Avir At Beaumont
Inspection history, citations, penalties and survey trends for this long-term care facility in Beaumont, Texas.
- Location
- 4195 Milam St, Beaumont, Texas 77707
- CMS Provider Number
- 455001
- Inspections on file
- 40
- Latest survey
- November 18, 2025
- Citations (last 12 mo.)
- 21 (2 serious)
Citation history
Health deficiencies cited at Avir At Beaumont during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and total dependence for toileting did not receive incontinence care for over four hours, despite staff expectations for two-hour checks. The resident was found with a wet brief and recent bowel movement, and staff interviews revealed inconsistent adherence to incontinence care protocols and lack of a specific facility policy.
A facility failed to maintain accurate records for the administration of Lorazepam, a controlled antianxiety medication, to a resident with significant cognitive and communication impairments. Lorazepam tablets were signed out on the controlled medication count sheet, but there was no documentation on the MARs or nurse notes to confirm administration or wastage, as required by facility policy. Staff and leadership were unable to verify whether the medication was given, resulting in incomplete and inaccurate controlled substance records.
The facility did not ensure that laboratory services or tests were provided in a timely and quality manner to meet the needs of residents, as identified during the survey.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents experienced abuse and neglect when one resident with behavioral issues inappropriately touched a female resident with PTSD and later engaged in a physical altercation with a cognitively impaired male resident. Both incidents were witnessed or discovered by staff after the events occurred, and the residents involved had known histories of behavioral and cognitive challenges.
Two residents with cognitive and behavioral impairments were involved in an unwitnessed altercation after one wandered into the other's room during the night. Staffing on the memory care unit was insufficient to supervise a high number of residents with wandering behaviors, and staff frequently had to leave areas unattended to assist elsewhere. Facility policies required evaluation and adjustment of staffing based on resident needs, but no increased supervision or interventions were implemented prior to the incident, resulting in injuries and an Immediate Jeopardy finding.
All dryers in the facility's laundry room were out of service, leading to a shortage of clean linens and personal clothing for residents. Staff and residents reported difficulties obtaining clean, properly fitting, and undamaged linens, with some linens described as dingy, thin, or stained. The laundry supervisor had to use an external laundromat to meet linen needs, and CNAs confirmed linen closets were often empty, impacting resident care and comfort.
A resident with multiple medical conditions was given Primidone at the wrong time and received Artificial Tears instead of the prescribed Pataday eye drops, with the substitution made without physician authorization. The LPN responsible cited nervousness during observation and lack of supervision as contributing factors. These actions resulted in a medication error rate of 11.11%, exceeding the acceptable threshold.
Three dietary staff members worked with expired food handler certificates, and the dietary manager did not ensure their certifications were renewed as required by facility policy. The administrator expected staff to maintain current certificates, but oversight was lacking, resulting in non-compliance with training and competency requirements.
The facility did not maintain the staff and visitor smoking area, resulting in overgrown grass and weeds, as well as accumulated trash such as plastic wrappers, paper towels, and cigarette butts. Maintenance staff acknowledged responsibility for the area and reported equipment failure and issues with contracted lawn services. The Administrator confirmed ongoing challenges in obtaining lawn care, despite facility policy requiring a clean and homelike environment.
Surveyors identified multiple environmental deficiencies, including unkempt courtyards with tall grass, weeds, and trash, damaged resident rooms with missing trim and exposed sheetrock, inadequately stocked and poor-quality linens, and broken exit door windows covered with cardboard. Staff and residents reported ongoing issues with maintenance and linen supply, and the facility's environment was found to be unsanitary and uncomfortable.
A nurse failed to follow established procedures for administering medications via G-tube to a resident with a history of stroke and dysphagia, who was NPO and dependent on enteral feeding. Instead of giving medications one at a time with water and using gravity flow, the nurse mixed multiple medications together and used the syringe plunger to force the mixture through the tube, contrary to physician orders and facility policy.
Surveyors found that a lockbox for controlled medications was not permanently affixed to a medication room refrigerator, and a resident's enalapril medication card was left unsecured on top of a medication cart while unattended. Both the DON and Administrator confirmed that staff were educated on proper medication security procedures.
A CNA failed to consistently perform hand hygiene between assisting multiple residents with feeding, despite having received recent education and being aware of facility policy. This lapse was observed and acknowledged by staff, and confirmed through interviews with the DON, ADON/IP, and Administrator, who all stated that hand hygiene should be performed between each resident interaction.
The facility failed to maintain a safe and clean environment, with disrepair in a shower room and cockroach infestations in two resident rooms. A resident reported the shower room issues, including a non-operable shower and missing tiles, but no action was taken. Two residents reported cockroach infestations, but the facility did not address the issue. The Administrator and Maintenance Director were unaware of these problems due to poor communication and documentation practices.
Two residents reported a cockroach infestation in their rooms, with one resident experiencing cockroaches crawling on him at night. The facility's Administrator was unaware of the reports, despite a pest control log indicating issues on Unit 2. The Maintenance Director was not informed, and the facility lacked a pest control policy.
The facility failed to maintain proper sanitation standards in the main dining room and kitchen, with thick dust on an air vent in the dining room and multiple pieces of rusted, unsanitizable kitchen equipment. Both the dietary manager and the administrator acknowledged these issues, which had been identified by the public health department but not addressed, posing a risk of food contamination for residents.
The facility failed to ensure accurate resident assessments for two residents. One resident's smoking status and another's anxiety disorder were not correctly documented in their MDS assessments, despite evidence in their records. Interviews revealed that the previous MDS nurse had not been completing the assessments correctly.
A facility failed to ensure a resident with limited range of motion received appropriate treatment, specifically not applying a splint to the resident's contracted right hand as ordered. Staff were either unaware of their responsibilities or too busy with other duties, and the facility lacked a policy on contracture or splint management.
The facility failed to maintain a medication error rate of less than 5 percent, resulting in an 8 percent error rate. One LVN administered midodrine HCL outside the prescribed parameters, and another LVN administered clopidogrel 75 mg over three hours late. Both actions were against facility policies and physician orders.
