Avir At Commerce
Inspection history, citations, penalties and survey trends for this long-term care facility in Commerce, Texas.
- Location
- 2901 Sterling Hart Dr, Commerce, Texas 75428
- CMS Provider Number
- 675788
- Inspections on file
- 25
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Avir At Commerce during CMS and state inspections, most recent first.
The facility did not provide enough CNAs on night shifts to meet the staffing ratio outlined in its facility assessment, resulting in only one CNA being present for a resident census that exceeded 30. Staff reported delays in care, use of mechanical lifts without proper assistance, and management awareness of the ongoing staffing shortages. The DON and Administrator confirmed that staffing levels were below the planned ratios, and time sheets supported that only one CNA was scheduled during affected shifts.
A resident with Parkinsonism and mental health diagnoses, who was cognitively intact and required significant assistance, was not treated with dignity when a CNA spoke loudly and patted the resident's hand during care. The CNA admitted to making pressuring statements to residents, and an LVN reported witnessing disrespectful communication. Facility leadership was unaware of the CNA's behavior prior to the incident, which did not align with the facility's policy on resident rights.
A medication cart was found unlocked and unattended near the nurse's station while the assigned LVN was on break. The cart was moved by a housekeeper, and the LVN later admitted to forgetting to lock it. Facility policy and staff interviews confirmed that medication carts must be locked when not in use, but this protocol was not followed.
Two residents in the facility were not provided with complete informed consent for their psychotropic medications. One resident with severe cognitive impairment was prescribed multiple medications without documented consent, while another resident with bipolar disorder was aware of his medication but had not signed the consent form. Staff interviews revealed a lack of clarity in responsibility for ensuring consent forms were completed, leading to these deficiencies.
The facility failed to resolve grievances from three residents regarding cold coffee. A resident with COPD, another with Alzheimer's, and a third with liver cancer all reported dissatisfaction with the coffee temperature, which was served below the desired level. Despite multiple complaints, the issue remained unaddressed, with observations confirming the coffee was lukewarm.
A facility failed to document pre and post-dialysis assessments for a resident with ESRD, as required by professional standards. Despite having a care plan for dialysis three times a week, assessments were missing on multiple occasions. Interviews revealed that the LVN did not document assessments in the electronic medical records or follow up with the dialysis center for missing communication sheets. The facility's policy required staff training and communication with the dialysis center, which was not consistently followed.
The facility failed to establish a system for logging and securing controlled medications awaiting disposal. Controlled drugs, including Ativan/Benadryl gel and Hydrocodone-apap tablets, were stored in a locked closet in the DON's office without proper logging. The DON was the only person with the key, and the facility's policy required accountability records to be maintained, which was not done, potentially risking medication loss and diversion.
The facility failed to use the correct scoop size for serving chicken alfredo during a lunch meal, using a 6 oz scoop instead of the required 8 oz. This error was observed after 10 resident trays had been served, potentially affecting the nutritional intake of residents. The Dietary Manager and another staff member acknowledged the mistake, which was contrary to the facility's policies on portion control.
The facility failed to provide palatable and appropriately heated food for several residents, who reported cold, bland, and unappetizing meals. The Dietary Manager and surveyors confirmed these issues during a meal sampling. The Dietary Manager acknowledged ongoing complaints about repetitive menus and seasoning, while the Administrator was unaware of specific complaints about blandness.
A LTC facility failed to maintain effective infection control, with staff not adhering to hand hygiene and PPE protocols. An LVN did not change gloves or sanitize hands during wound care for a resident with a pressure ulcer. A CNA wore PPE in the hallway after assisting a resident in contact isolation, and an LVN did not sanitize hands between glove changes while administering insulin. These actions could lead to infection control issues.
The facility did not follow its smoking policy, leading to unsafe conditions in the smoking area. Observations showed flammable items in a red metal trash can meant for cigarette butts, posing a fire risk. Staff interviews revealed inconsistencies in policy enforcement, with the HR Coordinator and Maintenance Supervisor acknowledging the need for regular checks, but the Administrator expecting daily oversight.
