Avir At Fort Worth
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 7100 Trail Lake Dr, Fort Worth, Texas 76133
- CMS Provider Number
- 676132
- Inspections on file
- 82
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Avir At Fort Worth during CMS and state inspections, most recent first.
A resident with severe visual and cognitive impairment, bowel and bladder incontinence, and cardiac and renal diagnoses was found standing motionless in her room needing bathroom assistance, with a BM odor present and no use of the call light. The resident stated she did not know what the call light was or how to use it, and the call light cord was wrapped and inaccessible behind a privacy curtain. An LVN and a CNA reported that the resident did not use the call light and that they relied on the resident shouting for help, open doors, and frequent rounding, and both were unaware of any alternative communication method. The DON confirmed that no alternative to the call system had been identified or documented in the care plan, despite facility policy requiring an alternative means of communication for residents unable to use the call system.
A resident admitted with a cerebral infarction, intact cognition (BIMS 13), a Foley catheter, and bowel incontinence did not have a complete baseline care plan developed within 48 hours of admission. The electronic record in PCC contained only a limited fall-risk entry with related goals and interventions, and no other baseline care instructions were documented. In interviews, the Social Worker and DON confirmed that the baseline care plan was missing, acknowledged that the IDT is responsible for completing it, and stated it had been missed, despite facility policy requiring care plans to be developed per regulatory timeframes.
Surveyors found that staff failed to follow the facility’s infection prevention and control program during incontinence care for two residents. One resident with severe cognitive impairment, total dependence for ADLs, incontinence, and a feeding tube had active orders for Enhanced Barrier Precautions (EBP), with signage requiring hand hygiene on room entry/exit and gown and glove use for high-contact care. Two CNAs entered this resident’s room without performing hand hygiene or donning a gown, performed perineal and buttocks cleansing, handled a soiled brief, and then applied a clean brief and repositioned the resident without changing gloves or cleaning their hands, and exited without hand hygiene despite available PPE and sanitizer. For another fully dependent, incontinent resident with hemiplegia and aphasia, the same CNAs performed hand hygiene on entry and used gloves, but one CNA applied a clean brief after soiled care without changing gloves or performing hand hygiene and then left the room without cleaning her hands. Interviews with the CNAs, ADON, DON, and Administrator confirmed expectations for hand hygiene, glove changes, and EBP use, and acknowledged that the observed practices did not comply with facility policies or CDC hand hygiene guidelines, creating a risk of infection transmission.
Fifteen rooms were found with significant environmental deficiencies, including non-functioning toilets, missing toilet seats, lack of hot or cold water, poor lighting, leaking fixtures, and unsafe electrical outlets. A resident was moved through multiple rooms with unresolved issues before being transferred out, and other residents reported ongoing maintenance problems and lack of communication about repairs. Staff interviews revealed confusion about the maintenance reporting process, with most continuing to use outdated paper forms despite a new digital system, resulting in unaddressed deficiencies.
A resident with psychiatric and physical conditions, under one-to-one supervision, was involved in a verbal altercation with a CNA who subsequently sprayed the resident with pepper spray. The supervising CNA failed to intervene or remove the resident from the escalating situation, and staff interviews confirmed prior threats to use pepper spray. The incident resulted in exposure to the spray for the resident and others, violating resident rights and facility policy.
A resident with behavioral health diagnoses was threatened and subsequently sprayed with pepper spray by a CNA after a verbal altercation. Multiple staff overheard the threat but did not report it to the Administrator as required, resulting in a delay in intervention. The resident was evaluated at a hospital with no injuries found, but the failure to report the initial threat and intervene placed the resident at risk.
Two CNAs did not change gloves or perform hand hygiene during incontinence care for a resident with multiple health conditions, despite being aware of facility policy and infection control requirements. Both staff handled the resident and personal items without proper glove changes or hand hygiene, as confirmed by interviews and policy review.