The facility failed to maintain essential kitchen equipment, including the gas stove and convection ovens, in safe operating condition. Observations and interviews revealed that the double oven, single gas convection oven, and the bottom half of the double convection oven were non-functional, potentially delaying meal service for residents. The dietary manager and the administrator acknowledged the need for the equipment to be in working order.
The facility failed to ensure that six employees received the required effective communication training during their orientation or annually. This deficiency was identified through a review of employee files and training records, and both the DON and the Administrator acknowledged the oversight. The HR representative indicated an issue with the computer-based training system.
The facility failed to ensure that staff members were educated on resident rights and facility responsibilities during orientation and annually. Three employees did not complete the necessary training, which could affect residents by leaving them uninformed. Interviews revealed an issue with the computer-based training system, which failed to trigger the required training.
The facility failed to ensure that an OT and LVN completed dementia management training during orientation, and the OT also did not complete ANE training. Additionally, a Housekeeper did not complete the annual ANE training. The DON and Administrator acknowledged the oversight, and an issue with the computer-based training system was identified as a contributing factor.
The facility failed to ensure QAPI training was completed for 15 out of 21 employees reviewed, including the Administrator, BOM, DON, and several LVNs and CNAs. This oversight was due to an issue with the computer-based training system, which did not trigger the required trainings. The lack of training could result in residents not receiving necessary care.
The facility failed to ensure that infection prevention and control training was completed for four staff members, including during orientation and annual training. The DON and Administrator acknowledged the issue, which was attributed to a failure in the computer-based training system.
The facility failed to ensure compliance and ethics training was completed for 21 employees during orientation and annually. Interviews with the DON, Administrator, and HR revealed that a computer-based training system issue prevented the required trainings from being triggered. This lapse could result in residents not receiving necessary care.
The facility failed to ensure that behavioral health training was completed for four employees, including an OT, LVN, CNA, and the Administrator. The training was not completed during orientation for the OT, LVN, and CNA, and the Administrator did not complete the annual training. Interviews revealed that the lack of training could result in residents not receiving necessary care, and an issue with the computer-based training system was identified.
The facility failed to consult with a resident's physician when there was a need to alter treatment for a UTI. The resident's prescribed Oxacillin IV was not administered as scheduled, and the physician was not notified of the missed dose or the pharmacy's indication that the dose was outside the recommended range. The DON confirmed that the medication should have been administered timely and any issues reported, but this protocol was not followed.
The facility failed to maintain a clean and homelike environment for a resident by not removing personal belongings from a previously discharged resident and not deep cleaning the room before the new resident's admission. This oversight was confirmed by the DON, ADON, and Housekeeping Supervisor.
The facility failed to refer a resident with a newly diagnosed mental disorder for a Level II resident review. Despite a new diagnosis of anxiety and a prescription for Depakote, no new PASRR Level 1 or PE was conducted. Staff interviews revealed lapses in the facility's procedures and the absence of a PASRR policy.
The facility failed to ensure accurate PASRR screening for a resident with mental illness, intellectual disability, or developmental disability. The resident was admitted without an accurate PASRR Level 1 screening, and the error was not corrected until after surveyor intervention. Interviews revealed that the previous MDS nurse was terminated for not performing required duties, and the new MDS nurse corrected the screening after being educated on PASRR forms.
The facility failed to administer ferrous gluconate as prescribed to a resident with anemia, due to an error in placing the order on the wrong MAR. The DON confirmed the medication was not given and acknowledged responsibility for the oversight.
The facility failed to ensure proper medication administration and monitoring for two residents. One resident received midodrine HCL despite blood pressure readings above the prescribed parameters, while another resident was not monitored for side effects of the anticoagulant Eliquis. Nursing staff admitted to misreading parameters and failing to document monitoring, leading to potential risks and complications.
The facility failed to monitor a resident for side effects of prescribed psychotropic medications, despite care plans indicating the need for such monitoring. Interviews revealed that the responsibility for adding monitoring into the system was not completed, leading to a deficiency in care.
The facility failed to ensure a CNA completed mandatory Abuse, Neglect, and Exploitation (ANE) and dementia management trainings during orientation. This deficiency was due to an issue with the computer-based training system, as confirmed by the DON, Administrator, and HR representative.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a male resident with severe cognitive impairment and total dependence on staff for toileting and hygiene. On the observed date, the resident was not provided with incontinence care for approximately 4.5 hours, from 9:30 a.m. until 1:45 p.m., despite being always incontinent of bowel and bladder and requiring substantial assistance for all activities of daily living. During this period, the resident was observed in various locations throughout the facility, including the dining room and common areas, but was not checked or changed by staff. When care was finally provided, the resident was found to have a wet brief and a recent bowel movement, though no skin breakdown was noted at that time. Interviews with CNAs and facility leadership confirmed that staff were expected to check residents for incontinence at least every two hours, but this was not consistently done. Staff reported relying on spot checks or passing by residents rather than following a scheduled rounding protocol. The facility did not have a specific policy on perineal or incontinence care, and the existing Activities of Daily Living policy only generally referenced providing necessary assistance. The lack of timely care placed the resident at risk for skin breakdown and infection, as acknowledged by the DON.
Failure to Accurately Document and Reconcile Controlled Medication Administration
Penalty
Summary
The facility failed to establish and maintain a system for the accurate receipt and disposition of controlled drugs, specifically Lorazepam, for one resident. Review of the controlled medication count sheet showed that Lorazepam tablets were signed out on multiple occasions, but there was no corresponding documentation on the Medication Administration Records (MARs) or in the nurse notes to indicate that the medication was actually administered to the resident. The controlled medication count sheet also did not indicate that any doses were wasted. Interviews with nursing staff and facility leadership confirmed that they could not verify administration of the medication based on available records, and acknowledged the discrepancy between the count sheet and the MARs. The resident involved was an older female with diagnoses including acute respiratory failure, generalized anxiety disorder, and autistic disorder. She had significant cognitive impairment and communication difficulties, as documented in her Minimum Data Set (MDS). At the time of observation, the resident was calm and unable to answer questions appropriately. The facility's policy required staff to document medication administration on the MAR immediately after giving each medication, but this was not followed in the instances identified, resulting in incomplete and inaccurate records for controlled substances.