The facility failed to ensure accurate advanced directives for two residents. One resident's OOH-DNR form was incomplete, lacking a physician's signature and license number, while another resident's code status was not updated from full code to DNR despite signing a DNR form. These oversights could lead to residents' end-of-life wishes not being honored.
A resident with mobility challenges was unable to easily open her room door, which was hard to open due to the building's shift. Despite reporting the issue multiple times, no work orders were recorded, and the Maintenance Supervisor had not addressed the problem. The Administrator expected the door to be fixed, and the facility's policy emphasized accommodating individual needs.
A facility failed to provide appropriate care for a resident with an indwelling catheter. The resident was observed without a securement device, and the catheter drainage bag was on the floor, contrary to care plans and physician orders. Staff interviews confirmed the necessity of a leg strap and proper placement of the drainage bag to prevent dislodgement and infection, as outlined in facility policy and Lippincott procedures.
The facility failed to provide appropriate respiratory care for two residents with COPD, as oxygen was administered at incorrect levels and tubing was not changed weekly as required. Staff interviews revealed a lack of oversight and communication regarding supply availability and adherence to physician orders.
A facility failed to provide trauma-informed care for a resident with PTSD by not conducting a trauma screening upon admission and not documenting triggers in the care plan. Staff interviews revealed confusion about the trauma-informed care process, and the facility's policy requiring trauma assessments was not followed.
A LTC facility reported a medication error rate of 24.24%, involving two residents. One resident did not receive scheduled medications on time, while another received an incorrect dosage of MiraLAX. The LVN responsible cited being the sole person on duty for medication administration and admitted to not receiving proper training. The DON and Administrator were unaware of the specific risks associated with these errors.
A resident in an LTC facility experienced significant medication administration delays on two consecutive days, with medications given 1 hour and 36 minutes late on the first day and 4 hours and 55 minutes late on the second day. The delays were due to an LVN being the sole person responsible for medication administration in the facility. Despite informing the DON and Administrator, no additional support was provided. Interviews revealed a lack of awareness of the risks associated with late medication administration.
A facility failed to secure medications and wound care supplies properly, as observed with an unlocked medication cart and unsecured insulin pen, and wound care supplies left on a resident's dresser. Staff acknowledged the importance of securing these items to prevent unauthorized access and ensure resident safety, as per facility policies.
A facility failed to coordinate hospice care and maintain accurate records for a resident receiving hospice services. The resident's updated plan of care and medication list were not included in their medical records, and the hospice binder was not properly maintained. Interviews with staff revealed a lack of clarity and responsibility for maintaining hospice documentation, with recent staffing changes contributing to the oversight. The facility's hospice contract and policy required accurate documentation, which was not followed.
A malfunction in the wander guard system on the north side door was identified when the alarm failed to activate during a test by the Maintenance Supervisor. Although other doors functioned correctly, this issue posed a risk of resident elopement. The Maintenance Supervisor was responsible for weekly checks, and the facility had six residents at risk of elopement. Interviews revealed a lack of policy on door checks, despite the facility's policy on wandering and elopements requiring regular supervision and device checks.
The facility failed to provide a nourishing, well-balanced diet for residents, as observed during a lunch meal review. A resident with multiple health conditions reported frequent food shortages, and another had previously filed a grievance about the dietary department running low on food. During the survey, the facility ran out of the main lunch meal and alternate meat, requiring the test tray to be used for a resident. Staff interviews revealed inconsistencies in ensuring adequate food portions, despite the facility's policy to meet residents' nutritional needs and preferences.
