Avir At Converse
Inspection history, citations, penalties and survey trends for this long-term care facility in Converse, Texas.
- Location
- 7700 Mesquite Pass, Converse, Texas 78109
- CMS Provider Number
- 675452
- Inspections on file
- 30
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Avir At Converse during CMS and state inspections, most recent first.
Surveyors found an unlabeled vial of insulin on the 300/400 hall medication cart, not in a box and lacking a pharmacy label or resident name, although it had an open date. An LPN responsible for the cart reported that unlabeled medications are usually discarded or clarified with the prior nurse and acknowledged that medications should bear residents’ names to prevent sharing. The DON stated that insulin must be labeled with the medication name, resident name, directions, and open date, and that the pharmacy is responsible for labeling while nurses oversee the cart. Review of the facility’s policy confirmed that medication labels must include the drug name, prescribed dose, strength, expiration date, resident name, route, and instructions, requirements that were not met for this insulin vial.
The facility failed to maintain infection control practices and Enhanced Barrier Precautions (EBP) for three residents. A resident using a PureWick urinary system, care planned as at risk for UTI and on EBP, was observed with the PureWick tubing touching the floor, which staff and the DON acknowledged was an infection control and contamination concern. Two residents with chronic wounds, including unstageable pressure injuries, did not have required EBP signage or supplies at their doors, despite the facility’s EBP policy stating that residents with wounds or indwelling devices must be on EBP and staff relying on such signage and carts to identify these precautions.
A medication cart assigned to an LVN was observed left unlocked and unattended in a hallway, accessible to staff, the public, and residents, while the nurse was inside a resident's room and unable to monitor the cart. The DON and Administrator confirmed the cart was not secured as required by facility policy, which mandates that all medications be stored in locked compartments and not left unattended.
Surveyors found that several residents received insulin from pens that were not discarded after 28 days as required, and one resident missed ten days of prescribed Lorazepam due to a failure in timely medication reordering and communication among staff. These deficiencies were confirmed through observation, record review, and staff interviews, with staff acknowledging that procedures for medication disposal and reordering were not followed.
Insulin pens for several residents were found in the medication cart without open dates, despite facility policy and manufacturer instructions requiring dating and discarding after 28 days. Nursing staff and the DON confirmed that the pens should have been dated, but were unable to determine when the insulin was opened, leading to uncertainty about the safety and effectiveness of the medication being administered.
The facility did not ensure that all new and existing staff received required initial and annual trainings, as evidenced by missing documentation for multiple staff members across various roles. Personnel records and staff interviews confirmed that trainings on topics such as communication, QAPI, ethics, falls, HIV, and emergency preparedness were not consistently provided or documented, despite a facility policy outlining these requirements.
Four staff members, including a housekeeper, CMA, CNA, and LVN, did not receive required annual communication training as evidenced by a review of their personnel records. The facility's process involved the HR Coordinator initiating monthly in-services and department heads presenting them to staff, but documentation showed the communication training was not completed for these employees, contrary to facility policy.
The facility did not provide required annual QAPI program training to several staff members, including a housekeeper, CNA, dietary aide, CMA, and RN. Personnel records lacked evidence of this training, and interviews with facility leadership confirmed the deficiency in the training process and documentation.
The facility did not provide required annual ethics training to several staff members, including housekeeping, CNAs, RNs, and LVNs, as evidenced by missing documentation in personnel files. The process for delivering and verifying in-service trainings involved the HR Coordinator and department heads, but records showed that the annual ethics training was not completed for these employees.
Three CNAs did not receive the required 12 hours of annual in-service training, with personnel records lacking evidence of completion for key topics such as communication, QAPI, ethics, falls, restraint, and emergency preparedness. The HR Coordinator, DON, and Administrator confirmed the process for distributing and verifying in-service trainings but could not provide documentation or a policy confirming compliance.
The facility did not provide required behavioral health training to two dietary staff members, with one not receiving annual training and the other not receiving training upon hire. Documentation and interviews confirmed gaps in the training process, despite facility policy requiring annual education on behavior interventions.
A resident with severe cognitive impairment and total dependence on staff for care was repeatedly observed with their call light out of reach while in bed, despite care plan interventions and facility policy requiring accessibility. Staff interviews confirmed the call light was not accessible and acknowledged responsibility for proper placement.
A resident with multiple chronic conditions was discharged, but the required discharge MDS assessment was not completed or transmitted to CMS within the mandated timeframe. The MDS coordinator, responsible for this task, was unable to explain the oversight, and the assessment did not appear on the facility's tracking report. Interviews confirmed that the facility's monitoring systems failed to identify the missed assessment.
