Avir At Beeville

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide required written notice of transfer or discharge to a resident and his responsible party (RP). A male resident with schizoaffective disorder and dementia, who had an initial admission date of 06/14/25 and a discharge date of 03/25/26, was discharged to another facility without receiving written notice of the discharge, the reasons for the move, or related rights. His Discharge MDS showed a BIMS score of 3, indicating severe cognitive impairment, and his care plan documented behavior problems related to dementia, including physical aggression, yelling, swinging at staff, urinating in inappropriate areas, and episodes of sexual inappropriateness toward staff. The Discharge Summary indicated he was discharged early in the morning, released to a different facility, his RP was notified, and he was not expected to return. During interviews, the DON acknowledged that no formal written discharge notice was given to the RP, explaining that the transfer had been agreed upon by the RP and that no one disputed the discharge. The DON stated she verbally informed the RP the day before the discharge and that the facility had been searching for a new facility for the resident due to ongoing issues, describing the discharge as urgent because the resident posed a safety risk to himself and others. The ADM also confirmed that, to her knowledge, no written discharge notice was provided, and stated she was usually responsible for sending discharge notices when appropriate. Both the DON and ADM recognized that important information not written down and provided to the RP could be forgotten after a meeting. Review of the facility’s transfer and discharge policy showed it did not specify that a formal written discharge notice must be given to the RP when health and safety of others are at risk.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect multiple residents from physical abuse by other residents, resulting in several altercations. In one incident, a male resident with severe cognitive impairment and a history of physical and verbal behaviors was involved in a physical altercation with another male resident, also with severely impaired cognition and a history of aggression. The altercation occurred when one resident attempted to assist the other, leading to both residents striking each other. Staff attempted to redirect and separate the residents, but the altercation still occurred, and both residents were assessed afterward. Another incident involved two female residents, both with dementia and significant cognitive impairment. One resident, who had a history of aggressive behaviors and delusions, initiated a physical altercation in the hallway by grabbing and hitting another resident after a verbal exchange. The second resident sustained a superficial abrasion and complained of elbow pain. Staff responded by separating the residents and assessing for injuries. Both residents had documented behavioral issues and required supervision and monitoring, but the altercation still took place. In both cases, the residents involved had known behavioral and cognitive challenges, including histories of aggression, delusions, and difficulty with redirection. Care plans for these residents included interventions such as monitoring for danger to self or others, analyzing triggers, and providing cues to alleviate anxiety. Despite these interventions, the facility did not prevent the physical altercations, and residents were not adequately protected from abuse by other residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a wound care nurse (WCN) failed to perform proper hand hygiene before and after providing wound care to a resident. Specifically, the WCN washed her hands for approximately 9 seconds prior to wound care and for about 18 seconds after completing the procedure, both of which were less than the facility's policy requirement of at least 20 seconds. The resident involved was an elderly female with multiple diagnoses, including Alzheimer's disease, dementia, cerebral infarction, chronic atrial fibrillation, and hypertension, and had a stage four pressure injury to the coccyx requiring daily wound care as ordered by her physician. Interviews with the WCN, Director of Nursing (DON), and Staff Development Nurse confirmed that staff are expected to perform hand hygiene for a minimum of 20 seconds, using methods such as singing "Happy Birthday" twice or counting to 20 seconds to ensure thorough cleaning. The facility's hand hygiene policy and procedure forms also specify a minimum of 20 seconds for handwashing. Despite recent competency checks indicating no concerns, the WCN did not meet the required hand hygiene duration during the observed wound care procedure.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A certified nursing assistant (CNA) failed to properly don the required personal protective equipment (PPE) before entering the room of a resident who was COVID-19 positive and on contact, droplet, and airborne precautions. The CNA entered the resident's room wearing gloves, a gown, and an N95 respirator over a surgical mask, but did not wear any eye protection or face shield as required by facility policy and CDC guidelines. The CNA remained in the resident's room for approximately ten minutes without the appropriate eye protection. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease, type 2 diabetes mellitus, and hypertensive heart disease, and was confirmed COVID-19 positive at the time of the incident. Facility records indicated that the resident was on isolation precautions, and signage on the resident's door specified the need for contact, droplet, and airborne precautions. The CNA stated she was trained to use an N95 mask but was not specifically instructed about not wearing a surgical mask underneath, and she was unaware of the need for eye protection, despite competency validation records indicating she had been trained in proper PPE use. Interviews with the infection preventionist and the director of nursing confirmed that the CNA did not follow facility policy regarding PPE use, specifically the requirement for eye protection and the correct use of the N95 respirator. Both staff members stated that appropriate PPE, including N95 masks and eye protection, was available and that staff had been trained on these procedures. The facility's policy required adherence to CDC-recommended infection prevention and control practices, including the use of appropriate PPE for residents on transmission-based precautions.