Insufficient CNA Staffing on Night Shifts
Penalty
Summary
The facility failed to provide a sufficient number of nursing staff, specifically Certified Nursing Assistants (CNAs), on a 24-hour basis to meet the needs of all residents in accordance with the facility assessment and resident care plans. On multiple dates, the facility operated with only one CNA on the night shift (10 PM-6 AM), despite a resident census that exceeded the staffing ratio outlined in the facility assessment, which required at least one CNA per 30 residents. Census records showed that on the dates in question, the number of residents ranged from 44 to 49, but only one CNA was scheduled for the night shift. Interviews with staff members revealed that working short-staffed was a recurring issue, with some staff reporting that they were the only CNA for the entire building during certain shifts. Staff described difficulties in providing timely care, with residents having to wait for assistance and some care tasks being delayed. Staff also reported that the shortage of CNAs led to situations where mechanical lifts were used without the required assistance, as nurses were not always available to help. Staff consistently stated that management was aware of the staffing shortages and the challenges in meeting residents' needs. The Director of Nursing (DON) and the Administrator acknowledged the staffing challenges, with the DON stating that the facility often operated below the planned CNA staffing levels for each shift. The Administrator indicated that the facility assessment allowed for one to two CNAs on the night shift, depending on census, and that the direct care staff ratio was intended to be one CNA per 30 residents. Despite this, time sheets confirmed that only one CNA was present on the night shift during the dates reviewed, even when the census exceeded 30 residents. The facility's policy required sufficient nursing staff to ensure resident safety and well-being in accordance with care plans and the facility assessment.
Failure to Treat Resident with Dignity and Respect During Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with respect and dignity during care. The resident, an older female with Parkinsonism, anxiety disorder, and major depressive disorder, was cognitively intact and required significant assistance with daily activities. On the day of the incident, the CNA spoke to the resident in a loud manner and patted her hand while attempting to provide care, actions that were not consistent with maintaining a calm and respectful environment as outlined in the resident's care plan. Interviews revealed that the CNA admitted to tapping the resident's hand in response to the resident's physical and verbal aggression, and acknowledged making statements to residents that could be perceived as disrespectful or pressuring. A licensed vocational nurse (LVN) who witnessed the incident reported that the CNA raised her voice at the resident and had previously spoken to residents in a manner that was not dignified, including making demands and disregarding refusals of care. The LVN stated she had to intervene and had reported the CNA's behavior to management. Further interviews with facility leadership indicated that the director of nursing (DON) and administrator were not previously aware of the CNA's pattern of loud or disrespectful communication with residents. The facility's policy required all employees to treat residents with kindness, respect, and dignity, but the CNA's actions on the day in question did not align with these expectations. The incident was documented and investigated, with staff and leadership interviews confirming the failure to provide care in a manner that promoted the resident's dignity and quality of life.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A deficiency occurred when a medication cart in the South Hall was left unlocked and unattended next to the nurse's station. During an observation, the cart was found unlocked while the assigned nurse, LVN C, was on break and not present in the hallway. A housekeeper moved the unlocked cart, believing the nurse was on break. LVN C later confirmed that she had been on break and had forgotten to lock the cart, acknowledging the importance of keeping it secured, especially given the presence of dementia patients in the facility. Interviews with the DON and the Administrator confirmed that facility policy requires medication carts to be locked at all times when not in use or out of the nurse's view. Record review of the facility's policy, revised April 2007, also indicated that medication carts must be securely locked when unattended. The failure to secure the medication cart was directly observed and acknowledged by staff, constituting a breach of professional standards for the storage of drugs and biologicals.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were fully informed and provided consent for their psychotropic medications. Resident #1, a female with severe cognitive impairment due to Alzheimer's disease, was prescribed multiple psychotropic medications including trazadone, Xanax, lorazepam, and sertraline. However, the informed consent forms for these medications lacked clinical indications for use, benefits of the medications, and a statement of consent. Despite her cognitive impairment, the facility did not ensure that the necessary information was documented to confirm informed consent. Resident #9, a male with a diagnosis of bipolar disorder and a BIMS score indicating cognitive intactness, was prescribed Zyprexa, an antipsychotic medication. Although Resident #9 was aware of the medication's purpose and its risks and benefits, the consent form for this medication was not signed by him or his representative. This oversight indicates a failure in the facility's process to secure and document informed consent for psychotropic medications. Interviews with facility staff, including an LVN and the DON, revealed that there was a lack of clarity and responsibility in ensuring that consent forms were completed and signed. The DON acknowledged that the responsibility for ensuring complete consent forms had shifted after the departure of the ADON, and the Administrator expected nursing management to monitor this process. The facility's policy required written consent for psychotropic medications, but this was not adhered to, leading to the deficiencies noted in the report.