A resident with severe cognitive impairment and multiple medical conditions was incorrectly coded as receiving an anticoagulant on her MDS assessment, when she was actually prescribed and administered clopidogrel, an antiplatelet. The MDS nurse confirmed this was a coding error, as the medication should have been documented as an antiplatelet per CMS guidelines.
A resident with multiple medical conditions and moderate cognitive impairment was identified as a smoker requiring adaptive equipment, but the facility failed to include smoking-related interventions in the resident's care plan. Despite documentation and staff awareness of the resident's smoking status, the care plan did not address this need, contrary to facility policy.
A CNA did not follow proper perineal care procedures for a female resident with severe cognitive impairment and incontinence, failing to separate and clean the labia as required by facility policy. The resident was dependent for all ADLs and at risk for urinary tract infection, but the correct technique was not used during observed care.
A resident with chronic respiratory failure and other medical conditions was found to have their oxygen nasal cannula left uncovered on the nightstand when not in use, contrary to physician orders and infection control guidelines. Both an LVN and the DON acknowledged that the cannula should have been covered to prevent possible infection, but the facility lacked a specific policy for this practice.
A resident's personal refrigerator contained an unlabeled and undated food item brought in by family or visitors, in violation of facility policy requiring perishable foods to be labeled and dated. Staff interviews confirmed that night nurses were responsible for monitoring the refrigerator, but the required procedures were not followed.
A medication aide did not clean a blood pressure cuff between uses before measuring the blood pressure of a resident with multiple chronic conditions and a non-healing wound. This action was observed by surveyors, and both the aide and DON confirmed that the cuff should have been cleaned according to facility policy.
A resident with multiple medical conditions experienced several falls, but the facility's fall risk assessment inaccurately indicated a low risk and did not document the resident's fall history. Additionally, required neuro checks after a fall were not properly documented, and both the DON and ADON confirmed the lack of accurate recordkeeping and absence of a specific policy on clinical record accuracy.
CNAs did not fully close the privacy curtain while providing incontinent care to a resident with severe cognitive impairment and frequent incontinence, resulting in exposure of the resident's genital area in the presence of a roommate. Both CNAs and the DON confirmed that privacy should have been maintained and that staff had received training on resident rights.
A facility failed to include a high fall risk in a resident's care plan, despite the resident's severe cognitive impairment and multiple diagnoses. The resident was identified as high risk for falls in the admission assessment, but the care plan was not updated until after the resident fell. The DON and MDS Nurse acknowledged the oversight, citing busyness as a factor.
A resident with severe cognitive impairment and multiple health conditions received inadequate incontinence care from two CNAs, who failed to follow proper cleaning techniques. The CNAs did not use a new wipe for each pass and did not clean the genital area correctly, which could lead to infections. Interviews with facility staff confirmed the improper technique and emphasized the risk of infection due to inadequate care.
A resident with a full code status was found unresponsive, but the nursing staff failed to initiate CPR due to a misunderstanding of the resident's code status. The LVN on duty did not verify the code status and mistakenly believed the resident was a DNR because she was on hospice. CPR was not performed until EMS arrived, and the resident was pronounced deceased. This incident highlighted a significant failure to adhere to emergency protocols in the facility.
A facility failed to document a physician's order to crush medications for a resident with difficulty swallowing, despite the order being communicated by hospice. This oversight was confirmed through staff interviews and record reviews, highlighting a lapse in following proper medication administration protocols.
A resident with Parkinson's disease and dementia exited a facility through an alarming door without staff response, despite wearing a wander guard. The alarm was heard by multiple staff members but was not acted upon immediately, leading to an Immediate Jeopardy situation. The facility's policy on elopement was not followed, and the incident was not treated as a true elopement, contributing to the deficiency.
A resident's personal health care information was exposed when an LVN left a medication cart unattended with a laptop displaying the resident's details. The resident had conditions including cerebral infarction and dysphagia. The LVN acknowledged the risk of unauthorized access, and the DON emphasized the need for privacy screens.
A resident was discharged without a discharge MDS in the electronic record, despite having Parkinson's disease and dementia. The MDS coordinator missed the discharge MDS due to an oversight in scheduling, and neither the DON nor the Administrator were aware of the issue. This failure to adhere to the facility's policy on MDS implementation was identified during interviews and record reviews.
A medication cart was found unattended and unlocked, contrary to facility policy, posing a risk of unauthorized access to medications. The LVN responsible for the cart admitted it should have been locked. The RN Supervisor and DON confirmed the expectation for carts to be locked when unattended, aligning with the facility's policy.