A deficiency was identified when a medication cart's keys were left inside a count binder on top of the cart, making them accessible to unauthorized individuals. Staff interviews revealed that this practice was common during shift changes, especially when the medication aide was late, and the keys were not consistently handed over as required by facility policy. The DON confirmed that keys should always be in the possession of authorized personnel and not left unattended.
A cook prepared pureed meals by adding water instead of using approved liquids such as milk or broth, contrary to facility recipes and policy. The cook was unaware that water should not be used, and the dietary manager confirmed that only specified liquids are permitted to maintain nutrition and flavor in pureed diets.
During a lunch meal, pureed scalloped potatoes were served without being fully blended to a smooth, pudding consistency as required for residents on pureed diets. Dietary staff and the Dietary Manager did not check the consistency after blending, resulting in the presence of potato chunks. Both staff members acknowledged the food did not meet the necessary standard, as confirmed by facility policy and recipe requirements.
Two residents in a LTC facility experienced deficiencies in feeding tube management. One resident did not receive g-tube stoma site dressing changes and water flushes as ordered, while another had a feeding tube infusion pump set at an incorrect rate, risking malnutrition and weight loss. The facility's Enteral Nutrition policy was not followed, and the ADON was unaware of these lapses, which involved agency staff.
The facility did not follow the planned menu for residents on mechanical soft and pureed diets, serving diced chicken instead of chicken fried steak. The staff member responsible believed the chicken provided a smoother texture and misunderstood the difference between the two dishes. The Registered Dietitian and Administrator confirmed the importance of serving the specified menu items.
The facility failed to provide palatable and appropriately heated meals, as observed during a lunch meal. Multiple residents reported dissatisfaction with the taste and temperature of the food, with some opting for alternate menu items or personal food. The Dietary Manager acknowledged the lack of flavor, attributing it to the absence of salt in cooking. Resident council meetings documented complaints about food quality and temperature, but grievances did not reflect these issues.
Two staff members at a facility failed to adhere to enhanced barrier precautions by not wearing gowns during high-contact care activities for residents with medical devices. An LVN did not wear a gown while flushing a g-tube, and a CNA did not wear a gown while emptying a colostomy bag, despite facility policies requiring such precautions to prevent infection transmission.
A resident with quadriplegia and neuromuscular dysfunction of the bladder experienced significant trauma when an agency LVN improperly inserted a Foley catheter, inflating the balloon in the urethra. This resulted in severe bleeding and required hospitalization and a blood transfusion. The facility failed to ensure nursing staff had the necessary competencies to care for residents' needs, leading to this deficiency.
The facility's dish machine failed to reach the required minimum temperature of 120°F for wash and rinse cycles, potentially risking cross-contamination and resident illness. The Dietary Manager, temporarily handling dishwashing duties, confirmed the issue, which was linked to a recent hot water heater replacement. Despite the Administrator's assurance of good sanitation, records showed consistent failure to meet temperature standards.
The facility failed to provide adequate hygiene and grooming care for three residents, leading to deficiencies in personal care. A resident with a history of stroke had long fingernails and a foul-smelling substance in her hand, indicating poor hygiene. Another resident with cognitive impairment had dirty and untrimmed nails despite having a hospice aide. A third resident with communication deficits was not groomed as desired, highlighting a failure in communication and care coordination.
The facility failed to maintain RN coverage for at least eight consecutive hours on weekends over a three-month period. This deficiency was confirmed through record reviews and interviews with the DON and Administrator, who acknowledged the absence of RN coverage on 13 specific weekend days. The facility's policy requires staffing in line with resident needs and regulations, which was not met.
A resident with a history of cerebral infarction and muscle contractures did not have these conditions addressed in their care plan, despite observations of a contracted hand with a foul odor. Interviews with facility staff revealed confusion and lack of responsibility regarding care plan updates, with the ADON and Social Worker acknowledging the oversight. The DON was unaware of the deficiency but believed there was no risk due to other communication methods.