Failure to Address Grievances on Coffee Temperature
Penalty
Summary
The facility failed to promptly resolve grievances related to coffee temperature for three residents. Resident #42, a female with COPD and moderately impaired cognition, complained that the coffee was served cold and stated that the facility staff attributed the issue to state regulations. Despite being aware of the complaints, the facility staff did not address the issue, leaving the resident dissatisfied with the coffee temperature. Resident #47, a female with Alzheimer's disease and moderately impaired cognition, also reported that the coffee was cold. She expressed that multiple complaints had been made without improvement, and she desired her coffee to be served hot as she had been accustomed to throughout her adult life. During an observation, Resident #47 confirmed that the coffee was cold, reinforcing her grievance. Resident #44, a male with liver cancer and intact cognition, similarly complained about the cold coffee. He mentioned that the coffee was not served at the desired temperature due to a policy limiting it to 140 degrees F or less. Despite his grievances, the issue remained unresolved. Observations confirmed that the coffee was served at 119.8 degrees F, which was considered lukewarm. The facility's Administrator and Dietary Manager acknowledged receiving complaints but did not identify any problems with the coffee temperatures, despite the residents' dissatisfaction.
Failure to Document Dialysis Assessments
Penalty
Summary
The facility failed to ensure that a resident requiring dialysis received appropriate pre and post-dialysis assessments, as per professional standards of practice. The resident, a male with end-stage renal disease (ESRD), was dependent on dialysis and had a care plan indicating he attended dialysis sessions three times a week. Despite this, there were multiple instances where pre and post-dialysis assessments were not documented in the resident's records, specifically on several dates in October and November. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) responsible for the resident's care was aware that the resident sometimes did not return with the communication sheets from the dialysis center. However, the LVN did not document the assessments in the resident's electronic medical records or follow up with the dialysis center for missing communication sheets. The Director of Nursing (DON) expected nurses to perform these assessments, but the process was not consistently followed. The facility's policy on the care of residents with ESRD required staff to be trained in the specific needs of these residents, including the completion of assessments and communication with the dialysis center. However, the lack of documentation and communication indicated a failure to adhere to these policies, potentially affecting the quality of care provided to the resident.
Failure to Log and Secure Controlled Medications
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation and maintaining drug records. During an observation, it was noted that several controlled medications, including Ativan/Benadryl gel, Hydrocodone-apap tablets, Alprazolam tablets, and Tramadol tablets, were stored in a basket inside a controlled medication closet in the Director of Nursing's (DON) office, awaiting disposal. The DON stated that she was the only person with the key to the locked closet and was responsible for reconciling medications for disposal. However, she had not located a blank destruction log to record these medications, which is a critical step in ensuring accountability and preventing drug diversion. The Administrator expected narcotic medications to be logged and secured appropriately, but acknowledged that the DON was the only one with the key, implying there was no risk of medications going missing. Despite this, the facility's policy required accountability records for discontinued controlled substances to be maintained with the unused supply until destroyed, and stored for five years or as required by law. The lack of a proper logging system for controlled substances awaiting disposal indicates a failure to comply with these policies, potentially placing residents at risk for loss of prescribed medications and drug diversion.
