dining area was found to have copious amounts of black debris on the ice chute, despite being cleaned by a vendor recently. The maintenance supervisor noted that the kitchen staff were supposed to clean the machine regularly, but there was no documentation to support this. Furthermore, a reach-in cooler contained an opened container of nectar thick orange juice that was not labeled with the open date, contrary to the package instructions. These deficiencies in food storage, preparation, and sanitation could place residents at risk of foodborne illness, as the facility did not adhere to its own policies and professional standards for maintaining sanitary conditions.
Failure to Document Enteral Feeding Orders
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for a resident who was admitted with multiple diagnoses, including dysphagia and a gastrostomy tube for enteral feeding. Upon review, it was found that the order for enteral feedings from the hospital was not documented in the resident's physician's orders at the facility. Additionally, there was no documentation of the administration of liquid nutrition for four consecutive days after the resident's admission, despite observations confirming that the resident was receiving the nutrition. Interviews revealed that the failure to document the enteral feeding order was due to an oversight by LVN B, who did not enter the order into the electronic health records (EHR) after receiving a verbal report from an agency nurse. The Director of Clinical Operations Nurse confirmed that LVN B completed the new admission form but missed entering the feeding order, although all other admission orders were entered correctly. The facility's policy requires nurses to document assessments and orders accurately, especially during admissions, but this was not adhered to in this case.
Failure to Provide Necessary Hygiene Services
Penalty
Summary
The facility failed to provide necessary services to maintain acceptable grooming and personal hygiene for two residents. Resident #1 did not receive a bath until five days after his admission, despite being dependent on staff for all activities of daily living (ADLs) including bathing. His family member observed that he remained in the same clothes for the first four days and did not appear to have received a shower. Documentation confirmed that Resident #1 did not receive a shower or bath from the date of admission until five days later. Resident #2, who required substantial assistance for bathing due to paraplegia and other medical conditions, did not receive a bath or shower for four weeks. During interviews, Resident #2 reported not receiving a shower or bed bath and noted that staff seemed unwilling to go through the process of providing a shower. Observations confirmed that Resident #2 had greasy hair and a faint body odor. Documentation inconsistencies were found, with some CNAs denying they had provided the documented care, and one CNA admitting to sharing login information with agency staff for documentation purposes. Interviews with staff, including CNAs and the Director of Nursing (DON), emphasized the importance of regular bathing for hygiene and skin health. However, the facility's policy and procedure on activities of daily living did not specifically address ensuring dependent residents received regular showers or baths. This lack of adherence to proper hygiene protocols placed residents at risk for poor personal hygiene and potential skin infections.
Failure to Prevent Elopement of Resident with Dementia
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident with a history of elopement. Resident #3, who had diagnoses including dementia, was admitted without a proper assessment of her elopement risk. The facility did not have a secure unit or a wander guard system and would not have accepted her had they known about her history of elopement. On the day following her admission, Resident #3 eloped from the facility, triggering an alarm that led to staff intervention to bring her back safely. The incident revealed that the facility's admission process did not capture critical information about Resident #3's elopement history, which was known to her family but not documented in the admission paperwork. Interviews with various staff members, including the admissions coordinator, DON, and social worker, confirmed that they were unaware of Resident #3's elopement history. The admission assessment was also inaccurately completed, marking Resident #3 as not physically able to leave the building on her own, which was incorrect. The facility's policy did not explicitly state that residents with a history of elopement would not be accepted, leading to a significant oversight in Resident #3's case.
Failure to Monitor Adverse Side Effects of Lorazepam
Penalty
Summary
The facility failed to ensure that Resident #1's drug regimen was free from unnecessary psychotropic drugs and that the resident was consistently and adequately monitored for adverse side effects of Lorazepam. Resident #1, who had multiple diagnoses including Alzheimer's disease, anxiety disorder, and major depressive disorder, was prescribed Lorazepam for anxiety. The medication orders for Lorazepam were changed multiple times between 4/1/24 and 4/18/24, but the monitoring for antianxiety side effects was not consistently documented during this period. Specifically, there were gaps in the documentation of side effects monitoring on the MAR and in the nursing progress notes, particularly from 4/11/24 to 4/19/24. This lack of consistent monitoring could have led to the resident experiencing adverse effects without timely intervention. Interviews with the nursing staff and the ADON revealed that they were aware of the importance of monitoring but failed to document it consistently. The DON acknowledged the lapse in monitoring and documentation, stating that there was no specific system in place to ensure consistent monitoring of psychotropic medications prior to 4/19/24. A facility policy and procedure regarding the monitoring of residents on psychotropic medications was requested but not received.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tyler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Briarcliff Health Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Reunion Plaza Healthcare & Rehabilitation | 1.3 mi | ★★★★★ | 0 | 0 |
| Providence Park Rehabilitation And Skilled Nursing | 2.2 mi | ★★★★★ | 1 | 1 |
| Meadow Lake Health Center | 2.4 mi | ★★★★★ | 0 | 0 |
| The Heights Of Tyler | 2.6 mi | ★★★★★ | 7 | 0 |
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