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide pharmaceutical services to meet the needs of a resident by not administering the prescribed anticoagulant medication, Eliquis 5mg BID, over a four-day period. The medication was not given from 01/03/2025 to 01/06/2025 because it was unavailable, and no refill was requested by the clinical staff. Both the LVN and RN involved documented the medication as unavailable but did not notify the Director of Nursing (DON) or the physician about the missed doses or the need for a refill. The DON was only made aware of the missed doses after being informed by a federal government agent during a record review on 01/17/2025. The resident involved had significant medical conditions, including paroxysmal atrial fibrillation, atherosclerosis, venous insufficiency, and chronic heart failure, and was dependent on staff for activities of daily living with severe cognitive impairment. The resident's care plan and physician orders specifically required the administration of Eliquis to manage the risk of blood clots associated with his cardiac conditions. Despite clear protocols for medication administration and refills, the staff did not follow procedures to ensure the resident received his prescribed medication, nor did they escalate the issue when the medication was not available. Interviews with the involved nursing staff revealed that neither took steps to notify supervisory staff or the physician about the medication shortage, and both relied on documentation or informal communication with colleagues rather than following established protocols. The DON confirmed that she was not notified of the issue and that the facility had procedures in place for medication refills and emergency medication access, which were not utilized. The failure to administer the prescribed anticoagulant as ordered constituted a deficiency in pharmaceutical services for the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident receiving enteral feeding received appropriate care and services to prevent complications. Specifically, the facility did not verify the placement and check the residual of the resident's G-tube before administering water and medications. This oversight was observed during a medication administration session where the LVN did not check the placement or residual of the G-tube prior to flushing it with water and administering medications. The LVN admitted to forgetting this crucial step, acknowledging that it is necessary to ensure the G-tube is correctly positioned to prevent medications from being delivered to the wrong location in the body. The resident involved was an elderly female with a history of dysphagia, aphasia, cerebral infarction, Alzheimer's, dementia, hemiplegia, and gastrostomy status. Her care plan included the use of a feeding tube, and physician orders specified an NPO diet with enteral feed orders to flush the tube with water before and after medications. The Director of Nursing confirmed that the procedure for administering medications through an enteral tube includes checking the residual to ensure the tube is patent. The facility's policy on administering medications through an enteral tube also emphasizes verifying the placement of the feeding tube to prevent improper administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate respiratory care to a resident who required oxygen therapy, as observed during a survey. The resident, who had a history of Chronic Obstructive Pulmonary Disease (COPD), cerebral infarction, severe vascular dementia, and generalized muscle weakness, was found with her oxygen tubing not connected to the concentrator. The nasal prongs were incorrectly positioned on her cheek instead of her nostrils, and the oxygen concentrator was on but not delivering oxygen. This oversight was discovered while a Licensed Vocational Nurse (LVN) was administering medications through the resident's feeding tube. The LVN, responsible for the resident's care, was unaware of the disconnection until informed by the surveyor. Upon checking, the resident's oxygen saturation was at 89%, which is considered low. After correcting the tubing placement and connection, the saturation improved to 97%. The LVN admitted to not recalling the last time he received in-service training on respiratory care. The Director of Nursing (DON) confirmed that the LVN was responsible for checking oxygen administration during each shift and while providing care, acknowledging that failure to do so could lead to hypoxia and respiratory distress.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate. This was based on 2 errors out of 25 opportunities, involving a resident who was administered medications via a Gastrostomy tube (G-Tube). The resident, who had a history of dysphagia, aphasia, cerebral infarction, Alzheimer's, dementia, hemiplegia, pain, and gastrostomy status, was prescribed Acetaminophen-Codeine for pain and Memantine for Alzheimer's. During medication administration, it was observed that residual medication remained in the cups used for the crushed tablets, indicating that the full dose was not administered. The Licensed Vocational Nurse (LVN) responsible for administering the medications did not notice the residual medication left in the cups. The Director of Nursing (DON) confirmed that the expectation was for no residual to remain and that additional water should be used to ensure the full dose is given. The facility's policy on administering medications through an enteral tube required diluting crushed medications with at least 30ml of purified water, which was not adequately followed, leading to the medication errors.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety by not ensuring that unit refrigerators were free of unlabeled and undated items. During an observation, it was found that unit 1 contained an unlabeled and undated near-empty bottle of salad dressing, while unit 2 had three bottles of water, a hamburger bun, a hamburger patty, and a near-empty container of orange juice, all without labels or dates. This oversight could potentially expose residents to foodborne illnesses due to cross-contamination. Interviews with two LVNs revealed that the refrigerators were kept locked for patient safety, with only the nurse holding the key. Both LVNs acknowledged the importance of labeling and dating items to prevent cross-contamination and stated that they were unaware of how the unlabeled items ended up in the refrigerators. The DON confirmed that the LVNs were trained and reminded about the importance of labeling and dating items. A review of the facility's policy indicated that food brought by family or visitors should be labeled and stored properly, but there was no specific policy provided regarding food storage in unit refrigerators.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by several observed deficiencies involving staff members and residents. One incident involved an LVN who did not remove his gloves after preparing insulin medication for a resident with multiple health conditions, including diabetes and heart disease. The LVN proceeded to administer the medication without changing gloves, acknowledging that he forgot to do so, which could lead to contamination. Another deficiency was observed with the same LVN during medication administration for a resident with severe cognitive impairment and a feeding tube. The LVN failed to wash his hands or use hand sanitizer between glove changes, admitting that he forgot to perform hand hygiene. This oversight was recognized by the LVN as a potential cause of contamination and infection spread among residents. A third incident involved an LVN performing wound care on a resident with severe cognitive impairment and at risk for skin breakdown. The LVN washed her hands for only 11 seconds after removing gloves, contrary to the facility's policy of washing hands for at least 20 seconds. The LVN believed she had washed her hands long enough by singing the Happy Birthday song twice in her head, but acknowledged the importance of proper handwashing to prevent infection spread.