Failure to Use Correct Scoop Size for Meal Portions
Penalty
Summary
The facility failed to ensure that the meals served met the nutritional needs of residents during a lunch meal, specifically with the serving of chicken alfredo. The dietary spreadsheet indicated that an 8 oz scoop should be used for serving, but observations revealed that a 6 oz scoop was used instead. This discrepancy was noted after approximately 10 resident trays had already been served and delivered. The Dietary Manager acknowledged the error, stating that the correct scoop size was documented on the dietary spreadsheet and that she was responsible for ensuring the correct scoop size was used. Further interviews revealed that another staff member, [NAME] E, also misread the spreadsheet and used the incorrect scoop size, placing residents at risk of not receiving adequate nutrition. The Director of Nursing (DON) and the Administrator both expressed expectations that the dietary staff should use the correct scoop size to ensure residents receive the correct portions. The facility's policies on tray service and portion control emphasize the importance of accurate portion sizes for resident wellbeing and safety, but these were not adhered to during the incident.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to provide food that was palatable and served at an appetizing temperature for four residents. Residents reported that the food was cold, bland, and unappetizing. Specific complaints included cold meals, bland taste, and unappealing textures, such as gravy with the consistency of milk and dry eggs. These issues were confirmed during interviews with the residents, who expressed dissatisfaction with the quality and temperature of the food served. The Dietary Manager and surveyors sampled a lunch tray and found the food to be unappetizing, with bland and mushy vegetables. The Dietary Manager acknowledged receiving constant complaints about the food, mainly regarding repetitive menus and over-seasoning, which led to reduced seasoning. However, the Dietary Manager was unaware of complaints about blandness and overcooked vegetables until the test tray was sampled. The Administrator also received monthly food complaints but was unaware of specific issues with blandness. The facility's Food and Nutrition Services policy requires that food be palatable, attractive, and served at a safe and appetizing temperature.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies in hand hygiene and personal protective equipment (PPE) usage. One incident involved a Licensed Vocational Nurse (LVN) who did not change gloves or perform hand hygiene while providing wound care to a resident with a stage 3 pressure ulcer. The LVN left the resident's room to gather supplies without removing her gown or performing hand hygiene, and later re-entered the room to continue treatment without proper hand hygiene. This lapse in protocol was acknowledged by the LVN, who admitted that such actions could lead to infection control issues. Another deficiency was observed when a Certified Nursing Assistant (CNA) wore PPE in the hallway after assisting a resident in contact isolation due to shingles. The CNA did not remove her gown and gloves or perform hand hygiene before leaving the resident's room, and subsequently interacted with another resident. The CNA admitted to not following proper procedures, which could contribute to the spread of infection. The Director of Nursing (DON) and the Administrator both expressed expectations that staff should adhere to proper PPE and hand hygiene protocols to prevent infection. A third incident involved an LVN who failed to perform hand hygiene between glove changes while obtaining a resident's blood sugar and administering insulin. The LVN acknowledged the oversight, attributing it to distraction from a loud alarm. The DON reiterated the importance of hand hygiene after removing dirty gloves to prevent infection risk. The facility's policies on hand hygiene and transmission precautions were not followed in these instances, leading to potential infection control issues.
Failure to Maintain Safe Smoking Practices
Penalty
Summary
The facility failed to adhere to its established smoking policy, which mandates maintaining safe smoking practices for residents. During an observation, it was noted that four residents were smoking in the designated smoking area with staff present. However, the red metal trash can, intended solely for cigarette butts and ashes, contained flammable items such as an empty cigarette box, a piece of a paper towel, a blue sticky note, and a sonic cup. This improper disposal of trash in the smoking can was observed, which could potentially lead to a fire hazard. Interviews with facility staff, including the HR Coordinator, Maintenance Supervisor, and Administrator, revealed a lack of compliance with the facility's smoking policy. The HR Coordinator acknowledged that staff responsible for supervising residents during smoking should ensure the red can is free of trash. The Maintenance Supervisor confirmed that all staff are responsible for keeping the red can clear of trash and that he checks it weekly. However, the Administrator expected the Maintenance Supervisor to check the can daily. This inconsistency in practice and oversight contributed to the failure to maintain a safe smoking environment, as outlined in the facility's policy.