Failure to Provide Timely, Quality Laboratory Services
Penalty
Summary
The facility failed to provide timely and quality laboratory services or tests to meet the needs of residents. This deficiency was identified during the survey process, indicating that the laboratory services did not meet the required standards for promptness or quality as needed by the residents. Specific details regarding the residents affected, the nature of the laboratory services delayed or lacking, or the circumstances leading to the deficiency are not provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from abuse and neglect, resulting in two separate incidents involving three residents. In the first incident, a female resident with a history of PTSD, anxiety disorder, and schizophrenia was inappropriately touched by a male resident during a smoke break. The male resident, who had diagnoses including metabolic encephalopathy and personality disorder, was witnessed by staff touching the female resident's face, hair, and breast area without her consent. The female resident expressed that she did not want to be touched, and staff intervened immediately after witnessing the event. The incident was reported to the police, and both residents were assessed by medical and psychiatric staff. The female resident later reported feeling angry and fearful as a result of the incident. In the second incident, a male resident with severe cognitive impairment, schizophrenia, and Alzheimer's disease was involved in a physical altercation with the same male resident who had previously committed the inappropriate touching. The altercation occurred in the early morning hours and was unwitnessed by staff. The cognitively impaired resident was found with injuries including skin tears, a raised area on the forehead, and a laceration to the upper lip. The male resident involved in both incidents admitted to hitting the other resident, stating he was defending himself after the other resident entered his room. Staff interviews and documentation indicated that the cognitively impaired resident had a history of wandering into other residents' rooms due to his dementia. Both incidents were confirmed through observation, interviews, and record reviews. The facility's failure to prevent these incidents resulted in residents being exposed to sexual and physical abuse. The events were not prevented despite the known behavioral and cognitive issues of the residents involved, and the incidents were only addressed after they occurred. The survey identified these failures as past noncompliance, with Immediate Jeopardy beginning on the date of the first incident and ending after the second incident.
Failure to Provide Adequate Supervision and Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision and assistance devices to prevent accidents for two residents on the memory care unit. One resident with severe cognitive impairment and a history of wandering entered another resident's room during the night. This resident, who had diagnoses including Alzheimer's disease, schizoaffective disorder, and psychosis, was known to wander and had previously been redirected by staff when found in other residents' rooms. On the night of the incident, the resident wandered into another resident's room at approximately 4:00 a.m., resulting in a physical altercation. The resident sustained injuries including skin tears, a raised area on the forehead, and a laceration to the upper lip. The other resident involved, who had moderate cognitive impairment and a history of behavioral issues, reported defending himself and was found with blood on his hand. There was no incident report regarding the injuries, wandering, or altercation for either resident in the facility's records for that month. Staff interviews revealed that only two CNAs and one nurse were assigned to the memory care unit during the night shift, despite a significant number of residents with wandering behaviors. Staff reported that it was common for residents to wander into others' rooms and that redirection was frequently required. On the night of the incident, one CNA left her assigned hall to assist on the other side, leaving one area unattended. Staff also indicated that there was no additional staff assigned to monitor residents when two staff members were required to provide care elsewhere. The Director of Nursing and other staff stated that the staffing pattern was considered sufficient, but acknowledged that additional help was sometimes needed due to the high number of residents who wander. The facility's policies required the Director of Nursing or designee to evaluate staffing needs based on resident acuity and to provide additional staff or training if current levels were insufficient. However, prior to the incident, there was no evidence that interventions or increased supervision were implemented for residents at risk of wandering or altercations. The lack of adequate supervision and failure to implement appropriate interventions led to an Immediate Jeopardy finding by surveyors, as the facility did not ensure the safety of residents with known wandering and behavioral risks.
Failure to Maintain Laundry Equipment Results in Linen Shortages
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically in the laundry room where all four dryers were found to be nonfunctional. Observations and interviews revealed that the dryers had been out of service since the previous Friday, requiring the laundry supervisor to use an external laundromat to dry linens and residents' personal clothing. As a result, staff and residents reported a shortage of clean linens, with some residents noting that available linens were dingy, did not fit beds properly, had holes, or were stained and thin. Certified Nursing Assistants (CNAs) confirmed that linen closets were empty at times, and they had to search other halls or wait for clean linens to become available. Residents interviewed expressed dissatisfaction with the quality and availability of linens, stating that they had difficulty obtaining clean and suitable bedding and towels. The maintenance supervisor acknowledged awareness of the broken dryers, and the administrator confirmed that repairs were pending and that additional linens had been ordered. The facility's policy requires a safe, clean, and homelike environment, including the provision of clean bed and bath linens in good condition, which was not met during the period reviewed.
Medication Error Rate Exceeds 5% Due to Incorrect Administration and Unauthorized Substitution
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, as evidenced by 3 errors out of 27 observed opportunities, resulting in an 11.11% error rate. One resident, a female with diagnoses including bipolar disorder, diabetes mellitus type 2, myopia, and an intraocular lens, was administered Primidone in the morning instead of at hour of sleep as ordered by her physician. Additionally, she was given Artificial Tears instead of her prescribed Pataday eye drops, and the dosage administered was not consistent with the physician's order. The nurse responsible for the medication pass stated she was nervous due to being observed and using paper MARs during a Wi-Fi outage, which contributed to the errors. She also reported that she had not been supervised by the DON or administration during medication administration and had only trained with other charge nurses before working independently. The nurse further explained that she substituted Artificial Tears for Pataday based on information from the Central Supply Assistant, without obtaining a physician's order for the substitution. The Central Supply Assistant confirmed that Artificial Tears were kept in stock and Pataday required a special order, but no authorization was obtained for the substitution. The facility's medication administration policy requires medications to be given as prescribed, but this was not followed in these instances, resulting in the resident not receiving medications as ordered.