The facility failed to maintain proper kitchen sanitation due to a lack of hot water, leading staff to boil water for washing, rinsing, and sanitizing dishes. This issue persisted for about 1 1/2 months, during which time proper logging of water temperatures and sanitation levels ceased. The sanitizer level in the three-compartment sink exceeded the recommended 200 ppm, reaching 400 ppm.
A resident with quadriplegia was unable to use his call light despite it being placed near his shoulder as requested. Staff were aware of the issue but struggled to check on him frequently due to isolation protocols and a busy hall. The RN and RDO were unaware of the resident's inability to use the call light and were in the process of finding a better solution.
The facility failed to develop comprehensive care plans for two residents, neglecting to include specific medical interventions for a pacemaker and gastrointestinal issues. Lack of communication and coordination among staff members contributed to these deficiencies.
Failure to Provide Alternative Call System for Visually and Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide an alternative means of communication for a resident who could not effectively use the call light system. The resident was an older adult with severely impaired vision, a BIMS score of 6 indicating severe cognitive impairment, and incontinence of bowel and bladder, with diagnoses including hypertensive heart disease and chronic kidney disease. The resident’s care plan addressed visual impairment with interventions to evaluate functional safety and remove environmental barriers, but it did not document that the resident was known not to use the call light or identify any alternative communication method. During observation, the resident was seen standing motionless and silent in the middle of the room, later stating she needed the bathroom; a BM odor was present in the room. When asked, the resident reported she did not know what a call light was or how to use it, and the call light cord was observed wrapped up against the wall behind the privacy curtain, making it inaccessible. Staff interviews confirmed that the resident did not use the call light and that no alternative communication method had been designated or documented. An LVN stated the resident was fully blind, could not press the call light, and would not use it even if placed within reach or clipped to her shirt; instead, staff relied on the resident shouting for help and on keeping her door open so staff could see her. A CNA, who had worked at the facility for three days, knew the resident was blind and did not think she used the call light, and reported she was not aware of any alternative method to the call system, relying instead on frequent rounding. The DON acknowledged that while the resident had used the call light in the past, there were days she might not recognize it, and confirmed that no alternative communication method had been identified or documented in the care plan. This was inconsistent with the facility’s Call System, Residents Policy, which requires that if a resident has a disability preventing use of the call system, an alternative means of communication usable by the resident must be provided and documented in the care plan.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors found that the facility failed to develop and implement a complete baseline care plan within 48 hours of admission for one resident. Record review showed that the resident was an older adult admitted with a primary diagnosis of cerebral infarction, had an intact BIMS score of 13, had a Foley catheter, and was incontinent of bowel. The initial MDS confirmed these conditions. Review of the resident’s baseline care plan in the PCC electronic health record revealed it was essentially not completed, containing only a single fall-risk entry with a focus on risk for falls related to gait and balance problems and fear of falling, along with associated goals and interventions. No other baseline care plan components or instructions for care were documented. During interviews, the Social Worker confirmed that the baseline care plan in PCC for this resident was not completed and stated that every discipline of the IDT was responsible for ensuring their section was complete, acknowledging that they “must have missed that one.” The Social Worker identified that if the care plan was not present, staff did not know what care they needed to provide. The DON also reviewed the resident’s record in PCC, checked the miscellaneous tab where documents were sometimes scanned, and confirmed that the baseline care plan was not in the chart. The DON stated she usually checked care plans in PCC but had missed this one and acknowledged that the care plan was needed so staff would know what to do, describing it as the staff’s plan of care. The facility’s policy stated that the IDT is responsible for development of resident care plans according to timeframes and criteria established by §483.21.