Avir At Coronado
Inspection history, citations, penalties and survey trends for this long-term care facility in Abilene, Texas.
- Location
- 1751 N 15th St, Abilene, Texas 79603
- CMS Provider Number
- 675746
- Inspections on file
- 52
- Latest survey
- October 15, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Avir At Coronado during CMS and state inspections, most recent first.
Surveyors found a medication cart left unlocked and unattended near the nurse's station, containing various OTC medications, medical supplies, and personal items such as a butter knife and nail clippers. Staff interviews confirmed the cart should have been locked and monitored, and facility policy required all medications and biologicals to be stored securely in locked compartments.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions. Review of documentation showed incomplete planning and insufficient detail to ensure comprehensive care.
A care plan was not developed within 7 days of the comprehensive assessment and was not prepared, reviewed, or revised by a team of health professionals as required.
The facility was found deficient in food safety and hygiene practices, including improper thawing of ground meat, inadequate hand hygiene by the cook, and failure to label and store food items correctly. These actions could lead to contamination and foodborne illnesses among residents.
Two residents received Seroquel without proper consent at a facility. One resident with schizoaffective disorder was given increased dosages without consent, and another with neurocognitive disorder received the medication over several months without documented consent. Staff interviews revealed confusion and lack of clear policy on obtaining consent for antipsychotic medications.
The facility failed to develop comprehensive care plans with measurable objectives for six residents, affecting areas such as resisting care, visual function, pain, and cognitive loss. This deficiency could impact residents' needs and preferences.
The facility failed to implement its policy on food storage, leading to improper temperature logging and expired goods in residents' personal refrigerators. Observations showed that several residents' refrigerators lacked temperature logs or thermometers, and interviews revealed that staff did not consistently check these appliances. This oversight could risk foodborne illnesses.
A resident in a LTC facility experienced a safety risk due to a broken toilet that was not promptly repaired. Despite the resident's intact cognition and independence in toileting, the cracked and unstable toilet base posed a fall risk. The maintenance director was aware but absent due to an injury, and the administrator was unaware of the issue due to a lack of communication and oversight of the electronic repair request system.
A facility failed to store medications securely, as a resident's personal refrigerator contained a prescription hydrocortisone cream without a physician's order. The resident could not apply the cream themselves, suggesting it was left for staff convenience. Staff interviews confirmed that medications should not be in resident rooms, and the DON noted the oversight could lead to improper administration. The facility's policy mandates locked storage for medications, which was not followed.
A facility failed to ensure proper use of PPE during catheter care for a resident on enhanced barrier precautions. The CNA did not wear a gown while performing care, contrary to facility policy requiring full PPE, including a gown, gloves, and mask. Interviews with staff confirmed the deficiency in infection control practices.
Two residents in a facility experienced unsanitary conditions due to cockroach infestations and clogged air conditioner units. Despite complaints from a resident's family and reports to staff, the issues persisted. The facility's pest control measures were inadequate, as documented in the Pest Control Logbook, and the Administrator acknowledged the ongoing problem.
A facility failed to report an alleged abuse incident involving a resident within the required timeframe. A family member reported that a CNA placed her elbow on the resident's thigh, causing discomfort, and provided a video of the incident. Despite the evidence, the facility did not report the incident to the state agency, citing a lack of intent to harm. The resident had multiple diagnoses and was dependent on assistance for mobility.
A facility failed to investigate an alleged abuse incident involving a resident and a CNA. A family member reported the incident, including a video, but the facility did not conduct a thorough investigation or suspend the CNA. The resident, who had multiple medical conditions and was dependent on assistance, was allegedly leaned on by the CNA, causing concern. The facility's response was limited to reassigning the CNA and providing education, without a formal investigation, contrary to their abuse prevention policy.
The facility failed to maintain an effective pest control program, resulting in cockroach infestations in common areas and the bathrooms of two residents. One resident, with multiple health conditions, reported seeing cockroaches in her bathroom, while another resident, also with significant health issues, experienced cockroaches in his bathroom and prosthetic legs. Despite a pest control contract, the problem persisted, with sightings documented since early 2023.
The facility failed to maintain an effective infection control program, resulting in COVID-19 exposure among residents. COVID-19 positive residents were not isolated from negative ones, and staff did not adhere to PPE protocols, increasing transmission risk. A COVID-19 positive resident left quarantine, exposing others. The facility's infection prevention policy was not properly implemented.
A resident with severe cognitive impairment eloped from the facility due to inadequate supervision and monitoring. The resident was missing for approximately six and a half hours before being located by law enforcement. Staff failed to verify the resident's location when his meal tray was left untouched, and the facility's policy on wandering and elopement was not effectively implemented.
A resident with severe cognitive impairment eloped from the facility and was found at a Salvation Army location. The incident was not reported to the State Survey Agency within the required timeframe, despite facility policies mandating such reporting. The administrator admitted to preparing the report but failing to send it due to distraction.
A resident with multiple medical conditions was discharged without proper notice or documentation after testing positive for illegal substances. The facility did not provide a written discharge notice, discharge summary, or medications, leading to the resident experiencing multiple health issues and emergency room visits.
A facility failed to develop a comprehensive person-centered care plan for a resident with severe cognitive impairment and a history of wandering. The care plan lacked specific interventions for supervision, despite the resident's identified need. Interviews with staff revealed awareness of the issue but incomplete and inaccurate care plans.
The facility failed to have sufficient nursing staff to ensure resident safety and well-being. Observations and interviews revealed that the facility was consistently understaffed, with only 3 LVNs and 4 CNAs scheduled for both day and night shifts for 78 residents. Record reviews showed that the facility did not meet the required direct care staff hours, and residents reported unmet needs and delays in care.
The facility failed to provide necessary care and services for two residents, leading to unmet requests for showers and transfers. One resident did not receive showers as per her care plan, while another was not transferred from bed to chair as requested. Staffing issues were acknowledged by the facility administrator.
Unattended and Unlocked Medication Cart with Accessible Drugs and Items
Penalty
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.
Incomplete Care Plan Development and Implementation
Penalty
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.
Failure to Timely Develop and Review Care Plan
Penalty
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.
Deficiencies in Food Safety and Hygiene Practices
Penalty
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.
Failure to Obtain Consent for Antipsychotic Medication
Penalty
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.
Deficient Care Plans Lacking Measurable Objectives
Penalty
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.
Failure to Implement Food Storage Policy
Penalty
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.
Facility Fails to Maintain Safe Environment Due to Broken Toilet
Penalty
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.
Medication Storage Deficiency
Penalty
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.
Inadequate Use of PPE During Catheter Care
Penalty
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.
Facility Fails to Maintain Sanitary Environment for Residents
Penalty
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.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
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.
Failure to Investigate Alleged Abuse Incident
Penalty
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.
Facility Fails to Maintain Effective Pest Control Program
Penalty
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.
Inadequate Infection Control and PPE Protocols Lead to COVID-19 Exposure
Penalty
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.
Failure to Prevent Resident Elopement
Penalty
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.
Failure to Report Elopement Incident
Penalty
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.
Failure to Provide Proper Discharge Notice and Documentation
Penalty
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.
Failure to Develop Comprehensive Person-Centered Care Plan
Penalty
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.
Insufficient Nursing Staff
Penalty
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.
Failure to Provide Necessary Care and Services
Penalty
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.
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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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