Unlabeled Insulin Vial Found on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all drugs and biologicals were properly labeled and stored according to professional standards on one of two medication carts reviewed (the 300/400 hall medication cart). During an observation, surveyors found a vial of insulin on this cart that was not in a box and lacked a pharmacy prescription label and resident name, although it had an open date. The LPN responsible for the 300/400 medication cart stated that if a medication does not have a label, they usually discard it or contact the nurse previously in charge of the cart, and acknowledged that residents’ names should be on medications to track usage and prevent sharing among residents. In a separate interview, the DON stated that insulin should be labeled with the medication name, resident’s name, directions, and the date it is opened, and confirmed that the nurse is in charge of the medication cart while the pharmacy is responsible for labeling medications. The DON indicated that if a medication does not have a label, staff must contact the pharmacy for one, and acknowledged that an unlabeled insulin could result in giving the wrong person the wrong insulin. Review of the facility’s “Medication Labeling and Storage” policy, revised February 2023, showed that medication labels must include, at a minimum, the medication name, prescribed dose, strength, expiration date when applicable, resident’s name, route of administration, and appropriate instructions and precautions, which was not met for the unlabeled insulin vial found on the 300/400 medication cart.
Failure to Maintain Infection Control Practices and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three residents. For one resident, a female with dysphagia, diabetes, chronic kidney disease, cognitive communication deficit, and muscle weakness, records showed she used a PureWick urinary system and was care planned as having a PURE WICK urinary system and being at risk for UTI, with interventions including catheter care and monitoring urine. She was also on Enhanced Barrier Precautions per signage at her room. During observation, her PureWick catheter was seen on a pad to the right of the bed with the tubing touching the floor. A CNA assigned to her care and the LVN overseeing her hall both acknowledged that the PureWick tubing should not be on the floor and identified this as an infection control issue and a risk of contamination. The DON stated catheter tubing should not be on the floor due to the risk of bacteria on the outside of the tube. The facility also failed to implement Enhanced Barrier Precautions (EBP) correctly for two other residents with wounds. One male resident with chronic kidney disease, urinary retention, dysphagia, and an unhealed pressure injury/ulcer had orders for heel protectors due to multiple unstageable wounds. Another resident also had wounds. The facility’s Enhanced Barrier Precautions Program, revised March 2024, stated that EBPs are indicated for residents with wounds and/or indwelling medical devices, including chronic wounds such as pressure ulcers and urinary catheters. However, observations showed that these two residents did not have EBP signage or supplies (such as a cart) by their doors. Nursing staff, including LVNs and the DON, stated that residents with wounds or indwelling catheters should be on EBP, that staff rely on signage and carts to know a resident is on EBP, and that lack of EBP or signage could result in cross contamination, spread of infectious diseases, or wound infections.
Medication Cart Left Unlocked and Unattended in Hallway
Penalty
Summary
A medication cart assigned to a nurse (LVN A) was observed on two occasions to be left unlocked and unattended in a hallway, with the drawers facing the hallway and accessible to staff, the public, and residents passing by. During these times, LVN A was inside a resident's room with the door shut and could not see the cart. The Director of Nursing (DON) and the Administrator witnessed the unlocked cart and confirmed that LVN A was responsible for it. Upon being questioned, LVN A acknowledged leaving the cart unattended and unlocked while providing care in the resident's room. A review of the facility's policy on medication labeling and storage indicated that all medications and biologicals must be stored in locked compartments and only authorized personnel should have access to the keys. The policy also specified that medication carts should not be left unattended if open or otherwise accessible. The observed practice was not in accordance with the facility's policy or accepted professional standards, as the medication cart was left accessible to unauthorized individuals.
Failure to Discard Expired Insulin and Timely Reorder Medications
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for several residents, specifically in the management and administration of insulin and antianxiety medications. For five residents reviewed, surveyors found that insulin pens (Humalog, Lispro, Novolog) were not discarded after the required 28 days from opening, as per facility policy and manufacturer guidelines. These insulin pens remained in the nursing carts past their expiration, and nursing staff were unable to provide a reason for not discarding them. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that it was the nurses' responsibility to remove expired insulin but could not explain why this was not done. Additionally, one resident did not receive their prescribed Lorazepam 0.5 mg for anxiety for ten consecutive days because the medication was not available. The medication was not reordered in a timely manner, and there was a lack of communication between medication aides, nurses, and the ADON regarding the need for a refill. The facility's policy required medication aides to reorder medications before they ran out and to notify the charge nurse if medications were unavailable. However, this process was not followed, resulting in missed doses. The residents involved had significant medical histories, including diabetes, schizoaffective disorder, neurocognitive disorder, paraplegia, and anxiety disorder. At the time of the deficiencies, some residents had severe cognitive impairment, while others were cognitively intact. The failures in medication management were identified through observation, record review, and staff interviews, with staff confirming that the required procedures for medication disposal and reordering were not followed.
