Avir At Coronado

Penalty

No penalty information released

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

Summary

The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 6 of 54 days reviewed for DON coverage. The DON worked as a charge nurse on 03/07/2026, 03/16/2026, 04/04/2026, 04/11/2026, 04/18/2026, and 04/19/2026, despite the facility policy stating the DNS may serve as charge nurse only when the average daily occupancy is 60 or fewer residents. During interviews, the DON stated she was falling behind on monitoring nurse assessments and care plan updates because she was working nights as a CNA and nurse to fill open shifts. The RCN stated the DON was getting behind on comprehensive care plans because leadership turnover and staffing shortages had required the DON to work on the floor as a nurse and CNA at times. The ADMN stated he knew the DON should not be working as a CNA or charge nurse when the facility had over 60 residents, but said it was better to have the shifts filled to perform resident care.

Penalty

No penalty information released

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

Summary

The facility failed to treat residents with dignity and respect by leaving ostomy and urinary drainage equipment visible and, in one case, not emptied when residents were in common areas or their rooms. Resident #37, a cognitively intact male with a history of colon cancer and an ostomy, was observed walking in the hallway with his shirt raised so that his ileostomy bag was visible to staff and other residents. Resident #54, a cognitively intact female with a urinary catheter, had physician orders for a privacy bag for her urinary drainage bag while in bed, walking, or in a wheelchair. She was observed multiple times with the urinary catheter collection bag hanging on the side of the bed or attached to her chair without a privacy bag, making it visible to anyone passing by or in the room. Resident #67, a female with dementia, dehydration, constipation, and lower abdominal pain, had both a colostomy and an indwelling urinary catheter. She was observed in the dining room with her shirt not pulled down in the back, exposing a colostomy bag that appeared more than 3/4 full of liquid stool, while her urinary collection bag was about 1/2 full and not in a privacy bag. Staff assisted her into her wheelchair but did not cover the bag or take her to empty either collection bag at that time. Later, the DON removed her from the dining room, emptied the colostomy bag, and assisted her to change her shirt. The resident stated she did not like it when the colostomy bag was not covered and reported that when the bag was too full it caused pain and discomfort due to pulling on her skin.

Penalty

No penalty information released

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

Summary

The facility failed to honor residents’ right to organize and participate in resident/family groups by not providing a verbal or written response to the Resident Council regarding grievances raised in multiple meetings. The report states that the facility did not consider the views of the resident group or act promptly upon grievances and recommendations concerning resident care and life in the facility, and did not demonstrate its response and rationale for its response for 12 of 15 confidential residents reviewed for meeting grievances. Record review showed the Resident Council submitted grievances related to nursing services, dietary services, housekeeping services, and other daily living concerns across several months. These included reports that bed sheets were not being changed for a month or more, housekeepers were noisy and disrespectful in the mornings, exterminator visits were requested more often, a shower room heater needed repair before winter, staff talked too loudly in the hallway, residents wanted boiled eggs instead of powdered eggs, more outside activities were requested, beds should be made daily with fresh sheets, nursing staff made negative remarks about other staff members, carts were being banged into walls, medication drawers were being slammed, laundry staff should label personal items, toast was not being served because bread was too soft or too hard, meal trays were left in the hallway overnight, a night nurse aide spent too much time with one resident and was loud, and nurse aides were not paying attention during shower chair transfers.