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including required hand hygiene and use of personal protective equipment (PPE), during incontinence care for two residents. For one resident with cerebral palsy, severe cognitive impairment, total dependence for care, bowel and bladder incontinence, and a feeding tube, the record showed active orders for Enhanced Barrier Precautions (EBP) every shift. The resident’s care plan documented dependence on staff for all ADLs, including incontinence care and repositioning. An EBP sign posted by the resident’s name plate instructed that everyone must clean their hands before entering and when leaving the room, and that staff must wear gloves and a gown for high-contact resident care activities such as dressing, bathing, transferring, changing linens, and providing hygiene. PPE was available just inside the room door and hand sanitizer was located outside the room. On observation, two CNAs entered this resident’s room without performing hand hygiene and without donning a gown or gloves prior to entry, despite the EBP signage and available PPE. Once inside, they applied clean gloves, closed the door, and pulled the privacy curtain. One CNA prepared supplies on a clean barrier, unlatched the resident’s brief, and cleansed the perineal area, then turned the resident to her side and cleansed the buttocks. The CNA rolled the soiled brief inward and discarded it in the trash. Without changing gloves or performing hand hygiene, the CNA then obtained a clean brief, placed it under the resident, turned her back, and secured the brief. Both CNAs then repositioned the resident, removed their gloves, and exited the room without performing hand hygiene, proceeding down the hallway. This sequence did not follow the facility’s EBP policy, hand hygiene policy, or perineal care policy, which required gown and glove use for high-contact care under EBP, hand hygiene before and after resident contact and after glove removal, and glove removal and hand sanitizing before handling clean linens or briefs. A second observation involved another resident with hemiplegia following cerebral infarction, aphasia, seizure disorder, anxiety, severe cognitive impairment, and total dependence on staff for toileting, showering, dressing, and incontinence care. For this resident, the two CNAs performed hand hygiene upon room entry, shut the door, pulled the privacy curtain, gathered supplies on a clean barrier, and donned clean gloves. One CNA unlatched the brief and cleansed the perineal area using a new wipe with each swipe, while the other CNA assisted with turning the resident to her side so the buttocks could be cleansed. The soiled brief was folded inward and discarded. Without changing gloves or performing hand hygiene, the CNA then obtained and applied a clean brief, and both CNAs repositioned the resident. After care, both CNAs removed their gloves; only one performed hand hygiene, while the other exited the room and went down the hallway without cleaning her hands. This conduct conflicted with the facility’s hand hygiene and perineal care policies, which required hand hygiene before moving from soiled to clean body sites, immediately after glove removal, and before touching clean linens or briefs. In interviews, one CNA reported working at the facility for two months and stated that hand hygiene should be performed anytime she enters or exits a resident’s room, acknowledging she had washed her hands in the utility room when gathering supplies for the first resident but did not perform hand hygiene upon entering or exiting the room and that she “must have forgotten.” She stated she washed her hands before incontinence care on the second resident but forgot to do so afterward, and reported she had not been taught to change gloves during incontinence care, usually using the same gloves throughout and only changing them before putting on new sheets. She also stated she was not aware the first resident was on EBP, missed seeing the sign, and had not been trained to use a gown for that resident’s care, despite recognizing that not wearing PPE and not performing appropriate hand hygiene or glove changes could cause cross contamination and spread infections. The second CNA stated that hand hygiene should be performed before and after any care but admitted she did not perform hand hygiene before or after incontinence care on the first resident, explaining she normally washes her hands but had not been feeling well and forgot. She stated she was familiar with EBP and believed a gown and gloves should be worn before entering the room, was aware of the sign and saw the PPE, but thought it was only needed if the resident was sick and did not know that a feeding tube required gown use. The ADON stated her expectation that staff perform hand hygiene when entering or leaving a resident room and that, with any incontinence care, hand hygiene should be performed between glove changes, specifically between removing a soiled brief and applying a clean brief. She stated that if CNAs were not performing hand hygiene or glove changes appropriately, it could cause a risk of spreading infections or UTIs, and that staff should use PPE for any resident care when a resident is on EBP, as indicated by signage and PPE bins. The DON, who served as the infection preventionist, stated she expected staff to perform hand hygiene when entering or leaving rooms and when going from dirty to clean during incontinence care, and that failure to perform hand hygiene or change gloves appropriately was an infection control issue with a risk of infection. She also stated she expected staff to wear a gown and gloves before entering a resident room on EBP, that staff were trained upon hire and as needed on infection control and incontinence care, and that failure to use PPE was an infection control issue. The Administrator stated he expected staff to wash their hands before and after care, before wearing gloves, and with any glove changes, and that improper hand hygiene could transfer infections. The facility’s written policies and CDC guidelines reviewed by surveyors supported these expectations for hand hygiene, glove changes, and EBP use, which were not followed in the observed care for the two residents.