Penalty

Inspection fine: $38,687

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents from sexual abuse, leading to a deficiency identified by surveyors. Resident #2, a female with severe cognitive impairment, was not adequately supervised, resulting in an incident where Resident #3, a male with Alzheimer's disease but cognitively intact, was recorded touching Resident #2 inappropriately. The incident was captured on video by Resident #2's family member, who reported it to the facility the following day. Despite Resident #2's cognitive impairment, which rendered her unable to consent to sexual activities, the facility did not have measures in place to prevent such interactions. Resident #2's care plan indicated severe cognitive impairment and a history of attention-seeking behavior from males, yet the facility did not implement specific supervision interventions to prevent inappropriate interactions. The care plan also noted Resident #2's tendency to make inappropriate sexual comments and false accusations, but there was no evidence of updated supervision strategies following the incident. The facility's staff, including the DON and Administrator, were unaware of the incident until it was reported by the family, indicating a lack of proactive monitoring and supervision. The facility's policy required immediate reporting and investigation of abuse allegations, but there was a delay in recognizing and addressing the incident. The staff were not adequately trained or prepared to handle such situations, as evidenced by the lack of in-service documentation and specific monitoring for Resident #2. The facility's failure to protect Resident #2 from potential harm and abuse highlights deficiencies in supervision, staff training, and adherence to abuse prevention policies.