Penalty

No penalty information released

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

Summary

The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for multiple resident rooms observed for environmental conditions. During observations, several resident room sinks on Hall 1 had hot water temperatures measured at 74.1 degrees F, 73.9 degrees F, 74.3 degrees F, and 74.1 degrees F. A family member of Resident #53 stated they had concerns about the facility not having hot water for residents and family members to wash their hands, and said the issue had been going on for a while. In a confidential group interview, 3 of 15 residents stated they had no hot water in their rooms and said the Maintenance Director was aware of the issue and it had not been fixed. The facility also failed to ensure that mattresses in several resident rooms had intact nonpermeable outer covers. During an observation and interview, Resident #72 stated his mattress was peeling and bothered him when he slept because he could feel the cracks; the mattress cover was observed cracked and peeling on the top half. In another room, a mattress was observed without sheets and with the protective nonpermeable outer cover cracked and peeled throughout the whole mattress, and Resident #26 was not present during the observation. Resident #27 and Resident #53 each stated their mattresses were peeling and uncomfortable because they could feel the cracks and peeling, and their mattresses were observed with cracked and peeling protective covers. Staff interviews confirmed awareness of the conditions. A housekeeper stated some mattresses had cracks and were peeling and that management was likely aware, and said she used disinfect spray to sanitize the mattresses. The ADMN stated mattresses were being replaced as needed but only four could be ordered per month, and said residents should have mattresses that were not cracked or peeling and were comfortable. The Maintenance Director stated he was aware of the hot water problem on Hall 1, had called a repair company, and was waiting for corporate approval for repairs. The ADMN later stated he was aware of hot water issues in multiple halls and that the facility was waiting for upper management approval before repairs could be made.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and time frames for 4 of 18 residents reviewed. Resident #2 had diagnoses including dementia, schizoaffective disorder, bipolar disorder, major depressive disorder, and anxiety disorder, and the quarterly MDS showed severe cognitive impairment with active diagnoses of anxiety and depression. The care plan dated 11/01/2025 did not include a care plan addressing Major Depressive Disorder or Anxiety Disorder, and the DON acknowledged that such care plans should have been present but were not. Resident #3 was cognitively intact and stated that he smoked cigarettes and had no issues with the smoking process. His care plan, last revised 1/20/26, did not address smoking. During interview and record review, the ADMN and DON confirmed that he smoked and that there should have been a specific care plan for smoking, but none was present. The DON stated she had assessed him for safe smoking and that there had been no negative outcome, but the smoking status was still not included in the care plan. Resident #4 had diagnoses including neurogenic bladder, dysphagia, and nontraumatic cerebral hemorrhage, and the admission MDS showed severe cognitive impairment. She had a gastrostomy tube since admission, and physician orders included monitoring and assessing the unused gastrostomy tube and flushing it every 12 hours with 30 mL of fluid as needed. The comprehensive care plan did not include any focus, goal, or interventions related to flushing the gastrostomy tube. Resident #33 had diagnoses including neuromuscular dysfunction of bladder and UTI, was cognitively intact, had an indwelling catheter, and had orders to change the Foley catheter as needed and monitor urinary output every shift, but the comprehensive care plan did not include any focus, goal, or interventions related to Foley catheter care.

Penalty

No penalty information released

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

Summary

The facility failed to provide each resident with a nourishing, well-balanced diet to meet daily nutritional and special dietary needs for 21 of 73 residents reviewed for food and nutrition services. On the posted menu for a regular diet, lunch included soft tacos, refried beans, tortilla soup, and brownie. During observation of food preparation and service in the kitchen, the facility did not have enough refried beans or a comparable substitute, resulting in 21 residents not receiving refried beans. After 17 residents were served trays without refried beans, the Dietary Manager provided rice to the last 4 trays/residents. In interviews, the Dietary Manager said there were 53 residents on a regular diet and that she would try to identify the residents who did not receive refried beans and give them rice. The Dietician stated that rice was not an appropriate substitute for refried beans and would not have approved that substitution, and that when the kitchen runs out of food, a nutritional equivalent substitute should be provided. The substitution log for April 2026 was blank, and the Dietary Manager said she had not filled it out yet. The Dietary Manager and Administrator stated they did not know why the facility ran out of refried beans, and the Dietary Manager said she was not sure whether rice was a comparable nutritional substitute and should have called the Dietician before making the substitution.

Penalty

No penalty information released

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

Summary

The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an initial tour, the floors throughout the kitchen were observed to be soiled with dirt and food crumbs, especially around the baseboards. The stand that the mixer was on was also soiled with dirt and food crumbs, and there was a pile of food thickener or flour underneath the stand. The plastic container holding the food thickener had spilled dried food and dust on the outside, and a plastic scoop was lying on top of the container. Additional observations showed the convection oven and stove had dried baked-on food on the inside and grease and dust on the outside. Extra oven shelves stored on top of the convection oven were covered with old baked food and grease. The shelf above the stove was soiled with food crumbs and dust, the bottom shelf of the refrigerator had food crumbs, and the stand holding residents' plates was soiled with food crumbs. The Dietary Manager stated it was her expectation for the kitchen to be clean after every meal, and the Administrator stated it was his expectation for the kitchen to be clean. A policy regarding kitchen sanitization was requested but not provided by the time of exit.

Penalty

No penalty information released

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

Summary

The facility failed to accurately assess Resident #4’s status on the admission MDS. Resident #4 was a [AGE]-year-old female admitted with diagnoses including dysphagia and nontraumatic cerebral hemorrhage. The admission MDS, dated 03/14/2026 and reviewed on 04/24/2026, documented a BIMS score of 00 indicating severe cognitive impairment, a gastrostomy tube since admission, and a weight loss of 5% or more in the last month or 10% or more in the last 6 months. The MDS also coded Eating as partial to moderate assistance for bringing food and liquid to the mouth and swallowing once the meal was placed before the resident. Record review showed a physician order dated 04/23/2026 with a start date of 4/21/2026 to monitor and assess a non-used gastrostomy tube and flush it every 12 hours with 30 milliliters of fluid as needed. The resident’s regular diet was Mechanical Soft texture with Regular consistency. The comprehensive care plan for Resident #33 reviewed on 04/24/2026 reflected no focus, goal, or interventions related to weight loss or gastrostomy tube feedings. During interview, the MDS coordinator stated she was responsible for MDS assessments and acknowledged she made a mistake in the documentation and had coded the assessment incorrectly for weight loss. The DON stated her expectation was for the MDS assessment to be completed in a timely manner and accurately.