Failure to Maintain Safe, Functional, and Sanitary Resident Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 15 of 18 rooms reviewed for physical environment. Observations revealed multiple deficiencies, including non-functioning toilets, missing toilet seats, lack of hot or cold water at sinks, dim or burnt-out bathroom lighting, leaking toilet tanks, and unsafe or broken electrical outlet covers. In several instances, air conditioner plugs and cords were found with scorch marks or were identified as fire hazards. These issues were present in both occupied and unoccupied rooms, and some residents reported having to use hand sanitizer instead of washing hands due to lack of hot water, or being unable to use the bathroom facilities as intended. Interviews with residents and their family members indicated that maintenance issues were not being addressed in a timely manner, and there was a lack of communication regarding the status of repairs. One family member described moving a resident through multiple rooms, each with significant environmental deficiencies, before ultimately transferring the resident to another facility within 24 hours. Residents reported ongoing maintenance problems, delays in repairs, and a lack of feedback from staff or maintenance about when issues would be resolved. Some residents had adapted to the deficiencies, such as turning water valves on and off themselves or avoiding the use of certain facilities. Staff interviews revealed confusion and inconsistency in the process for reporting maintenance issues. Although the facility had recently transitioned from paper maintenance request forms to a digital system (TELS), most staff continued to use the paper system, and many were unaware of the environmental issues present in the facility. The Maintenance Director stated he was only aware of issues that were reported to him and that he could not address unreported problems. The Director of Nursing and Administrator both acknowledged the importance of a safe and functional environment but noted that staff were not consistently using the new reporting system, and there was no policy provided that addressed maintaining a safe, comfortable, homelike environment.
Failure to Protect Resident from Abuse and Neglect During Staff Altercation
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to protect a resident from abuse and neglect during a verbal altercation with another CNA. The resident, a male with diagnoses including bipolar disorder, schizophrenia, and spinal stenosis, had intact cognition and a history of behavioral symptoms. He was on one-to-one supervision due to previous behaviors. On the day of the incident, the resident engaged in escalating verbal exchanges with staff, including cursing and making threats. Despite being under supervision, the resident entered the activity room and became involved in a heated argument with a CNA, who subsequently sprayed him with pepper spray. The supervising CNA did not intervene or attempt to remove the resident from the situation, later stating she was in shock and unsure of what to do. Multiple staff and residents witnessed the incident, and several staff members reported hearing the CNA threaten to use pepper spray earlier in the day. The resident reported burning sensations to his head and eyes and was sent to the hospital, where no injuries were documented. Staff interviews confirmed that the supervising CNA did not attempt to de-escalate the situation or seek help, and that the CNA who used the pepper spray had previously expressed intentions to do so if provoked. The incident resulted in other residents and staff experiencing coughing due to exposure to the spray. The facility's policy prohibits abuse, neglect, and the use of weapons such as pepper spray by staff. The failure to intervene and protect the resident from harm, as well as the use of pepper spray by a staff member, constituted a violation of resident rights and placed the resident and others at risk for harm. The deficiency was identified as past noncompliance, with the noncompliance period beginning and ending within a specified timeframe.