Expired Food Handler Certificates Among Dietary Staff
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service, as evidenced by three dietary staff members working with expired food handler certificates. Review of records showed that the food handler certificates for these staff members had expired in January 2025, and they continued to work full-time in the kitchen after their certifications had lapsed. Interviews revealed that the dietary manager was aware of the need for certificate renewal but did not ensure the process was completed, relying instead on staff to maintain their own certifications. The dietary manager acknowledged not following through to verify that renewals were completed, and the administrator stated that it was expected for staff to have valid certificates within 30 days of hire and before expiration. The facility's policy required ongoing education and training to ensure staff had the appropriate competencies for food and nutrition services. However, the lack of current food handler certificates for these dietary staff members indicated a failure to adhere to this policy. The deficiency was identified through record review and staff interviews, with the dietary manager and administrator both confirming the lapse in oversight and compliance with certification requirements.
Failure to Maintain Sanitary and Comfortable Staff Smoking Area
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the designated staff and visitor smoking area located in the courtyard between hall 200 and 300. During an observation, the grass in this area was found to be approximately 20 inches high, with weeds over 4 feet tall. Trash, including plastic wrappers, paper towels, and cigarette butts, was buried in the overgrown vegetation. This unkempt condition was directly observed and documented by surveyors. Interviews with maintenance staff revealed that the maintenance department was responsible for trash removal in the area, and that the area should be maintained to be homelike for residents. Maintenance staff acknowledged that tall grass could attract pests into the building. The maintenance worker reported that a contract lawn service was supposed to maintain the area, but the service had not been performed, and a weed eater had broken about a month prior. The Administrator confirmed ongoing difficulties in securing a lawn service and stated that the expectation was for the facility to be maintained in a homelike manner. Review of facility policy indicated that residents are to be provided with a safe, clean, comfortable, and homelike environment.
Environmental Deficiencies Impacting Resident Comfort and Safety
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, staff, and the public, as evidenced by multiple environmental deficiencies. Observations revealed that the courtyards used by residents were unkempt, with grass up to 20 inches high, weeds over 4 feet tall, and significant amounts of trash, including plastic wrappers, paper towels, and hundreds of cigarette butts. Maintenance staff acknowledged responsibility for these areas and noted that equipment failure and lack of contracted lawn service contributed to the neglect. Residents interviewed expressed dissatisfaction with the outdoor conditions, citing concerns about pests due to the tall grass. Inside the facility, two residents' rooms were found to have unrepaired damage, including missing trim, deep gouges in sheetrock, and exposed areas where paint was missing. One resident, who had dementia, blindness, and epilepsy, was observed to have a room with a 10-foot section of missing trim and a large area of damaged wall. Another resident, with a history of stroke and hypertension, reported that her room had deep gashes in the wall with exposed sheetrock and requested repairs. The Maintenance Director was unaware of these specific room conditions and confirmed that resident rooms should be free of such damage. Linen closets on two halls were inadequately stocked, with only a few sheets and towels available, many of which were discolored, stained, thin, or worn. Staff reported having to wait for linen or retrieve it from other halls, and residents complained about the poor quality and insufficient quantity of linens. Additionally, two exit doors had broken glass panes covered with cardboard and tape, a condition that had persisted for over five months. The Maintenance Director stated that he had reported the broken windows to the Administrator but had not received the necessary materials to make repairs.
Improper Administration of G-Tube Medications
Penalty
Summary
A deficiency was identified when a nurse failed to follow proper procedures for administering medications through a gastrostomy (G-tube) for a resident with a history of cerebral infarction, dysphagia, and who was NPO, requiring all nutrition, fluids, and medications via G-tube. The resident's care plan and physician orders specified that medications should be given one at a time, each diluted with water, and the tube flushed with water before and after each medication. The facility policy also required that medications not be mixed together unless there was a physician's order and that medications should be administered by gravity, not by using the syringe plunger. During a medication pass, the nurse crushed six tablets together, added a laxative powder and liquid medications, and mixed them all in a single cup with water, creating a medication cocktail. She then attempted to administer the entire mixture through the G-tube at once. When the mixture stopped flowing, she used the plunger of the syringe, inserting and rocking it to force the medication through the tube, rather than allowing it to flow by gravity as required by policy. The nurse acknowledged during interview that she did not have an order to mix the medications and that she was aware of the correct procedure but deviated from it because she was nervous during observation. The Director of Nursing confirmed that the facility policy was not followed, reiterating that medications should be given one at a time, diluted with water, and administered by gravity without use of the syringe plunger. The nurse had previously demonstrated competency in the correct procedure during skills observation, but failed to adhere to these standards during the observed medication administration.
Failure to Secure Controlled Medications and Resident Drugs
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in accordance with accepted professional principles, specifically by not having the lockbox for controlled medications permanently affixed to the refrigerator in one medication room. During an observation, the lockbox was found locked but not secured to the refrigerator, and staff interviews confirmed that it had previously been bolted but was no longer affixed. The Director of Nursing (DON) and the Administrator both acknowledged that the lockbox should have been permanently attached to prevent drug diversion, and neither could confirm when or why the bolts had been removed. Additionally, the facility failed to secure a resident's medication inside the locked medication cart. A medication card containing enalapril, prescribed for hypertension, was found left unattended and unsecured on top of the medication cart in a common area while the responsible nurse was away retrieving trays. The nurse admitted to leaving the medication card out and acknowledged that she was aware of the policy requiring all medications to be secured. Both the DON and the Administrator confirmed that all nurses were educated on the need to keep medications secured at all times.