Failure to Ensure Accurate Advanced Directives
Penalty
Summary
The facility failed to ensure the right to formulate an advanced directive was provided for two residents. For one resident, the Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was incomplete, missing the physician's signature and license number, despite the resident having a physician's order for DNR status. This resident had a moderately impaired cognition with a BIMS score of 9, indicating some level of understanding and communication ability. The comprehensive care plan for this resident indicated a DNR status, but the lack of a complete OOH-DNR form could lead to a failure in honoring the resident's end-of-life wishes. For another resident, the facility did not update the code status from full code to DNR after the resident signed a DNR form. This resident had an intact cognition with a BIMS score of 15, indicating full understanding and communication ability. Despite the resident's clear wishes and a completed DNR form signed by all responsible parties, the active physician's order still indicated a full code status. Interviews with the social worker and administrator revealed that the oversight was due to a lack of proper documentation and monitoring, which could result in the resident's wishes not being carried out in an emergency.
Failure to Ensure Accessible Room Door for Resident
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for a resident who was unable to easily use the door to her room. The resident, who had chronic pain, difficulty in walking, muscle weakness, unsteadiness of feet, and lack of coordination, reported that her room door was extremely hard to open. Despite having moderately impaired cognition, she was usually able to understand others and was independent with bed mobility and transfers, using a walker. The comprehensive care plan did not address the need for easy use of functional items, and no work orders were recorded for the hard-to-open door. During an observation, the surveyor noted that the door required significant force to open, which the resident confirmed had been reported to the facility staff multiple times. The Maintenance Supervisor acknowledged awareness of the issue, attributing it to the building's shift, and admitted to not having tried other solutions due to time constraints. The Administrator expected the door to have been fixed and stated that issues should be entered into the system to generate a work order, which would alert the team for follow-up. The facility's policy emphasized accommodating individual needs and preferences, including modifications to the physical environment.
Failure to Secure Indwelling Catheter and Maintain Infection Control
Penalty
Summary
The facility failed to provide appropriate treatment and service of care for a resident with an indwelling catheter. The resident, a male with a diagnosis of obstructive uropathy secondary to prostate cancer, was observed on multiple occasions without a securement device for his indwelling catheter, and the catheter drainage bag was found resting on the floor. These observations were made despite the care plan and physician orders indicating the necessity of securing the catheter to the leg to promote comfort and minimize tension or tissue trauma. Interviews with facility staff, including a CNA, an LVN, the DON, and the Administrator, confirmed that the resident should have had a leg strap to prevent dislodgement and that the drainage bag should not have been on the floor due to infection control concerns. The facility's policy and Lippincott procedures also emphasized the importance of securing the catheter and keeping the drainage bag off the floor to prevent contamination and catheter-associated urinary tract infections (CAUTI).