Failure to Timely Report and Intervene in Suspected Abuse Incident
Penalty
Summary
Staff failed to immediately report an alleged violation involving abuse and neglect, as required by facility policy and federal regulations. On the morning of the incident, a certified nursing assistant (CNA) was overheard by other CNAs threatening to use pepper spray on a resident during a verbal altercation. Despite hearing this threat, the other CNAs did not report it to the facility Administrator or other appropriate authorities. Several hours later, the same CNA engaged in a further verbal altercation with the resident, which escalated to the CNA spraying the resident with pepper spray. The incident was not reported to the Administrator until after it had occurred, and the Administrator was unaware of the earlier threat that could have prompted preventive action. The resident involved was a male with diagnoses including bipolar disorder, schizophrenia, and spinal stenosis, and had a history of behavioral symptoms such as yelling, cursing, and physical aggression. On the day of the incident, the resident was under one-to-one supervision due to previous behaviors. Multiple staff, including CNAs and a housekeeper, witnessed the escalating situation and the use of pepper spray, but did not intervene or report the initial threat. The resident experienced burning sensations and was sent to the hospital for evaluation, where no injuries were documented. Interviews with staff revealed that several individuals were aware of the threat made by the CNA but assumed others would report it or did not know how to respond. The Administrator and Assistant Director of Nursing (ADON) confirmed they were not informed of the threat prior to the incident. Facility policy required immediate reporting of suspected abuse to the Administrator or designated supervisor, but this protocol was not followed, resulting in a delay in addressing the situation and potential risk to the resident.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
Certified Nursing Assistants (CNAs) A and B failed to follow proper infection prevention and control protocols during incontinence care for a resident who was dependent for toileting and had multiple diagnoses, including diabetes mellitus, heart failure, anemia, anxiety disorder, malnutrition, and chronic obstructive pulmonary disease (COPD). During the observed care, the resident had a bowel movement and was wet. CNA A cleaned the resident's front, including the penis, while CNA B cleaned the buttocks. Both CNAs did not change gloves or perform hand hygiene between tasks, and subsequently put a clean brief on the resident and handled the resident's personal belongings without changing gloves or sanitizing their hands. Interviews with both CNAs revealed that they were aware of the requirement to change gloves and perform hand hygiene but chose not to do so, citing reasons such as working quickly and feeling nervous under observation. The facility's Infection Preventionist and Director of Nursing (DON) confirmed that staff are expected to change gloves and perform hand hygiene after cleaning a resident, as per facility policy. The facility's hand hygiene policy, last updated in January 2025, emphasizes the importance of hand hygiene in preventing the spread of healthcare-associated infections and requires all personnel to adhere to these practices.
Medication Cart Keys Left Unsecured During Shift Change
Penalty
Summary
A deficiency occurred when the facility failed to ensure that only authorized personnel had access to the keys for a medication cart serving Halls 400/500/600. During an observation, the medication cart was found locked, but the keys were left inside a closed medication count binder placed on top of the cart. The keys were accessible upon opening the binder, and the surveyor was able to use them to open the cart. Interviews revealed that the keys were routinely left in the binder, especially during shift changes when the medication aide was not present at the scheduled time. The night nurse did not count the cart with the oncoming medication aide, and the keys were left in the binder for the aide to retrieve later. Further interviews with staff, including the RN, medication aide, and DON, confirmed that the facility's policy required the keys to be in the physical possession of authorized personnel at all times and not left unattended. The DON acknowledged that leaving the keys in the binder was not acceptable, as it allowed unauthorized access to medications. The facility's policy on medication labeling and storage specified that only authorized personnel should have access to the keys, but this protocol was not followed during the shift change process.
Improper Preparation of Pureed Foods Using Water Instead of Approved Liquids
Penalty
Summary
Cook E failed to prepare pureed lunch meals according to the facility's established recipes and policies. During meal preparation, Cook E added water without measuring to both the scalloped potatoes and cornbread while blending, instead of using the specified liquids such as milk, broth, or juice as outlined in the recipes. The recipes and the facility's pureed diet policy explicitly state that water should not be used when thinning pureed foods, as it can affect the nutrition, flavor, and palatability of the meal. Cook E stated she was unaware that water was not to be used and had not been instructed otherwise. Observation and interviews confirmed that the dietary manager and staff are responsible for reviewing recipes prior to meal preparation, and that the use of water in pureed foods is not permitted because it diminishes flavor. The dietary manager reiterated that only broth, juice, or other specified liquids should be used. The deficiency was identified during a review of the kitchen's food and nutrition services, specifically in the preparation of pureed meals for residents requiring this diet consistency.