Penalty

No penalty information released

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

Summary

The facility failed to ensure appropriate catheter care and urinary output monitoring for a resident with an indwelling urinary catheter and diagnoses including neuromuscular dysfunction of the bladder and UTI. The resident’s record showed she was cognitively intact, had an indwelling catheter, and was always incontinent of bowel movement. Physician orders included changing the indwelling urinary catheter as needed and monitoring urinary output every shift, but the MAR did not document urine output on several day shifts in April 2026, and the care plan did not include a focus, goal, or interventions related to Foley catheter care. During observation, the resident’s catheter tubing was found leaking into a brief and was not secured to her leg with a securement device. The catheter was changed, but the nurse who performed the change did not place a securement device on the tubing. On a later observation, the resident’s catheter bag was not covered with a privacy bag and there was no tape securing the catheter to her leg. The resident stated she had pain when moved and that the catheter had been replaced because it was hurting her. She also stated she wanted a privacy bag so her family would not see her urine when they visited. Interviews with the DON and LVN A confirmed that nurses were expected to secure catheter tubing to the resident’s leg and ensure a privacy bag was in place. The DON also stated urine output should be documented on the MAR when a resident had an indwelling urinary catheter. LVN A stated she did not secure the catheter because she forgot while being observed, that the catheter bag should have had a privacy bag, and that if outputs were not documented then she could not prove the bag had been emptied. The facility policy stated catheter tubing should remain secured with a leg strap, daily output should be maintained, and documentation should include catheter care provided and assessment data.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete and accurately documented medical records for one resident after hospitalization and readmission. Resident #54, a cognitively intact female with diagnoses including diastolic CHF, atrial fibrillation, and HTN, returned to the facility from the hospital after treatment for sepsis and a UTI. Record review showed no evidence that a readmission assessment was completed and no vital signs were documented for several days after the resident returned, despite the facility policy requiring a readmission assessment, medication reconciliation, infection screening, provider notification, and care plan update within 4 hours of return. Progress notes showed the resident arrived back at the facility from the hospital, and later that same day she was transported again after staff called 911 when she became nonresponsive. During interviews, an LVN stated the admitting nurse was responsible for obtaining vital signs and completing the readmission assessment, and that daily vital signs for three days were intended to reduce rehospitalization risk. Another LVN stated she had not taken vital signs because there was no order for blood pressure or pulse, while the DON stated she expected the nurse to complete the assessment and daily vital signs but was falling behind on monitoring whether nurses were completing those assessments. The MD stated he expected nurses to perform assessments on admission or readmission but did not expect continued vital signs unless ordered.

Penalty

No penalty information released

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

Summary

The facility failed to employ a qualified social worker on a full-time basis in a building with a licensed capacity of 188 resident beds. During interview, the SSD stated she had a master's degree in social work from Puerto Rico and had been licensed in New York, but she was not licensed in Texas at the time of the survey and was working to obtain reciprocity. She stated she had been performing social work duties for the facility since December 2025, but she did not come to the facility and all communication was by phone or virtually. During interviews, the VP of HR stated she was unfamiliar with Texas regulations for a social worker and needed to review them before answering questions about licensure requirements. The ADMN stated his expectation was to have a full-time social worker that was licensed, but the SSD was still working on transferring her license to Texas. He stated no other social worker was in the building to perform social work duties, although the SSD had corporate oversight. Record review showed the Social Services job description dated 12/12/2025 listed licensure as preferred, the Social Services Director job posting listed licensure as required, and the facility policy stated not all medically-related social services are provided by a qualified social worker, but the facility is responsible for ensuring residents receive these services.

Penalty

No penalty information released

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

Summary

During a medication storage inspection, surveyors observed that medication cart #1 was left unlocked and unattended outside the nurse's station, with residents and staff in close proximity and out of staff eyesight. The cart had unlocked drawers facing outward and contained various items including a butter knife, nail clippers, mouth wash, an unopened petrolatum dressing, glucometers, lancets, lab draw kits with needles, hand sanitizer, zinc oxide creams, moisture barrier creams, and several over-the-counter (OTC) medications such as Milk of Magnesia, cough suppressant, fish oil, gas relief tablets, B-Vitamins, Colace, Vitamin D, acid reducers, melatonin, and senna tablets. AA batteries were also found in one of the drawers. The cart was identified as previously used for isolation during COVID-19 but was no longer in use for that purpose. Interviews with the DON, LVN, and ADMN confirmed that the cart should have been locked when not in use and that staff were responsible for monitoring and securing it. The DON acknowledged that residents could have accessed the medications and items on the cart, potentially leading to harm. The ADMN stated that the responsibility for ensuring medication carts are locked ultimately rested with him and that the failure to secure the cart was due to staff being too busy to lock it after use. Facility policy reviewed by surveyors required all medications and biologicals to be stored in locked compartments, with access limited to authorized personnel.