Failure to Date Opened Insulin Pens in Medication Storage
Penalty
Summary
Facility staff failed to ensure that all insulin pens for multiple residents were labeled with the date they were opened, as required by both manufacturer instructions and facility policy. During observations, insulin pens for four residents were found in the nursing cart without open dates. The labels on these insulin pens specified that they should be discarded 28 days after opening, but the absence of open dates made it impossible to determine if the insulin was still safe and effective for use. For each of the four residents, record reviews confirmed active orders for daily insulin administration, and medication administration records showed that the insulin was being given as prescribed. Interviews with the LVN revealed that the nurse was unaware of when the insulin pens had been opened and therefore could not determine if the insulin should be discarded. The LVN acknowledged that the pens should have been dated upon opening, in accordance with the label instructions, but did not know if or when this had occurred. The DON confirmed that facility policy requires all insulin to be dated when opened and discarded after 28 days. The DON stated that nurses are responsible for labeling insulin with the open date and that periodic reviews of nursing carts are conducted by DON and ADON. However, the DON was unable to explain why the nurses had not written the open dates on the insulin pens, acknowledging that this omission could result in improper use of insulin.
Failure to Ensure Required Staff Training for New and Existing Employees
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff, as evidenced by the lack of required annual and initial trainings for 11 out of 23 employees reviewed. Personnel records showed missing documentation of mandatory trainings such as communication, QAPI, ethics, falls, HIV, restraint, emergency preparedness, and behavioral health for various staff members, including housekeepers, certified medication aides, certified nursing assistants, licensed vocational nurses, registered nurses, dietary aides, and the dietary manager. Specifically, the dietary manager did not receive required trainings upon hire, and several other staff members lacked evidence of receiving annual trainings as outlined in facility policy. Interviews with the HR Coordinator, DON, and Administrator confirmed that the facility's process involved the HR Coordinator initiating monthly in-service trainings, which were then distributed to department heads to present to their staff. However, the system relied on department heads to ensure completion, and the HR Coordinator to verify compliance, which did not consistently occur. The HR Coordinator acknowledged uncertainty regarding why all required trainings for the dietary manager were not completed upon hire and recognized the importance of staff receiving both initial and annual trainings. A review of the facility's in-service education policy revealed a comprehensive list of required training topics to be covered annually or upon hire, including but not limited to communication, QAPI, infection control, emergency preparedness, ethics, and abuse prevention. Despite this policy, the facility did not ensure that all staff received the necessary trainings, as evidenced by the gaps found in personnel records and confirmed by staff interviews.
Failure to Provide Annual Communication Training to Staff
Penalty
Summary
The facility failed to provide annual communication training to four staff members, including a housekeeper, a certified medication aide (CMA), a certified nursing assistant (CNA), and a licensed vocational nurse (LVN). Review of personnel records for these employees showed no evidence of communication training being completed within the previous 12 months, despite the facility's policy requiring annual training on this topic. The HR Coordinator was responsible for initiating monthly in-service trainings and providing them to department heads, who were then expected to present the trainings to their staff. However, the records indicated that the required communication training was not completed for these staff members. Interviews with the HR Coordinator, DON, and Administrator confirmed that the process for delivering and verifying in-service trainings relied on department heads to present the material and the HR Coordinator to verify completion. Despite this process, the communication training was not documented as completed for the identified staff. The facility's policy specified that an educational calendar should include communication as a required topic each year, but this was not reflected in the training records for the affected employees.
Failure to Provide Annual QAPI Training to Staff
Penalty
Summary
The facility failed to provide mandatory annual training on its Quality Assurance and Performance Improvement (QAPI) program to five employees, including a housekeeper, a certified nursing assistant (CNA), a dietary aide, a certified medication aide (CMA), and a registered nurse (RN). Review of personnel records for these staff members showed no evidence of QAPI training being completed within the previous 12 months. The HR Coordinator confirmed that while monthly in-service trainings were conducted on various topics, QAPI training was not documented as being provided annually to these employees. The facility's policy requires annual education on the QAPI program, but this was not followed for the staff in question. Interviews with the HR Coordinator, DON, and Administrator revealed that the process for delivering in-service trainings involved the HR Coordinator preparing materials and department heads presenting them to their staff, with the HR Coordinator responsible for verifying completion. Despite this process, the required QAPI training was not completed or documented for the identified staff members. The lack of annual QAPI training was acknowledged by facility leadership as a gap that could leave staff uninformed about essential quality assurance practices.