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, both of whom required oxygen therapy due to chronic obstructive pulmonary disease (COPD). Resident #11 was observed with oxygen set at incorrect levels, first at 5 liters and then at 3 liters per nasal cannula, despite a physician's order for 2 liters. Additionally, the oxygen tubing for Resident #11 had not been changed since 10/28/24, contrary to the facility's policy of weekly changes on Sunday nights. Resident #15 also experienced a lapse in care, as her oxygen tubing had not been changed since 10/25/24. The facility's policy required weekly changes, but due to a lack of nasal cannulas, the tubing was not replaced. The Licensed Vocational Nurse (LVN) on duty admitted to signing the medication administration record out of habit, despite not having changed the tubing due to the unavailability of supplies. Interviews with staff, including the Director of Nursing (DON) and the Administrator, revealed a lack of oversight and communication regarding the availability of necessary supplies and adherence to physician orders. The DON acknowledged the responsibility of charge nurses to follow orders and ensure tubing changes, but was unaware of the supply shortage until informed by an LVN. The Administrator deferred clinical responsibilities to the DON, indicating a gap in administrative oversight of clinical practices.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident who is a trauma survivor received culturally competent, trauma-informed care. Specifically, the facility did not conduct a trauma screening upon admission for a resident with a history of trauma, including PTSD, which is a mental health condition that can develop after experiencing or witnessing a traumatic event. The resident, who had severely impaired cognitive skills and was dependent on staff for daily activities, did not have any identified triggers documented in their care plan, which is crucial for preventing re-traumatization. Interviews with facility staff revealed a lack of clarity and responsibility regarding the trauma-informed care process. The social worker, who was new to the facility, was unsure of the process and acknowledged that the trauma assessments should have been completed on admission and quarterly. The MDS nurse admitted that the care plans should have included the resident's PTSD triggers to alert staff on how to manage them. The Director of Nursing and the Administrator both emphasized the importance of having trauma assessments completed and accessible to staff to meet residents' needs effectively. However, the facility's policy on trauma-informed care, which requires identifying past trauma as part of the comprehensive assessment, was not followed in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 24.24% due to 8 errors out of 33 opportunities. This involved two residents, one of whom did not receive their scheduled medications on time, and another who received an incorrect dosage of a prescribed medication. The errors were observed during a survey, and interviews with staff confirmed the issues. Resident #4, a female with multiple diagnoses including dementia, depression, and congestive heart failure, did not receive her medications on time on a specific date. The medications included Bumetanide, Vitamin D3, Eliquis, Isosorbide mononitrate, Potassium chloride, and Ranolazine, but Tylenol was not administered as ordered. The LVN responsible for administering the medications cited being the only person on duty for medication administration as a reason for the delay. Resident #25, another female with diagnoses including gastrointestinal hemorrhage and atrial fibrillation, received an incorrect dosage of MiraLAX. The LVN failed to use the cap provided with the MiraLAX bottle for accurate measurement, potentially leading to under or over-administration. The LVN admitted to not receiving proper training for medication administration and reported the heavy workload to the DON and Administrator, who were unaware of the specific risks associated with late or incorrect medication administration.
Medication Administration Delays in LTC Facility
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a survey. The resident, a female with a history of dementia, depression, chronic pain, hypertension, and congestive heart failure, did not receive her medications at the scheduled times on two consecutive days. On the first day, her medications were administered 1 hour and 36 minutes late, and on the second day, they were administered 4 hours and 55 minutes late, both beyond the 1-hour grace period allowed by the facility's policy. The resident's medications included Eliquis, an anticoagulant, and Ranolazine, used for chronic chest pain, both of which were scheduled to be administered twice daily. The late administration of these medications was attributed to the fact that the LVN responsible for medication administration was the only person available to give medications in the entire building. The LVN reported that the medication load was too heavy for one person, and she had informed the DON and the Administrator about the issue, but no additional support was provided. Interviews with the LVN, DON, and Administrator revealed a lack of awareness and understanding of the risks associated with late medication administration. The LVN acknowledged the potential for reduced medication effectiveness and the risk of administering doses too close together. Despite the facility's policy requiring medications to be administered within 60 minutes of the scheduled time, the DON and Administrator were unable to articulate the potential consequences of the delays, indicating a gap in oversight and training.