Penalty

No penalty information released

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

Summary

A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover all assessed needs or provide clear, measurable interventions.

Penalty

No penalty information released

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

Summary

The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.

Penalty

No penalty information released

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

Summary

The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. The survey revealed improper thawing of ground meat, which was placed in a dish with running water but not fully submerged, leaving approximately 30% of the meat exposed. This method of thawing does not comply with the facility's policy, which requires meat to be thawed in a refrigerator or completely submerged under running water at a temperature of 70°F or below. Additionally, the facility did not ensure proper hand hygiene during food preparation. The cook was observed donning gloves without washing hands and handling food items without performing hand hygiene between glove changes. This practice contradicts the facility's hand hygiene policy, which mandates handwashing before donning and after doffing gloves to prevent cross-contamination and the spread of bacteria. The facility also failed to properly label and store food items. Several food items were found without proper labeling, including bags of food that were not sealed and expired items that were not disposed of. The dietary manager and dietician confirmed that food should be labeled with a description and date, and stored at least six inches off the floor. The lack of proper labeling and storage could lead to the wrong food being served, potentially causing allergic reactions or foodborne illnesses among residents.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that residents or their representatives were informed and provided consent for the administration of antipsychotic medication, specifically Seroquel (quetiapine), for two residents. Resident #29, who has a diagnosis of schizoaffective disorder, bipolar type, was administered Seroquel without a signed consent from either the resident or their representative. The medication was given at an increased dosage without obtaining the necessary consent, and there was no evidence that the side effects were communicated to the resident's representative. Attempts to contact the representative for consent were unsuccessful. Resident #44, diagnosed with neurocognitive disorder with Lewy bodies and major depressive disorder, also received Seroquel without a signed consent. The medication was administered multiple times over several months without documented consent from the resident or their representative. The facility's staff, including the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), acknowledged the oversight and the lack of a proper process for obtaining consent for antipsychotic medications. Interviews with facility staff revealed that there was confusion and a lack of clear policy regarding obtaining consent for antipsychotic medications. The DON admitted to not being aware that verbal consents were inappropriate for such medications, and the Clinical Care Nurse (CCN) mentioned that there were barriers to obtaining consents, such as unresponsive family members. The facility's policy, updated in July 2024, requires written consent for psychotropic medications, but this was not adhered to in these cases.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement comprehensive, person-centered care plans for six residents, which included measurable objectives and time frames to meet their highest practicable physical, mental, and psychosocial well-being. The care plans for these residents lacked specific, measurable objectives for various issues such as resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks. This deficiency was identified during interviews and record reviews, highlighting the absence of clear, actionable goals in the care plans. For Resident #23, the care plan did not define measurable objectives for problems related to resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks. Similarly, Resident #26's care plan lacked measurable objectives for issues concerning psychotropic drug use, psychosocial well-being, pain, mood, behaviors, activities of daily living, and daily tasks. Resident #36's care plan also failed to address mobility and daily tasks, as well as visual function and communication, which were triggered on the MDS. The care plans for Residents #39, #53, and #62 were similarly deficient. Resident #39's care plan did not include measurable objectives for visual function, self-care deficits, decreased cognition, and daily tasks, nor did it address dental care and communication. Resident #53's care plan lacked measurable objectives for daily tasks, pain, ADL function, and impaired cognition. Lastly, Resident #62's care plan did not define measurable objectives for self-care related to mobility, impaired cognition, and daily tasks. These failures could affect residents and place them at risk for not having their needs and preferences met.

Penalty

No penalty information released

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

Summary

The facility failed to implement its policy regarding the use and storage of foods brought to residents by family and other visitors, which is essential for ensuring safe and sanitary storage, handling, and consumption. Specifically, the facility did not maintain proper temperature logs for personal refrigerators of five residents, which could lead to foodborne illnesses. Observations revealed that Resident #17's refrigerator contained expired goods and lacked a temperature log, while Resident #43's refrigerator was missing a thermometer and a temperature log. Additionally, Residents #22, #5, and #49 had incomplete temperature logs for February 2025. Interviews with staff indicated that night shift staff were responsible for checking the residents' personal refrigerators, but this was not consistently done. The Administrator (ADMN) expected that refrigerator temperatures should be checked weekly and recorded, but acknowledged that staff did not perform thorough checks during their rounds. The facility's policy required that refrigerators maintain proper temperatures, be equipped with thermometers, and have temperatures recorded weekly. However, these procedures were not followed, leading to the potential risk of residents consuming spoiled food.