Failure to Provide Annual Ethics Training to Staff
Penalty
Summary
The facility failed to provide mandatory annual ethics training to 7 out of 23 employees reviewed, including housekeeping, certified nursing assistants, registered nurses, and licensed vocational nurses. Personnel records for these staff members showed no evidence of ethics training being completed within the previous 12 months, despite their varying hire dates. The HR Coordinator was responsible for initiating monthly in-service trainings and providing them to department heads, who were then expected to present the trainings to their staff. However, the records indicated that the required annual ethics training was not completed for these employees. Interviews with the HR Coordinator, DON, and Administrator confirmed that the process for delivering and verifying in-service trainings relied on department heads to present the material and the HR Coordinator to verify completion. The facility's policy required an educational calendar that included compliance and ethics training, but the lack of documentation in personnel files demonstrated that this requirement was not met for the identified staff members.
Failure to Provide Required Annual CNA In-Service Training
Penalty
Summary
The facility failed to ensure that three out of six reviewed CNAs received the required minimum of 12 hours of annual in-service training. Personnel records for these CNAs showed no evidence of completion of the mandated training topics, such as communication, QAPI, ethics, falls, restraint, and emergency preparedness. The HR Coordinator reported that in-service trainings were initiated monthly and provided to department heads, who were responsible for presenting them to their staff. However, the HR Coordinator was responsible for verifying completion, and there was no documentation that the required trainings were completed for the identified CNAs. Interviews with the HR Coordinator, DON, and Administrator confirmed the process for distributing and verifying in-service trainings but revealed gaps in ensuring all staff completed the required annual training. Additionally, when requested, none of the facility leaders were able to provide a policy addressing the required minimum 12 hours of annual in-service for CNAs prior to the survey exit.
Failure to Provide Required Behavioral Health Training to Dietary Staff
Penalty
Summary
The facility failed to provide behavioral health training in accordance with federal requirements and its own facility assessment for two staff members in the dietary department. Specifically, the Dietary Aide I did not receive annual behavioral health training, and the Dietary Manager did not receive behavioral health training upon hire. Personnel records and training in-service documentation reviewed by the HR Coordinator showed no evidence that these required trainings were completed within the specified timeframes. Interviews with the HR Coordinator, DON, and Administrator confirmed that the process for delivering and verifying in-service trainings involved the HR Coordinator preparing monthly topics and department heads presenting them to their staff. However, the system did not ensure that all staff, including new hires and those requiring annual updates, received behavioral health training as required. The facility's policy indicated that behavior interventions should be included in the annual educational calendar, but this was not consistently implemented for all staff.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and total dependence on staff for activities of daily living had their call light within reach while in bed. Observations on two separate occasions found the call light clipped to the privacy curtain, out of the resident's reach, while the resident was sleeping in bed. The resident's care plan specifically included interventions for call light placement within reach and prompt response, as well as reminders to use the call light for assistance. Interviews with staff confirmed that the call light was not accessible to the resident and that it was the responsibility of CNAs and nurses to ensure proper placement. The resident in question had multiple diagnoses, including epilepsy, essential hypertension, muscle weakness, and unspecified dementia, and was assessed as having severe cognitive impairment with total dependence for mobility and self-care. The facility's own policy required that call lights be within easy reach of residents when in bed or confined to a chair. Both the DON and the administrator acknowledged that the call light should have been accessible and that staff were responsible for ensuring this during rounds and room checks.
Failure to Complete and Transmit Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to complete and transmit a discharge Minimum Data Set (MDS) assessment for one resident within the required timeframe. Specifically, the discharge MDS assessment for a resident with multiple diagnoses, including chronic systolic heart failure, respiratory failure, hypertension, atherosclerotic heart disease, and unspecified dementia, was not completed or transmitted to CMS as required. The assessment remained open and unfinished after the resident's discharge, and the MDS coordinator acknowledged that it should have been completed by day 14 post-discharge but was unsure why it was overlooked. Interviews with the MDS coordinator, DON, and administrator confirmed that the responsibility for completing and tracking MDS assessments rested with the MDS coordinator, and that monitoring was supposed to occur through scheduled meetings and reports in the facility's electronic system. However, the discharge MDS assessment for this resident did not appear on the in-progress report, and there was no clear explanation for the omission. The facility's policy required comprehensive assessments to be completed and submitted according to CMS guidelines, but this process was not followed in this instance.