Removal Plan

• Resident #3 discharged from Birchwood of Beeville.
• Resident #2 was assessed and found to be in no immediate physical or mental harm safety check in place.
• 26 Interview able residents have been identified and resident safe surveys were initiated.
• Review of the F-tag 600.
• Medical Director notified.
• DON and the Administrator were in-serviced over the abuse and neglect policy and procedure by the Chief Operating Officer.
• One to one staff supervision or safety checks will be applied to any resident who alleges abuse and or causes abuse until the investigation is thoroughly completed.
• The Abuse and Neglect Policy and Procedure (identifying sexual abuse capacity) was reviewed in the facility protocol. All staff will be in-service before the start of their shift and no staff will be allowed to start work until the training has been completed.
• Walkie talkies purchased to help increase communication between the staff to assist with increased resident supervision. The nurse staff: charge nurse and certified nurse aide will use radios.
• Resident #2's care plan was updated, and it does include specific interventions for monitoring.
• Psych services to continue monthly visits with the resident to assist with her psychosocial well-being related to her ability to have needed sexual expression.
• The facility's process for determining whether residents have capability to give consent to sexual activities is BIMs, Resident Assessment and Care Plan, and Family Responsible Party Consent.
• The facility will recognize residents who lack capacity to make decisions or are making unsafe decisions by the Resident Assessment and Care Plan.
• Reviewed the facility conducted 100% review of all residents. 4 residents were identified with inappropriate sexual behaviors.
• Resident #2's care plan was updated reflecting no specific supervision interventions.
• Record review of Resident #2's 1:1 log sheet documented beginning 1:1 and maintained current during observation through review.
• Record review of the facility's What to do if you witness or suspect sexual abuse in-service had 100% clinical staff in attendance.
• Record review of the facility's in-service objective of the In-service: Free of accidents/hazards/supervision/devices, facility will provide adequate supervision to prevent sexual abuse, facility will provide interventions and monitoring to ensure residents safety from sexual abuse, freedom from abuse/neglect/ Misappropriation of property/and exploitation, facility will provide an environment free from sexual abuse-had Administrator and DON in attendance.
• Two-way walkie talkie's will be utilized in the facility to communicate with each other for the resident and staff safety. Please use same channel to communicate effectively to each other. Return radios to the charger ports after your shift. We must have radios on through your shift to communicate any behavior in the residents that maybe concern.

Penalty

Inspection fine: $38,687

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report alleged violations involving abuse to the State Survey Agency and other officials within the required timeframe for four residents. In one incident, two residents were involved in a possible sexual abuse situation that was not reported immediately. The facility's Director of Nursing (DON) and Administrator believed the interaction was consensual due to the residents' behavior and did not report it until prompted by an Ombudsman. The DON acknowledged that the resident involved had severe cognitive impairment and was unable to consent to sexual activities, yet the incident was not reported within the required two-hour window. Another incident involved a resident who experienced an unwitnessed fall resulting in an elbow fracture. The fall was initially assessed with no injuries noted, but a fracture was discovered days later. The facility did not report the incident as an injury of unknown origin to the Health and Human Services Commission (HHSC) within the required timeframe. The Administrator and DON stated that such incidents should be reported, but the delay in discovering the injury led to a failure in timely reporting. Additionally, the facility did not report an allegation of abuse involving a resident who claimed to have witnessed a staff member on top of another resident. The facility conducted an investigation and deemed the allegation unfounded due to the resident's history of hallucinations and false allegations. However, the facility did not notify local law enforcement as required by their policy, which mandates reporting all allegations of abuse immediately. The DON and Administrator concluded there was insufficient evidence to substantiate the claim, leading to a failure in following proper reporting procedures.