Penalty

No penalty information released

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

Summary

The facility failed to maintain a safe and comfortable environment for a resident by not ensuring that the resident's toilet was free from cracks and securely attached to the floor. The resident, who was cognitively intact and used a wheelchair, expressed concerns about the broken toilet, fearing a fall. Observations confirmed that the toilet base was cracked and moved when pressed, posing a risk to the resident's safety. Despite the resident's complaint and a repair request made by a staff member, the issue remained unresolved. The maintenance director (MD) was aware of the problem but had been on leave due to an injury, which contributed to the delay in addressing the issue. The administrator (ADMN) was unaware of the broken toilet and did not check the electronic system for repair requests, leading to a communication breakdown. The facility's admission agreement emphasized the residents' right to safe and clean conditions, which was not upheld in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to store all drugs and biologicals in locked compartments and allowed unauthorized access to medication for one resident. During an observation, a bottle of prescription hydrocortisone cream was found in a resident's personal refrigerator, which was not locked. The resident did not have a physician's order for the hydrocortisone cream, and it was noted that the resident was unable to apply the cream themselves. This indicates that the cream was likely left in the room for staff convenience, contrary to the facility's policy. Interviews with staff, including an LVN and the DON, confirmed that prescription medications should not be left in resident rooms and that the presence of the cream in the resident's refrigerator was a failure in following proper procedures. The DON acknowledged that the oversight could lead to improper medication administration and attributed the failure to staff not being thorough in their checks. The facility's policy requires that drugs and biologicals be stored in locked compartments, accessible only to authorized personnel, which was not adhered to in this instance.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the improper use of personal protective equipment (PPE) by a certified nursing assistant (CNA) during the care of a resident with a Foley catheter. The resident, a female with dementia, a disorder of the urinary system, and type 2 diabetes, was on enhanced barrier precautions due to her indwelling Foley catheter. During an observation, the CNA did not wear a gown while performing catheter care, despite the requirement for full PPE, including a gown, gloves, and mask, as per the facility's policy on enhanced barrier precautions. Interviews with the licensed vocational nurse (LVN) and the director of nursing (DON), who also serves as the infection preventionist, confirmed that the CNA should have worn a gown during the procedure to prevent the spread of bacteria. The facility's policy on enhanced barrier precautions mandates the use of targeted gown and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms. The absence of PPE outside the resident's room and the CNA's failure to don the required gown during catheter care were identified as deficiencies in the facility's infection control practices.

Penalty

No penalty information released

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

Summary

The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, leading to a deficiency in maintaining sanitary conditions. Resident #3, a female with multiple health conditions including cerebral infarction and generalized anxiety disorder, was found to have a bathroom infested with cockroaches. Despite repeated complaints from her family member, the issue persisted, and an inspection revealed a large cockroach and several smaller ones in her bathroom. Additionally, the air conditioner unit in her room was clogged with a thick layer of lint, further contributing to an uncomfortable environment. Resident #8, a male with type 2 diabetes and a history of amputations, also experienced similar issues with cockroaches in his bathroom. He reported seeing roaches frequently, including one that emerged from his pants containing his prosthetic legs, which nearly caused him to fall. The air conditioner in his room was similarly clogged with lint and dirt, and the unit was inadequately secured to the window with tape. Despite his reports to various staff members, including the CNAs, nurses, and the Administrator, the problem remained unresolved. The facility's pest control measures were inadequate, as evidenced by the ongoing presence of cockroaches documented in the Pest Control Logbook since early 2023. The facility had a contract with a pest control company for monthly services, but the infestation persisted. The Administrator acknowledged the issue and stated that while the situation had improved since her arrival, it was still a concern. The Maintenance Supervisor confirmed awareness of the problem and the facility's reliance on professional pest control services, which had not been recently utilized beyond the regular monthly visits.

Penalty

No penalty information released

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

Summary

The facility failed to report an allegation of abuse involving a resident within the required timeframe. A family member of the resident reported an incident where a CNA allegedly placed her elbow on the resident's thigh, causing discomfort. The family member provided a video of the incident to the facility's social worker, who then shared it with the Administrator and DON. Despite the evidence, the facility did not report the incident to the state agency as required. The resident involved was an elderly female with multiple diagnoses, including cerebral infarction, generalized anxiety disorder, cellulitis, and osteoarthritis of the knee. She was dependent on assistance for all bed mobility and had a moderate cognitive impairment. The incident was captured on video, showing the CNA sitting on the edge of the resident's bed and placing her elbow on the resident's thigh, which the resident found uncomfortable. Interviews with facility staff revealed that the incident was not reported because the family member did not believe the act was intentional and felt that training was appropriate. The Administrator and DON also did not report the incident, citing a lack of intent to harm. The facility's policy required all allegations of abuse to be reported immediately, but this protocol was not followed in this case.