Inaccurate MDS Assessment Coding for Medication Type
Penalty
Summary
The facility failed to ensure that a resident's assessment accurately reflected her medication status. Specifically, the quarterly Minimum Data Set (MDS) assessment indicated that the resident was receiving an anticoagulant, when in fact she was prescribed and administered clopidogrel, an antiplatelet medication. The MDS nurse acknowledged that this was a coding error, as clopidogrel should have been recorded as an antiplatelet, not an anticoagulant, according to the CMS RAI guidelines. The resident involved was an elderly female with multiple diagnoses, including urinary tract infection, cerebral palsy, heart failure, peripheral vascular disease, hypothyroidism, and cognitive communication deficit, with a BIMS score indicating severe cognitive impairment. Review of her physician orders and medication administration records confirmed she was receiving clopidogrel for blood thinning purposes, but not an anticoagulant. The facility's policy requires comprehensive and accurate assessments in line with CMS guidelines, which was not followed in this instance.
Failure to Include Smoking Status in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including a history of transient cerebral ischemic attacks, cerebral vascular disease, hyperlipidemia, hypertension, and muscle weakness. The resident was assessed as having moderate cognitive impairment and was dependent on staff for most activities of daily living. Despite documentation in the resident's records and a smoking assessment indicating the resident was a smoker and required adaptive equipment such as a smoking apron, the comprehensive care plan did not include any interventions or objectives related to the resident's smoking status. Observations confirmed that the resident was actively smoking in the designated area while using a smoking apron, and interviews with both the resident and staff corroborated the resident's smoking status and the use of adaptive equipment. The MDS nurse acknowledged that it was her responsibility to include smoking in the care plan and admitted to overlooking this requirement, which resulted in the absence of a care plan addressing the resident's smoking needs. The facility's own policy requires that care plans include measurable objectives and timeframes for all identified needs, but this was not followed in this case.
Failure to Provide Proper Perineal Care for Incontinent Resident
Penalty
Summary
A certified nursing assistant (CNA) failed to provide appropriate perineal care to a female resident who was incontinent of bowel and bladder. During an observed episode of incontinence care, the CNA did not separate the resident's labia or clean the base of the labia, as required by facility policy and standard perineal care procedures. The CNA acknowledged during an interview that she forgot to perform this step due to nervousness. The Director of Nursing (DON) confirmed that the CNA had previously demonstrated correct perineal care skills during a competency check-off, but did not follow the correct procedure during the observed care. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and had a history of frequent urinary and constant bowel incontinence. The resident's care plan included monitoring for signs and symptoms of urinary tract infection. Facility policy specifically required separating the labia and cleaning from front to back during female perineal care, which was not followed in this instance.
Failure to Cover Oxygen Nasal Cannula When Not in Use
Penalty
Summary
A deficiency was identified when a resident who required intermittent oxygen therapy was not provided with safe and appropriate respiratory care according to professional standards. The resident, who had multiple diagnoses including chronic respiratory failure, heart failure, and diabetes, had a physician's order for as-needed oxygen via nasal cannula and instructions to keep the cannula covered in a plastic bag when not in use. During an observation, the resident's nasal cannula was found uncovered on the nightstand while the resident was not present in the room. Interviews with both an LVN and the DON confirmed that the nasal cannula should have been covered in a plastic bag when not in use to prevent possible infection, as per the physician's order. However, the facility did not have a specific policy regarding the covering of nasal cannulas and masks when not in use. The failure to follow the physician's order and professional guidelines for infection control was documented through observation, interviews, and record review.
Failure to Enforce Food Storage Policy for Resident Brought-In Foods
Penalty
Summary
The facility failed to implement and enforce its policy regarding the use and storage of foods brought in by family and visitors for residents. During an observation of a resident's personal refrigerator, a small plastic cup containing food was found without a date or label. The facility's policy requires that perishable foods be stored in resealable containers with tightly fitting lids, labeled with the resident's name, the item, and a use-by date. However, this policy was not followed in this instance. The resident involved was an older female with multiple diagnoses, including type 2 diabetes mellitus, cholelithiasis, rheumatoid arthritis, intestinal obstruction, and dysphagia. She was cognitively intact and independent with eating. Interviews with staff, including an LVN and the DON, confirmed that night nurses were responsible for monitoring the resident's refrigerator daily, but the required labeling and dating of food items were not performed. This lapse in procedure was directly observed and acknowledged by facility staff.
Failure to Clean Blood Pressure Cuff Between Resident Uses
Penalty
Summary
A medication aide (MA C) failed to clean a blood pressure cuff between uses, specifically before measuring the blood pressure of a resident with multiple comorbidities, including chronic kidney disease, heart failure, type 2 diabetes mellitus, hypertension, and a chronic non-healing wound. The resident was severely cognitively impaired and required significant assistance with daily activities. The aide used the same blood pressure cuff on another resident and then on this resident without cleaning it, as observed by surveyors. Interviews with the medication aide and the Director of Nursing confirmed that the blood pressure cuff should have been cleaned between uses to prevent possible infection, in accordance with the facility's policy on cleaning and disinfecting reusable items. The failure to follow infection control protocols was directly observed and acknowledged by staff, and the facility's policy required such equipment to be cleaned and disinfected between residents.