Pureed Food Not Prepared to Required Consistency
Penalty
Summary
The facility failed to ensure that pureed scalloped potatoes were prepared to the required smooth, pudding consistency for residents on pureed diets during a lunch meal. Observations showed that after blending the scalloped potatoes, neither the dietary staff member nor the Dietary Manager checked the consistency to confirm it met the necessary standard. The test tray review revealed that the pureed scalloped potatoes contained chunks and were not fully blended, which was acknowledged by the Dietary Manager as not meeting the correct consistency. Interviews with the dietary staff and the Dietary Manager confirmed that the pureed food should have a smooth, pudding-like consistency, and that the scalloped potatoes served did not meet this requirement. The facility's recipe and policy for pureed foods specify the need for a smooth, pudding or soft mashed potato consistency, particularly for residents with swallowing difficulties or those unable to chew regular foods. The failure to properly prepare and check the consistency of the pureed food was directly observed and confirmed by staff.
Deficiencies in Feeding Tube Management for Two Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents who were dependent on feeding tubes. Resident #14 did not receive g-tube stoma site dressing changes and water flushes as per physician's orders. The resident, who had a history of heart failure, hypertension, renal insufficiency, diabetes mellitus, and malnutrition, was observed to have a dressing dated two days prior, indicating a lack of daily care. LVN C admitted to not flushing the g-tube as required, citing the resident's refusal, and was unaware of the missed dressing change. The Assistant Director of Nursing (ADON) was also unaware of these lapses in care, which could lead to infection and dehydration. Resident #54's feeding tube infusion pump was set at an incorrect rate, leading to a potential risk of malnutrition and weight loss. The resident, who had a stroke affecting her right side and required nutrition via a feeding tube, was supposed to receive Jevity 1.5 at 60 cc/hr. However, observations revealed the pump was infusing at 50 cc/hr for over 24 hours. LVN B, who restarted the pump, did not verify the rate, and the ADON confirmed the error, noting the risk of malnutrition and weight loss. The resident experienced a 1.56% weight loss within a month. The facility's Enteral Nutrition policy requires nurses to confirm complete orders for enteral nutrition, including volume and rate of administration. However, the policy was not followed, as evidenced by the incorrect pump rate for Resident #54 and the lack of g-tube care for Resident #14. The ADON acknowledged the responsibility to ensure nurses follow physician's orders and provide necessary care, but agency staff involvement and lack of oversight contributed to these deficiencies.
Failure to Follow Menu for Modified Diets
Penalty
Summary
The facility failed to adhere to the planned menu for residents on mechanical soft and pureed diets during a lunch meal observation. Instead of serving the specified chicken fried steak, residents were served diced chicken. This deviation from the menu was observed during a survey on November 5, 2024, where it was noted that the mechanical soft and pureed chicken fried steak was not available on the steam table. The staff member responsible for preparing the meal, identified as [NAME] D, stated that she opted for chicken as an alternative due to its smoother texture, believing it would be difficult to puree the chicken fried steak because of its crust. The Registered Dietitian was not aware of the issue until informed by the Administrator and confirmed that the same meal should be provided to all residents regardless of texture modifications. The Dietitian also noted that [NAME] D misunderstood the difference between chicken and chicken fried steak, thinking they were the same except for the frying process. The Administrator emphasized that residents have the right to receive the meals as reflected on the menu, and it is the responsibility of the cooks and Dietary Manager to ensure this. The Dietary Manager was unavailable for comment due to being on leave.