Penalty

No penalty information released

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

Summary

The facility failed to investigate an alleged abuse incident involving a resident and a Certified Nursing Assistant (CNA). A family member of the resident reported the alleged abuse to the facility's social worker, including a video showing the incident. Despite the report, the facility did not conduct a thorough investigation or suspend the CNA involved, as required by their abuse prevention policy. The Administrator and Director of Nursing (DON) viewed the video but did not consider the incident as intentional abuse, and thus did not report it as such. The resident involved was an elderly female with multiple medical conditions, including cerebral infarction, generalized anxiety disorder, cellulitis, and osteoarthritis of the knee. She was dependent on assistance for all bed mobility and had moderate cognitive impairment. The alleged abuse involved the CNA placing her elbow on the resident's sore leg, which was captured in the video provided by the family member. The facility's response was limited to reassigning the CNA to another resident and providing some education, without a formal investigation or suspension. Interviews with the facility staff, including the CNA, DON, and Administrator, revealed that the incident was not treated as an abuse allegation. The social worker, who first received the video, believed the movement was inappropriate and that the administration should have followed protocol by investigating the allegation and suspending the CNA if necessary. The facility's policy mandates that all allegations of abuse be thoroughly investigated and reported to the appropriate agencies, which was not done in this case.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in two common areas and in the bathrooms of two residents. Resident #3, a female with cerebral infarction, generalized anxiety disorder, cellulitis, and osteoarthritis of the knee, was reported by her family member to have cockroaches in her bathroom. The family member had observed roaches running across the floor and had resorted to using mothballs to address the issue, as the facility did not respond to her concerns. Resident #3 herself confirmed seeing cockroaches in her bathroom. Resident #8, a male with type 2 diabetes mellitus, acquired absence of both legs below the knee, generalized anxiety disorder, and a stage 3 pressure ulcer, also reported cockroaches in his bathroom. He described an incident where a cockroach emerged from his pants, which contained his prosthetic legs, causing him distress. Despite reporting the issue to various staff members, including CNAs, nurses, the DON, and the Administrator, the problem persisted. Observations confirmed the presence of cockroaches in Resident #8's bathroom. The facility's pest control measures were inadequate, as evidenced by the ongoing presence of cockroaches despite a contract with a pest control company for monthly services. The Maintenance Supervisor acknowledged the issue, noting that the facility was an older building with recurring pest problems. The Pest Control Logbook documented sightings of roaches since February 2023, with the most recent entry on the day of the investigation. The Administrator admitted awareness of the issue and stated that while the situation had improved since her arrival, it remained unresolved.

Penalty

Inspection fine: $171,377

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

Summary

The facility failed to establish and maintain an effective infection prevention and control program, leading to the exposure and potential transmission of COVID-19 among residents. The deficiency was observed in the facility's inability to isolate COVID-19 positive residents from those who tested negative. Specifically, COVID-19 positive residents were cohorted with negative residents on the same unit, and in some cases, shared the same room. This failure to properly isolate residents was evident when a COVID-19 positive resident was placed in the same room as a COVID-19 negative resident, increasing the risk of transmission. Additionally, the facility did not ensure that staff adhered to proper personal protective equipment (PPE) protocols. Staff members were observed not changing PPE between interactions with COVID-19 positive and negative residents, and some staff did not wear the required PPE, such as goggles or face shields, when caring for residents. This lack of adherence to PPE protocols further contributed to the risk of spreading the virus within the facility. The facility also failed to enforce quarantine measures for COVID-19 positive residents. One resident, who was COVID-19 positive, was observed leaving their room without wearing a mask, interacting with other residents, and using shared facilities, thereby exposing multiple COVID-19 negative residents. The facility's infection prevention policy was not effectively implemented, as evidenced by the lack of individual room isolation and the improper use of PPE by staff, which contributed to the spread of COVID-19 among residents.

Removal Plan

• COVID negative residents will be temporarily moved to another hall. Residents will continue to be tested per policy. As residents of the secure unit recover, they will be relocated to the negative cohort secure unit. Residents will be moved back into the secured unit if they test positive or there are no longer COVID+ residents on the male secured unit. The negative residents, who have not tested positive, are separated on their own hall, residents are residing in separate rooms, staff was wearing masks and eye protection.
• Testing will occur every three days, until the facility had been COVID free.
• Administrator and Director of Nursing educated by Clinical Resource Nurse over COVID policy as it related to isolation protocol. PPE must be donned correctly before entering the patient area. PPE should be doffed when leaving an individual patient room or isolation unit if cohorting. PPE must remain in place and be worn correctly for the duration of work in contaminated areas and should not be adjusted during patient care. If cohorting, positive residents' gown and gloves should be changed following patient care. PPE includes NIOSH approved respirator, well-fitting face masks, gowns, gloves, eye protection.
• N95 masks may be worn for the duration of the shift when used solely for source control but should be changed when soiled or compromised. Other PPE should be changed when it becomes soiled.
• All staff will be educated prior to working their next shift. Any new or temporary staff will be educated prior to working their first shift.
• Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will observe the secured unit to monitor for correct PPE usage and proper hand hygiene.
• Director of Nursing, Assistant Director of Nursing, and/or Designee will continue to test per protocol and will follow isolation guidelines per the facility policy.
• Ad hoc QAPI performed with Medical Director informing him of the IJ template for F880 and the facility's plan to remove immediacy.