Failure to Perform Hand Hygiene Between Residents During Feeding Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to perform proper hand hygiene while assisting with feeding a resident diagnosed with dementia who required maximum assistance with eating. The CNA was observed feeding the resident, then moving to assist another resident after performing hand hygiene, but subsequently returned to the first resident and resumed feeding without performing hand hygiene. This pattern was repeated, with the CNA alternating between residents and not consistently performing hand hygiene between each resident interaction as required by facility policy. The CNA acknowledged during the surveyor's intervention that she did not perform hand hygiene between residents, despite having received recent education on the subject and being aware of the policy. Interviews with the Director of Nursing (DON), Assistant Director of Nursing/Infection Preventionist (ADON/IP), and the Administrator confirmed that the CNA should have performed hand hygiene between each resident and that all staff had been educated on this requirement. The facility's policy on hand hygiene, which was reviewed, indicated that hand hygiene is required immediately before touching a resident and after contact with a resident or their environment. The failure to follow this protocol was directly observed and acknowledged by staff, constituting a breach in infection prevention and control practices.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two resident rooms and one shower room. Observations revealed that the shower room on Unit 100 Hall D was in disrepair, with issues such as peeling and rusted door frames, a missing sink drain, missing tiles, and a non-operable shower. Additionally, the light fixture was filled with debris, and the vent cover was coated with dirt and dust. Resident #3 reported these issues to staff, but no action was taken. The Administrator admitted to not being aware of the issues and acknowledged that staff were not properly informed of their responsibilities to report such conditions. In the resident rooms, cockroach infestations were observed in the nightstand drawers of two residents. Resident #1 reported the issue weeks prior, stating that cockroaches crawled on him at night, but no action was taken by the facility. Resident #2 also reported the presence of cockroaches but could not recall when or to whom. The Administrator was unaware of these reports and stated that the facility had a pest control log for staff to document such issues, which was not utilized effectively in this case. Interviews with the Maintenance Director and RT F revealed a lack of communication and follow-up regarding the reported issues. The Maintenance Director was not informed of the disrepair in the shower room or the cockroach infestation, and RT F admitted to documenting the cockroach issue in the pest control log but not informing the Administrator or Maintenance Director. The pest control log indicated a previous treatment for cockroaches, but no follow-up was conducted after the residents' reports.
Cockroach Infestation Due to Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a cockroach infestation in two resident rooms on Unit 2. During an observation, cockroaches were found in the nightstand drawers of two residents. One resident reported the issue weeks prior to the observation, stating that the cockroaches had been crawling on him at night, disrupting his sleep. The other resident also reported the presence of cockroaches in her room, including in the drawers, closet, and bathroom, but could not recall when or to whom she reported the issue. The facility's Administrator was unaware of the infestation reports and stated that the facility had a monthly pest control service and a log for staff to document pest issues. However, the Administrator admitted there was no policy for pest control. The pest control log indicated that cockroaches were reported on the entire D hall of Unit 2 on October 1st, but the Maintenance Director was not informed of these reports. The facility had been treated for cockroaches in early September, with the next treatment scheduled for October or as needed, but the specific date was unknown to the Maintenance Director.
Sanitation Deficiencies in Dining Room and Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation standards in the main dining room and kitchen, which could place residents at risk of foodborne illnesses. During an observation of the noon meal in the main dining room, an air conditioner return air vent was found to have thick dust approximately 1/4 inch thick on each slat, with air blowing through the vent slats. Both the dietary manager and the administrator acknowledged the issue, noting that the dust could potentially contaminate the residents' food. The housekeeping staff was identified as responsible for cleaning the vent, but it had not been maintained properly. In the kitchen, multiple pieces of equipment were found to be in disrepair and unsanitary. The three-compartment sink had rusted metal parts, chipped paint, and a leaking left sink, which had caused water damage to the wall behind it. Additionally, two refrigerators had rust lines down their doors, and metal shelves over the juice machine were rusted and unsanitizable. The double oven was found to be non-functional and had thick black buildup inside. The steam table's water wells and base were also rusted and unsanitizable. The dietary manager and dietitian confirmed these issues, stating that the equipment had been in this condition for at least a year and needed to be replaced. The facility's policies on maintaining clean and sanitary food preparation and service areas were not followed. The public health department had previously identified some of these issues, but they had not been addressed. The administrator and dietary manager both acknowledged that the kitchen equipment was not in working order and posed a risk of contamination to the residents' food. The facility's failure to maintain sanitary conditions in the dining room and kitchen could lead to residents ingesting harmful particles, such as dust and rust, from the unsanitizable equipment.
Inaccurate Resident Assessments
Penalty
Summary
The facility failed to ensure accurate resident assessments for two residents. Resident #13's assessment did not reflect her status as a tobacco user, despite multiple records indicating she was a smoker. This included a smoker list, a smoking assessment, and a care plan. An interview with an LVN confirmed that Resident #13 smoked occasionally and required monitoring of her oxygen saturation levels due to a previous episode of low oxygen levels. However, her Significant Change MDS inaccurately marked her as a non-smoker. Similarly, the facility failed to accurately assess Resident #109, whose diagnosis of anxiety disorder was not reflected in her MDS assessments. Despite nurse notes and physician orders indicating that Resident #109 was prescribed Depakote for anxiety, her MDS assessments did not include this diagnosis. Interviews with the DON and the Administrator revealed that the previous MDS nurse had not been filling out the assessments correctly, and there was no specific policy in place, only adherence to the MDS RAI manual.
Failure to Apply Splint for Resident with Contractures
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, the facility did not ensure that a splint was placed in the resident's contracted right hand as ordered. The resident, who had a history of right-sided hemiplegia and cerebrovascular disease, was observed multiple times without the splint in place, and the task sheet did not indicate that the splint was applied on several occasions. Interviews with the resident and staff revealed that the splint was not placed on the resident's hand on multiple days, and the staff responsible for this task were either unaware of their responsibilities or were too busy with other duties. The restorative aide, who was primarily responsible for ensuring the splint was applied, was off for two days and did not communicate the need for assistance to the transportation driver, who was trained in restorative care. The Director of Nursing (DON) confirmed that the nurses were not responsible for this task as it was not included in their Medication Administration Record (MAR). Further interviews indicated a lack of clear communication and responsibility among the staff regarding the application of the splint. The facility did not have a policy on contracture or splint management, which contributed to the oversight. The resident expressed a desire to have the splint placed in her hand, and staff acknowledged the potential negative outcomes of not applying the splint, including worsening contractures and possible skin damage from the resident's nails.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5 percent, resulting in an 8 percent error rate involving two residents. The first error involved a Licensed Vocational Nurse (LVN) administering midodrine HCL 5 mg to a resident with a blood pressure reading of 127/47, which was outside the prescribed parameters. The LVN admitted to misreading the parameter and acknowledged that the medication should have been held. The Director of Nursing (DON) and the administrator confirmed that the medication should have been held according to the physician's orders. The second error involved another LVN administering clopidogrel 75 mg to a resident over three hours past the designated administration time of 7:00 a.m. The LVN admitted to running late and provided no other reason for the delay. The DON stated that medications should be administered within one hour of their prescribed time and that no nurses had reported any delays in medication administration. Facility policies confirmed that medications should be administered according to prescriber orders and within the specified time frame.