Failure to Maintain Accurate Clinical Records and Fall Risk Assessments
Penalty
Summary
The facility failed to maintain accurate and complete clinical records for a resident with multiple medical conditions, including diabetes, vascular dementia, and hemiplegia. Specifically, the fall risk assessment for the resident was inaccurate, as it indicated a low risk for falls despite the resident having experienced four falls within a six-month period. The assessment also failed to document a history of falls, and the fall prevention interventions were not updated following the assessment. The Director of Nursing confirmed the inaccuracy of the fall risk assessment and acknowledged that the resident should have been classified as moderate to high risk for falls. Additionally, the facility did not accurately document neurological checks following an unwitnessed fall. Although neuro checks were required every 30 minutes for three intervals after the fall, documentation was only present for the one-hour mark, with no records for the earlier checks. The Assistant Director of Nursing confirmed that the nurse reported performing the checks but failed to document them in the electronic record. Both the DON and ADON acknowledged the lack of accurate documentation and stated that there was no facility policy specifically addressing the accuracy of clinical records and assessments.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to ensure personal privacy for a resident while providing incontinent care. During the provision of care, the privacy curtain was not completely closed, resulting in the resident's genital area being exposed. This occurred while the resident's roommate was present in the room. Both CNAs acknowledged that the privacy curtain should have been fully closed during care and confirmed that they had received resident rights training within the past year. The resident involved had significant cognitive impairment, as indicated by a BIMS score of 3, and was frequently incontinent of bowel and bladder. The care plan specified that the resident required extensive assistance with activities of daily living, including incontinence care, and directed staff to provide privacy by pulling the curtain around the bed. The Director of Nursing (DON) confirmed that privacy must be provided during care and that staff had been trained on resident rights and privacy policies.
Failure to Address High Fall Risk in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and psychosocial needs. The resident, a 74-year-old male with severe cognitive impairment and multiple diagnoses including COPD, respiratory failure, atrial fibrillation, and type 2 diabetes, was identified as high risk for falls in his admission fall risk assessment. However, the care plan did not address this high fall risk until after the resident experienced an actual fall. The Director of Nursing (DON) acknowledged that the resident's high fall risk should have been included in the comprehensive care plan from the beginning. The MDS Nurse, responsible for completing the initial and quarterly care plans, admitted to missing the inclusion of the fall risk due to being very busy. The facility's policy requires that each resident be assessed for fall risk on admission and that interventions be developed and implemented based on the level of risk, but this was not done in a timely manner for the resident in question.
Inadequate Incontinence Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinence care for a resident who was incontinent of bladder, which could lead to urinary tract infections. The resident, a male with severe cognitive impairment and multiple health conditions including type 2 diabetes and dementia, was observed receiving inadequate care from two CNAs. During the care, one CNA improperly cleaned the resident's genital area by using multiple passes with one wipe in a back-and-forth motion, rather than using a new wipe for each pass and cleaning in a proper outward motion. This improper technique was acknowledged by the CNA during an interview, who admitted to not being aware of the mistake until it was pointed out. Interviews with the staffing coordinator and the ADON revealed that the CNAs were trained to use a specific technique for incontinence care, which was not followed in this instance. The staffing coordinator and ADON both emphasized that improper cleaning techniques could lead to infections, as the area was not being properly cleaned. The facility's policy on perineal care was also reviewed, which outlined the correct procedure for cleaning male residents, including retracting the foreskin and cleaning the shaft of the penis. The failure to adhere to these procedures placed the resident at risk for developing infections.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
The facility personnel failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident, an elderly female with a history of cerebral infarction, dysphagia, hyperlipidemia, and malignant neoplasm of the colon, was documented as a full code, meaning she should have received resuscitation efforts. However, when the resident was found unresponsive with no pulse or respirations, the nursing staff did not initiate CPR as required by professional standards of practice. The incident occurred when a CNA found the resident unresponsive and alerted an LVN, who mistakenly believed the resident was a DNR due to her hospice status and did not verify the code status. The LVN failed to initiate CPR and instead contacted hospice and the DON. It was only after reviewing the resident's chart later that the LVN realized the resident was a full code, but by then, it was too late to start resuscitation efforts. The hospice RN and EMS were eventually called, but CPR was not initiated until EMS arrived, and the resident was pronounced deceased shortly thereafter. Interviews with facility staff revealed a lack of adherence to protocol and a misunderstanding of the resident's code status. The DON confirmed that the LVN did not check the resident's EMR or chart for the correct code status at the time of the incident. The facility's protocol required verification of code status and initiation of CPR for full code residents, which was not followed in this case. The failure to provide timely CPR to a full code resident was identified as an Immediate Jeopardy situation, indicating a serious breach in the standard of care expected in such situations.