Penalty

No penalty information released

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

Summary

The facility failed to ensure adequate supervision to prevent accidents, resulting in a resident with severe cognitive impairment eloping from the facility. The resident, who had a history of wandering in unsafe places and was care planned for elopement risk, was last seen by staff at 2:00 PM and was missing for approximately six and a half hours before being located by law enforcement. The facility was unaware of the resident's absence until 8:00 PM, indicating a significant lapse in monitoring and supervision. Interviews with staff revealed that the resident was seen in various locations within the facility throughout the day, but there was no consistent monitoring to ensure his whereabouts. The resident's meal tray was left untouched in his room, and staff failed to verify his location when the tray was not eaten. The facility's policy on wandering and elopement was not effectively implemented, as staff did not monitor the doors or ensure that residents at risk for elopement were adequately supervised. The facility's documentation and interviews indicated that the resident was not safe to be out of the facility unsupervised. Despite this, the resident managed to exit the building and walk several miles to a local homeless shelter, crossing busy streets and railroad tracks. The facility's failure to monitor the resident and secure the exits led to the resident's elopement, posing a significant risk to his safety and well-being.

Removal Plan

• Resident was sent to the hospital for evaluation when he arrived back to the nursing facility, no new orders received. Resident was assessed upon returning from the hospital.
• Resident was reassessed for being an elopement risk and placed in the secured unit for safety.
• Medical Director notified of the incident.
• Resident head count performed throughout the center to ensure no other residents were identified as missing. No other residents noted missing.
• All doors verified in working order. No issues noted with the door functions. Additionally, the doors were checked for functionality with no concerns.
• Gates checked for functionality; No concerns, all gates are functioning properly.
• Mock elopement drills performed each shift.
• Signage present on doors that state, 'Attention visitors please do not allow anyone to exit the building with you that did not come in with you, help us keep our residents safe, any questions please contact a staff member, thank you.'
• All residents in house received an updated elopement assessment. Ensured all care plans match the updated elopement assessment and are person-centered.
• All staff educated: Wandering & Elopement/Missing Resident Policy (to include adequate supervision to prevent accidents or elopements and when delivering meal trays in either dining area or in residents rooms staff should ensure residents are located and aware of meal. Any meal tray picked up that is not eaten staff need to verify resident is located and aware meal tray is ready. Charge nurse will be notified immediately if resident is not observed and informed.
• Certified Nurses Aides, Certified Medication Aides, and Charge Nurses educated on the resident profile to inform them of the level of supervision, elopement risk, and educated over accuracy of documentation. The type and frequency of resident supervision may vary among residents as determined by the residents' assessed needs and the identified hazards in the environment.
• If resident is not observed during medication pass, meal times, and/or routine resident care rounds the charge nurse will be notified and the center will initiate a search for the resident immediately. The clinical staff will know to perform this action through education.
• Action items in the above plan of removal will be monitored for effectiveness daily, for 1 month and until deemed by QAPI committee that the facility is in substantial compliance. If any changes are needed, they will be brought to the QAPI committee and discussed for a plan action.
• Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy template and the facility's plan to lower the Immediate Jeopardy.

Penalty

No penalty information released

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

Summary

The facility failed to report allegations of abuse and neglect to the State Survey Agency within the required timeframe following the elopement of a resident. The resident, who had severe cognitive impairment and was at high risk for elopement, was found missing from his room during a medication pass. The staff initiated a search and notified the administrator, Director of Nursing (DON), and law enforcement. The resident was eventually found at a Salvation Army location and returned to the facility without any immediate physical harm. However, the incident was not reported to the State Survey Agency as required by regulations and facility policy. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) on duty discovered the resident missing and followed the facility's emergency procedures for a missing resident. The Social Worker (SW) and DON confirmed that elopement is a reportable incident and that the administrator, who is the Abuse/Neglect Coordinator, was responsible for reporting it. The administrator admitted to having prepared the report but failed to send it due to being distracted by other tasks. This lapse in reporting was acknowledged during the interview. The facility's policies on emergency procedures for missing residents and the abuse prevention program clearly state the requirements for reporting such incidents to the State Survey Agency. Despite these policies, the failure to report the elopement incident in a timely manner was identified, which could potentially affect the safety and well-being of other residents by delaying necessary investigations and interventions.