Failure to Maintain Kitchen Equipment in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in safe operating condition, specifically the gas stove and convection ovens. During observations and interviews, it was noted that the double oven had a thick black substance on its interior walls, metal racks, and base, and had not been operational for about a year. The dietary manager confirmed that there was no open work order for the oven's repair. Additionally, the single gas convection oven and the bottom half of the double convection oven were also non-functional, leaving only the top section of the double convection oven available for use. This limited the kitchen's ability to prepare meals efficiently, as cooks had to wait for the oven to become available to bake different items, potentially delaying meal service for residents. The dietary manager and the administrator both acknowledged that the broken equipment should be in working order to ensure timely meal preparation and service. The facility's Equipment policy, dated January 2001, stated that all food service equipment should be clean, sanitary, and in proper working order. The FDA Food Code 2022 also requires that equipment be maintained in a state of repair and condition that meets specified requirements. The failure to maintain the kitchen equipment in safe operating condition could result in delays in meal service for residents, as confirmed by the dietary manager and the administrator during their interviews.
Failure to Ensure Effective Communication Training for Staff
Penalty
Summary
The facility failed to ensure that six employees received the required effective communication training during their orientation or annually. Specifically, LVN F, ST, PT, CNA K, and CNA M did not complete the communication training during their orientation, and HS did not complete the annual communication training. This deficiency was identified through a review of employee files and training records, which showed that the required training was not completed for these staff members. The Director of Nursing (DON) and the Administrator both acknowledged that the training was expected to be completed during orientation and annually, and they recognized that the lack of training could impact the care provided to residents. During interviews, the DON and the Administrator confirmed that all required trainings should be completed as per the facility's policy. The HR representative indicated that there was an issue with the computer-based training system, which failed to trigger the required trainings for staff during orientation and annually. The facility's Training Programs policy, dated October 2021, stated that employees would be provided with the necessary training to meet state and federal regulations. However, the failure to ensure that the effective communication training was completed as required led to this deficiency being cited.
Failure to Ensure Staff Training on Resident Rights and Facility Responsibilities
Penalty
Summary
The facility failed to ensure that staff members were educated on resident rights and facility responsibilities, as required during orientation and annually. Specifically, three employees (an Occupational Therapist, a Certified Nursing Assistant, and a Housekeeper) did not complete the necessary training. The Occupational Therapist and Certified Nursing Assistant did not complete the training during their orientation, and the Housekeeper did not complete the annual training as required. This lapse in training could affect residents by leaving them uninformed due to the lack of staff training. Interviews with the Director of Nursing, the Administrator, and the Human Resources Director revealed that there was an issue with the computer-based training system, which failed to trigger the required training for staff during orientation and annually. The Director of Nursing and the Administrator both indicated that they expected all required trainings to be completed during orientation and annually. The Human Resources Director acknowledged the issue with the training system and its failure to ensure that staff completed the necessary training. The facility's Training Programs policy, dated October 2021, mandates that employees receive appropriate training upon hire and on an ongoing basis to meet state and federal regulations.
Failure to Ensure Required Staff Training on ANE and Dementia Management
Penalty
Summary
The facility failed to ensure that employees received the required training on Abuse, Neglect, and Exploitation (ANE) and dementia management. Specifically, the Occupational Therapist (OT) and Licensed Vocational Nurse (LVN C) did not complete dementia management training during orientation, and the OT also did not complete ANE training during orientation. Additionally, the Housekeeper (HS) did not complete the annual ANE training as required. These deficiencies were identified through interviews and record reviews, which revealed gaps in the training records of these employees. The Director of Nursing (DON) and the Administrator both acknowledged that the required trainings were not completed and expressed concerns that this could negatively impact the quality of care provided to residents, particularly those with dementia. The report also highlighted an issue with the computer-based training system, which failed to trigger the required trainings for staff during orientation and annually. The facility's Training Programs policy, dated October 2021, mandates that employees receive appropriate training upon hire and on an ongoing basis to meet state and federal regulations. However, the failure to ensure that the OT, LVN C, and HS completed their required trainings indicates a lapse in the facility's adherence to this policy. The HR Director confirmed the issue with the training system, which contributed to the oversight in ensuring that staff received the necessary training.
Failure to Complete QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that Quality Assurance and Performance Improvement (QAPI) training was completed for 15 out of 21 employees reviewed. The employees who did not receive the required training included the Administrator, BOM, DON, ST, PT, SW, AD, several LVNs, and CNAs. This lack of training was identified through a review of employee files, which showed that the QAPI training was not conducted for these staff members. Interviews with the DON and Administrator revealed that they expected all required trainings to be completed during orientation and annually, but this did not occur due to an issue with the computer-based training system that failed to trigger the required trainings for staff. The DON indicated that the absence of these trainings could result in residents not receiving the necessary care. The Administrator acknowledged that it was ultimately her responsibility to ensure that staff completed their trainings. The HR representative confirmed that there was a problem with the computer-based training system, which led to the oversight. The facility's Training Programs policy, dated October 2021, stated that employees should receive appropriate training upon hire and on an ongoing basis to meet state and federal regulations, but this policy was not followed in this instance.