Failure to Document Physician Orders for Crushed Medications
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices for Resident #1, who required medications to be crushed due to difficulty swallowing pills. Despite having a physician order from hospice to crush medications, this order was not entered into the electronic medication administration record (EMAR). This oversight was discovered during interviews and record reviews, revealing that the order to crush medications was not properly documented in the EMAR, which could potentially lead to Resident #1 choking on uncrushed medications. Interviews with various staff members, including LVNs and a hospice nurse, confirmed that the order to crush medications was communicated but not properly entered into the EMAR. The facility's Director of Nursing (DON) acknowledged that the admitting nurse should have ensured the physician orders were correctly entered into the system. The facility's policy on medication administration emphasizes the importance of following the six rights of medication administration, which includes proper documentation. The failure to document the order to crush medications in the EMAR represents a significant lapse in following these standards, putting Resident #1 at risk for harm.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident who walked out of the facility through an alarming door without staff responding. The resident, who had a history of Parkinson's disease and dementia, was identified as being at moderate risk for wandering. Despite wearing a wander guard, the resident managed to exit the facility, triggering an alarm that went unheeded by staff for several minutes. This incident placed the resident at risk of being unsupervised, leading to the identification of an Immediate Jeopardy situation. Interviews with staff revealed that the alarm was heard by multiple employees, including a CNA and a Maintenance Director, but was not immediately acted upon. The Maintenance Director eventually noticed the resident outside and brought her back inside. Staff members, including a CNA and an LVN, admitted to hearing the alarm but did not respond due to being occupied with other tasks. The Director of Nursing and the Administrator did not consider the incident a true elopement since the resident did not leave the property, and thus did not notify the physician or the resident's representative. The facility's policy on elopement requires nursing personnel to report and investigate all reports of missing residents, but this was not followed in this case. The lack of immediate response to the door alarm and the failure to treat the incident as a serious elopement event contributed to the deficiency. The facility's inaction and lack of training on elopement response were significant factors leading to the deficiency, as staff were not adequately prepared to handle such situations.
Confidentiality Breach During Medication Pass
Penalty
Summary
The facility failed to protect the confidentiality of a resident's personal health care information during a medication pass. An LVN left a medication cart unattended for approximately five minutes, during which time the laptop on the cart displayed a resident's picture, name, and a progress note about their dietary intake via a PEG tube. This lapse in protocol was observed by surveyors, highlighting a breach in maintaining the privacy of resident information. The resident involved had been admitted to the facility with diagnoses including cerebral infarction, dysphagia, and depression. During an interview, the LVN admitted to not remembering leaving the laptop open and acknowledged the potential risk of unauthorized access to resident medical records. The Director of Nursing stated that the expectation was for the screen to be set to a privacy screen with no identifiable resident information visible. The facility's policy on confidentiality emphasized the importance of not sharing sensitive and personal information about residents.
Failure to Complete Discharge MDS for Resident
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the resident's status, specifically for a resident who was discharged without a discharge Minimum Data Set (MDS) in the electronic record. This oversight was identified during interviews and record reviews, which revealed that the resident, who had been admitted with Parkinson's disease and dementia, was discharged without the necessary documentation. The resident's admission record indicated a discharge date, and a physician's order for discharge was signed, but the discharge MDS was missing from the resident's chart. Interviews with facility staff, including the MDS coordinator, Director of Nursing (DON), and the Administrator, revealed a lack of awareness and oversight regarding the missing discharge MDS. The MDS coordinator admitted to missing the discharge MDS due to an oversight in her scheduling process, which involved manually noting due dates in a calendar. The facility's policy on the implementation of the MDS, which requires comprehensive assessments to be completed and submitted according to CMS guidelines, was not adhered to in this instance.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as required by professional principles. During an observation, a medication cart assigned to an LVN was found unattended and unlocked, with the lock button unengaged. This incident occurred while the LVN was away from the cart for a few minutes to assist a resident's family member. The LVN acknowledged that the cart should have been locked when unattended. Interviews with the RN Supervisor and the Director of Nursing (DON) confirmed that the facility's expectation was for medication carts to be locked when not in use. The RN Supervisor stated that she ensures compliance by observing the carts on the floor, and both she and the DON recognized the risk of residents accessing medications not intended for them. A review of the facility's Storage of Medications policy reiterated the requirement for compartments containing medications to be locked when not in use and for transport trays or carts not to be left unattended.
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.
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