Medication and Wound Care Storage Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely and labeled correctly, as observed with one of the medication carts and two residents. On November 5th, a nurse left the south side nurse's treatment cart unlocked and unattended, with an insulin pen placed on top of the cart. The nurse admitted to not locking the cart because she believed she could hear if someone accessed it while she was in a nearby room. This oversight was acknowledged by the nurse, who understood the importance of securing medications to prevent unauthorized access or potential drug diversion. Additionally, the facility did not properly secure wound care supplies for a resident with a stage IV pressure ulcer. The supplies, including a wound cleanser and gel, were left on the resident's dresser instead of being stored in the nurse's treatment cart. The charge nurse responsible for the resident did not notice the supplies were left out, and the Regional Compliance Nurse confirmed that such items should be stored securely to ensure resident safety. The Director of Nursing and the Administrator both emphasized the expectation that wound care supplies be stored properly and not left at the bedside. The facility's policies on medication administration and storage were not adhered to, as evidenced by the unlocked medication cart and unsecured wound care supplies. The Director of Nursing and the Administrator reiterated the importance of following these policies to maintain a safe environment for residents. The failure to secure medications and wound care supplies could potentially place residents at risk, as noted by the staff involved in the observations and interviews.
Failure to Coordinate Hospice Care and Maintain Accurate Records
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified through interviews and record reviews, which revealed that the facility did not ensure the resident's updated plan of care and most recent medication list from hospice were included in their current medical records. The hospice binder, which should have contained updated information, was not maintained properly, with the most recent plan of care update being over a month old and the medication report being nearly two months old. Interviews with facility staff, including an LVN, the DON, and the Administrator, highlighted a lack of clarity and responsibility regarding the maintenance of hospice documentation. The LVN was unsure if physical copies of hospice information were kept at the facility, while the DON acknowledged the importance of updated hospice paperwork but had not yet ensured its accuracy due to recent staffing changes. The Administrator expected nursing management to maintain updated hospice binders, emphasizing the importance of communication and continuity of care. The facility's hospice contract and policy required accurate and up-to-date documentation, which was not adhered to in this case.
Wander Guard System Malfunction on North Side Door
Penalty
Summary
The facility failed to ensure the proper functioning of the wander guard system on the north side door, which is crucial for preventing resident elopement. During an observation, the Maintenance Supervisor tested the door, and the alarm did not activate, indicating a malfunction. Although the other two wander guard doors were functioning correctly, this particular door posed a risk as it did not alert staff to potential elopement. The Maintenance Supervisor mentioned that he checks the doors weekly and had found them functioning properly during the last inspection. However, on this occasion, the system failed to operate as expected. Interviews with the Administrator and the DON revealed that the Maintenance Supervisor was responsible for ensuring the wander guard system's functionality. They stated that if the system was not working, a staff member should be stationed at the door to prevent residents from leaving the facility. The facility had six residents at risk of elopement who wore wander guards. The Regional Nurse Consultant noted that there was no policy on checking the doors, and the facility's policy on wandering and elopements emphasized the need for adequate supervision and regular checks of the wander guard devices. The TELS logbook indicated that the door was checked and working properly a week prior to the incident.
Inadequate Food Supply for Residents
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, as observed during a lunch meal review. On the date of the survey, the facility did not prepare an adequate amount of food for the lunch meal, which could potentially affect all residents by placing them at risk of not receiving adequate nutritive food value needed to promote or maintain health. This deficiency was highlighted by the experiences of two residents who reported issues with food availability. One resident, a male with diagnoses including liver cancer, cerebral vascular disease, congestive heart failure, and anemia, reported that the facility frequently ran out of food, and he had to send out for food. He mentioned that he was often told there was not enough food for extras, and he had received minimal portions for breakfast. Another resident, who had been discharged, had previously filed a grievance about the dietary department frequently running low on food or out of certain items, such as eggs and biscuits. During the survey, it was observed that the facility ran out of the main lunch meal and the alternate meat, requiring the test tray to be used for a resident. The Dietary Supervisor acknowledged the shortage and mentioned that while running out of food usually did not happen, they had ready-to-cook meats available if needed. Despite this, staff interviews revealed inconsistencies in ensuring adequate food portions, with some staff unaware of any complaints or issues. The facility's policy stated that each resident should be provided with a diet that meets their nutritional needs and preferences, but the observed deficiency indicated a failure to adhere to this policy.
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.