Infection Prevention and Control Training Deficiency
Penalty
Summary
The facility failed to ensure that standards, policies, and procedures for an infection prevention and control program were completed for four of 21 staff members reviewed for training. Specifically, the Occupational Therapist (OT), Licensed Vocational Nurse (LVN C), and Certified Nursing Assistant (CNA M) did not complete the required infection prevention and control training during their orientation periods. Additionally, the Housekeeper (HS) did not complete the required annual infection prevention and control training. These deficiencies were identified through a review of employee files and confirmed during interviews with the Director of Nursing (DON), the Administrator, and the Human Resources (HR) representative. The DON and Administrator both acknowledged that the lack of required training could result in residents not receiving the necessary care. The HR representative indicated that there was an issue with the computer-based training system, which failed to trigger the required training modules for both orientation and annual training. The facility's Training Programs policy, dated October 2021, mandates that employees receive appropriate training upon hire and on an ongoing basis to meet state and federal regulations. However, this policy was not adhered to in the cases of the OT, LVN C, CNA M, and HS, leading to the identified deficiencies.
Failure to Ensure Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure compliance and ethics training was completed for 21 of 21 employees reviewed for training. Specifically, the facility did not ensure that compliance and ethics training was completed during orientation for several staff members, including the BOM, ADON, multiple LVNs, ST, OT, PT, SW, MD, and several CNAs. Additionally, the facility did not ensure that annual compliance and ethics training was completed for the Administrator, DON, several LVNs, AD, HS, and several CNAs. This failure was identified through record review and interviews with staff members, including the DON, Administrator, and HR, who acknowledged the lapses in training and attributed the issue to a problem with the computer-based training system not triggering the required trainings. During interviews, the DON and Administrator both indicated that they expected all required trainings to be completed during orientation and annually as mandated. They acknowledged that the lack of training could result in residents not receiving the necessary care. The HR representative confirmed that there was an issue with the computer-based training system, which failed to trigger the required trainings for staff. The facility's Training Programs policy, dated October 2021, stated that employees would be provided with the necessary training to meet state and federal regulations, and that the Director of Staff Development and HR Director were responsible for ensuring these training needs were met. However, this policy was not effectively implemented, leading to the identified deficiencies.
Failure to Complete Behavioral Health Training
Penalty
Summary
The facility failed to ensure that behavioral health training was completed for four of the 21 employees reviewed. Specifically, the Occupational Therapist (OT), Licensed Vocational Nurse (LVN C), and Certified Nursing Assistant (CNA M) did not complete the required behavioral health training during their orientation. Additionally, the Administrator did not complete the annual behavioral health training as required. This lapse in training was identified through a review of employee files, which showed that the OT, LVN C, and CNA M, hired on 09/28/23, 07/12/23, and 12/07/23 respectively, had not completed the necessary training. The Administrator, hired on 01/17/23, last completed behavioral health training on 01/24/23, failing to meet the annual requirement. Interviews with the Director of Nursing (DON) and the Administrator revealed that both expected all required trainings to be completed during orientation and annually. The DON acknowledged that the lack of training could result in residents not receiving the necessary care. The Administrator admitted that it was ultimately her responsibility to ensure staff completed their trainings. An interview with the HR representative indicated that there was an issue with the computer-based training system, which failed to trigger the required trainings for staff during orientation and annually. The facility's Training Programs policy, dated October 2021, mandates that employees receive appropriate training upon hire and on an ongoing basis to meet state and federal regulations, a requirement that was not met in this instance.
Failure to Notify Physician and Administer Medication as Prescribed
Penalty
Summary
The facility failed to consult with the resident's physician when there was a need to alter treatment for a resident diagnosed with a urinary tract infection (UTI), altered mental status, and heart disease. The resident had an order for Oxacillin Sodium in dextrose IV solution to be administered every 6 hours for 5 days, starting on 04/30/24. However, the medication was not administered as scheduled at 6:00 a.m., and the physician was not notified of the missed dose. Additionally, the pharmacy indicated that the prescribed dose was outside the recommended range, but the physician was not consulted regarding this discrepancy. During an observation, it was noted that the resident did not have an IV infusing, and the resident was unaware of the antibiotic order. The LVN responsible for administering the medication acknowledged the delay but did not provide a valid reason for the missed dose. The Director of Nursing (DON) confirmed that the expectation was for medications to be administered as ordered and in a timely manner, and that any issues should be reported to the physician and herself. The DON also noted that the computer system would flag orders outside the recommended dose or frequency, prompting the nurse to call the physician, which did not occur in this case. The facility's policy on administering medications emphasized the importance of timely and accurate administration, but this protocol was not followed, leading to the deficiency.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for Resident #92. Upon admission, Resident #92's room contained personal belongings from a previously discharged resident, including boxes, bags, and a plastic chest with items such as female clothes and stuffed animals. This oversight was confirmed during an observation and interview with Resident #92, who was unsure about the items in his room. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the room should have been deep cleaned and all personal belongings removed before being assigned to a new resident to prevent the spread of germs and ensure a clean environment. The Housekeeping Supervisor also confirmed that her team is responsible for cleaning rooms of discharged residents once personal belongings are removed. She stated that there is a designated place for donated clothes and that all rooms should be cleaned prior to being occupied by new residents. However, in this instance, the room was not properly cleaned, and the personal belongings were not removed, leading to a failure in providing a safe and clean environment for Resident #92, who has a history of urinary tract infection, altered mental status, and heart disease.
Failure to Conduct PASRR Level II Review for New Mental Disorder Diagnosis
Penalty
Summary
The facility failed to refer a resident with a newly diagnosed mental disorder for a Level II resident review upon a significant change of condition. Specifically, Resident #109, a [AGE] year-old female with a history of depression and diabetes mellitus type 2, was diagnosed with anxiety by the NP on 02/21/24 and prescribed Depakote. Despite this new diagnosis and medication, no new PASRR Level 1 or PE was conducted for the resident, as confirmed by record reviews and staff interviews. During interviews, the Corporate MDS/PASRR Nurse and the DON acknowledged that a new PASRR Level 1 should have been completed and a referral for PE should have been made following the new diagnosis. The DON also revealed that the previous MDS nurse had not been properly checking PASRRs and that the facility lacked a PASRR policy. The Administrator confirmed that PASRRs were expected to be reviewed and completed correctly, indicating a lapse in the facility's procedures for ensuring residents receive necessary services.