Penalty

No penalty information released

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

Summary

The facility failed to permit Resident #2 to remain in the facility and did not provide a written discharge notice or a discharge summary. Resident #2, a male with multiple medical conditions including Type II Diabetes Mellitus, Hypertension, and bilateral leg amputations, was informed by the social worker that he needed to find an alternate residence by 3:30 PM on the day of discharge. The facility did not provide any discharge paperwork or medications to Resident #2 at the time of discharge, which led to him experiencing multiple health issues and emergency room visits due to not having his medications. Resident #2 reported that he was told to leave the facility because he tested positive for illegal substances, specifically Delta-8, which he believed to be legalized marijuana. He stated that he did not feel he had a choice in taking the drug test and was told he had to leave the facility that day. The facility planned to discharge him to a local homeless shelter, which he refused because it was not a permanent place and he needed help with his medications. The resident expressed concerns about his safety and well-being after being discharged without proper arrangements. The facility's administrator confirmed that their policy had recently changed to immediate discharge for residents testing positive for illegal substances. However, Resident #2 had not signed any confirmation of this policy, and the facility did not follow their own policy of providing a 30-day written notice or ensuring the discharge was done correctly. The administrator admitted that the failure to provide a written discharge notice and proper documentation was due to following the corporate policy without ensuring compliance with the facility's established procedures.

Penalty

No penalty information released

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

Summary

The facility failed to develop a comprehensive person-centered care plan for a resident with severe cognitive impairment, Alzheimer's disease, type 2 diabetes mellitus, hypertension, and Major Depressive Disorder. The care plan did not include specific interventions to address the resident's need for supervision for wandering, despite a history of wandering behaviors reported by the resident's family member. The resident's care plan included general approaches for behavioral symptoms, falls/safety risk, delirium, and cognitive loss but lacked detailed, measurable actions for supervision related to wandering. Interviews with facility staff revealed that the MDS Coordinator and the DON were aware of the resident's wandering behavior but did not include specific supervision interventions in the care plan. The MDS Coordinator noted that the resident's MDS was coded with no wandering because the behavior did not occur during the lookback period, and the DON acknowledged that the care plans were incomplete and not double-checked for accuracy. The DON also mentioned that the resident exhibited wandering issues but not elopement issues, which led to the omission of elopement interventions in the care plan. The facility's policy on comprehensive care plans requires that care plans describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. However, the care plan for this resident did not meet these standards, as it lacked person-centered interventions for supervision despite the resident's identified need. This deficiency was identified during a survey, and the facility's failure to address the resident's supervision needs placed the resident at risk for not receiving appropriate care and services.

Penalty

Inspection fine: $13,242

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

Summary

The facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. On 04/09/2024, observations revealed that the facility had a census of 78 residents with only 3 LVNs and 4 CNAs scheduled for both day and night shifts. Unit 1 had 2 LVNs and 3 CNAs for 61 residents, while Unit 2, a secured unit, had 1 LVN and 1 CNA for 16 residents. The total hours scheduled to be worked during this 24-hour period equaled 168, which was insufficient according to the facility's assessment tool. Interviews with the ADMN confirmed that the facility was experiencing staffing issues, including agency staff canceling shifts and a no-call no-show incident on the morning of 04/09/2024, which left the facility short-staffed and unable to fill the shift at that time. Record reviews of timesheets from various dates in 2024 showed that the facility consistently failed to meet the required direct care staff hours based on their census and facility assessment. For example, on 02/20/2024, only 168.200 hours were worked by direct care staff, whereas 225.15 hours were needed. Interviews with residents further highlighted the impact of insufficient staffing. One resident reported not having had a shower in three weeks, while another resident expressed concerns about not being transferred out of bed as requested and experiencing delays in call light responses. The facility's assessment tool, last updated on 04/02/2024, indicated that the average HPPD was 2.85, but the facility failed to meet this standard, leading to unmet resident needs and compromised safety and well-being.

Penalty

Inspection fine: $13,242

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

Summary

The facility failed to provide necessary care and services to ensure the highest practicable physical, mental, and psychosocial well-being for two residents. Resident #10, a [AGE] year-old female with multiple diagnoses including moderate cognitive impairment, chronic obstructive pulmonary disease, and heart failure, did not receive showers as per her request on several documented dates. Despite her care plan indicating a preference for showers on specific days and times, there was no evidence of assistance provided on multiple occasions. During an interview, Resident #10 confirmed she had not had a shower in three weeks and attributed this to the facility being short-staffed. Resident #12, a [AGE] year-old female with diagnoses including Parkinson's disease, breast cancer, and depression, was not transferred from bed to chair as per her request. Her care plan specified her preference to be transferred after breakfast on certain days, but she reported that staff often delayed or failed to assist her. During an observation, Resident #12 expressed frustration over the lack of timely assistance and mentioned that she had called the Ombudsman and requested a meeting with the administrator to review her care plan. She also noted that other residents would enter her room, and staff were slow to respond to her call light. The facility administrator acknowledged the staffing issues, stating that the facility used a summary tool to determine staffing ratios and had started contracting agency nurses and CNAs to help with staffing. However, the facility continued to face challenges with agency staff canceling shifts, making it difficult to maintain appropriate staffing levels. The facility's assessment tool and policy on resident rights emphasized the need for adequate staffing to ensure residents' well-being, but the facility was still understaffed, impacting the quality of care provided to the residents.