Failure to Ensure Accurate PASRR Screening for Resident
Penalty
Summary
The facility failed to ensure preadmission screening for individuals identified with mental illness (MI), intellectual disability (ID), or developmental disability (DD) were evaluated for services for one resident. Resident #415, a [AGE] year-old female with diagnoses including psychosis, dementia, and anxiety disorder, was admitted without an accurate PASRR Level 1 screening. The initial screening completed by the transferring facility incorrectly indicated that the resident was negative for MI, ID, and DD, and there was no PASRR Level II Screening or Form 1012 found in the clinical record from the resident's admission date to 04/29/24. Despite being prescribed antipsychotic and anti-anxiety medications, the resident's PASRR Level 1 screening was not corrected until after surveyor intervention on 04/30/24. Interviews with facility staff revealed that the previous MDS nurse, who was responsible for PASRR forms, had been terminated for not performing required duties and incorrect documentation. The new MDS nurse, who took over the responsibility, was educated on PASRR forms on 04/29/24 and completed a new PL1 form for Resident #415 on 04/30/24. The Director of Nursing (DON) and the Administrator acknowledged that the PL1 form should have been corrected sooner and that the risk of an incorrect PL1 form was that a resident could miss out on qualifying services. The facility did not have a specific PASRR policy and followed the Resident Assessment Instrument (RAI) guidelines instead.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to ensure pharmaceutical services were provided to meet the needs of Resident #92, who was admitted with diagnoses including urinary tract infection, altered mental status, and heart disease. The physician had ordered ferrous gluconate 324 mg to be administered once daily starting on 04/18/2024. However, a review of the Medication Administration Record (MAR) revealed that the medication was not given from 04/18/2024 to 04/29/2024, and there were no initials indicating it had been administered. The Director of Nursing (DON) confirmed that the medication was not given due to an error in placing the order on the Medication Aide MAR instead of the Nurse MAR, despite the facility not using medication aides. The DON acknowledged responsibility for ensuring medications were correctly placed on the MARs and stated she would contact the physician regarding the missed doses. Resident #92's care plan, dated 12/06/2023, included interventions for managing anemia, such as educating the resident and caregivers about potential changes in stool color and monitoring for side effects and symptoms of anemia. The failure to administer the prescribed iron supplement as ordered by the physician could have impacted the resident's treatment for anemia. The facility's policy on administering medication, dated April 2019, emphasized that medications should be administered safely, timely, and as prescribed, which was not adhered to in this case.
Failure to Monitor Medication Administration and Side Effects
Penalty
Summary
The facility failed to ensure each resident's drug regimen was free from unnecessary drugs and adequately monitored for two residents. Resident #58 was prescribed midodrine HCL for hypotension with specific parameters to hold the medication if the systolic blood pressure (SBP) was greater than 100. Despite these parameters, the medication was administered multiple times when the resident's SBP was above the threshold, indicating a failure to follow physician orders. This was confirmed through record reviews and interviews with the nursing staff, who admitted to misreading the parameters and administering the medication incorrectly, thereby putting the resident at risk of hypertension and other complications. Resident #415 was prescribed Eliquis, an anticoagulant medication, for atrial fibrillation. The facility failed to monitor the resident for side effects of the medication from the start date of 04/12/24 to 04/29/24. The care plan indicated the need for monitoring, but the electronic records showed no documentation of such monitoring. Interviews with the nursing staff revealed that they were aware of the need to monitor for side effects but failed to document it properly. The Director of Nursing (DON) and the Administrator confirmed that the monitoring was overlooked, which could lead to potential adverse reactions and side effects from the medication. The facility's policies on administering medications and monitoring anticoagulant therapy were not followed, as evidenced by the lack of proper documentation and adherence to prescribed parameters. The DON and the Administrator acknowledged the deficiencies and the associated risks, emphasizing the importance of following physician orders and monitoring for side effects. The failure to adhere to these protocols resulted in the residents not receiving the intended therapeutic effects of their medications and being placed at risk of complications.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure that Resident #415, who was prescribed psychotropic medications, received appropriate monitoring for side effects and gradual dose reductions as required. The resident, a [AGE]-year-old female with diagnoses of psychosis and anxiety, was prescribed Abilify, buspirone, and quetiapine fumarate. Despite the care plan indicating the need for monitoring for side effects and effectiveness of these medications every shift, the nurses did not document such monitoring in the electronic record from 04/11/24 to 04/29/24. During interviews, LVNs and the DON acknowledged that the monitoring for side effects was not documented correctly, although they were aware of the requirement. The LVNs admitted that the responsibility for adding monitoring into the computer system fell on the admitting nurse, and in this case, it was not completed. The DON confirmed that the oversight in monitoring could lead to potential adverse reactions and side effects, and that the expectation was for all medications to be given as ordered and monitored for side effects as required. The facility's policy on antipsychotic medication use, revised in July 2022, mandates that such medications be prescribed at the lowest possible dosage for the shortest period and be subject to gradual dose reduction and re-review. Nursing staff are required to monitor and report any side effects and adverse consequences to the attending physician. However, this policy was not followed for Resident #415, leading to a deficiency in care.
Failure to Complete Mandatory Trainings for CNA
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA), identified as CNA M, completed mandatory Abuse, Neglect, and Exploitation (ANE) and dementia management trainings during orientation. CNA M, who was hired on December 7, 2023, did not receive these essential trainings, which are required to provide adequate care for residents, particularly those with dementia. This lapse was identified through a review of employee files and confirmed during interviews with the Director of Nursing (DON) and the Administrator, both of whom acknowledged the importance of these trainings and the potential negative impact on resident care if they are not completed as required. The facility's Training Programs policy, dated October 2021, mandates that employees receive necessary training upon hire and on an ongoing basis to meet state and federal regulations. However, an issue with the computer-based training system failed to trigger the required trainings for staff during orientation and annually. This oversight was confirmed by the Human Resources (HR) representative during an interview. The DON and the Administrator both expressed that the lack of required training could result in residents not receiving the care they need, highlighting a significant deficiency in the facility's training program.
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.