Deficiency in Food Palatability and Temperature
Penalty
Summary
The facility failed to provide palatable food during a lunch meal, as observed on 11/05/24. Multiple residents reported dissatisfaction with the taste and temperature of the food. Resident #52 often declined meals due to poor taste, opting for takeout or personal food. Resident #18 received cold meals, while Resident #33 found the food flavorless. Resident #9 noted inconsistency in taste, and a group of seven residents confirmed issues with cold and tasteless food, despite raising concerns in resident council meetings. Resident #13 preferred alternate menu items due to dissatisfaction with the regular offerings. The facility's menu for the observed meal included chicken fried steak, cream gravy, mashed potatoes, squash medley, and other items. However, test trays revealed the food was only slightly warm and bland. The Dietary Manager acknowledged the lack of flavor, attributing it to the absence of salt in cooking. The Registered Dietitian had not evaluated the meal but was aware of concerns. The Administrator was unaware of ongoing complaints but recognized the risk of weight loss and health issues from unappetizing food. Resident council meeting minutes from August to October 2024 documented complaints about food quality and temperature, but grievances did not reflect these issues.
Infection Control Lapses in PPE Usage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two separate incidents involving staff not adhering to enhanced barrier precautions. In the first incident, LVN C did not wear a gown while flushing the g-tube of a resident, despite the presence of an enhanced barrier precaution sign and a bin of PPE at the resident's door. LVN C acknowledged the oversight and recognized that not wearing a gown placed the resident at risk for infection. In the second incident, CNA E failed to wear a gown while emptying the colostomy bag of another resident. Although CNA E performed hand hygiene and wore gloves, he did not use a gown, contrary to the facility's enhanced barrier precautions policy. CNA E admitted to being trained on these precautions but did not consider the need for a gown during the task. LVN F confirmed that the resident was on enhanced barrier precautions and expected CNA E to wear both gloves and a gown. The facility's policy on enhanced barrier precautions, dated March 2024, requires the use of gowns and gloves during high-contact resident care activities, such as device care or use, to prevent the transmission of multi-drug resistant organisms. The policy specifies that these precautions are necessary for residents with wounds or indwelling medical devices, regardless of MDRO colonization. The failure to adhere to these precautions could place residents at risk for infections, as noted by the ADON.
Improper Catheter Insertion Leads to Resident Trauma
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based upon the comprehensive assessment of a resident. This deficiency was identified in the case of a male resident with a history of traumatic spinal cord dysfunction, quadriplegia, and neuromuscular dysfunction of the bladder, among other conditions. The resident had an indwelling catheter and was always incontinent. On a particular day, an agency LVN attempted to change the resident's Foley catheter but improperly inflated the balloon in the resident's urethra, causing urethral trauma and significant bleeding. The incident led to the resident being transported to the hospital, where a CT scan confirmed that the urinary catheter balloon had been inflated in the urethra, causing trauma. The resident experienced severe bleeding, which necessitated a blood transfusion to stabilize his vitals. Interviews with various staff members, including the agency LVN, revealed that the nurse had attempted to reinsert the catheter but encountered resistance and bleeding. Despite being trained in catheter insertion, the nurse failed to follow proper procedures, resulting in the catheter balloon being inflated in the urethra. The facility's records and interviews with staff indicated that the resident had a history of catheter-related issues due to his anatomy, which made catheter insertion challenging. The incident was not immediately addressed by the facility's management, and there was a lack of awareness about the severity of the situation. The facility's failure to ensure that nursing staff had the appropriate competencies and skills necessary to care for residents' needs led to this deficiency, which placed the resident at risk for adverse outcomes.
Removal Plan
- The facility Administrator notified the Medical Director of immediate jeopardy.
- The facility DON/designee assessed Resident #54 and all other residents in the facility with Foley Catheters to ensure their catheters were functioning properly.
- The DON/designee initiated Foley Catheter Insertion competencies for all nurses, which will continue until all nurses have completed their competencies before their next scheduled shift.
- The RNC/designee initiated in-servicing of all nurses, including PRN and Agency nurses, regarding not performing catheter insertion unless a competency has been completed or provided.
- The Foley Catheter insertion competency of the Agency nurse must be verified by the DON/designee via hand delivery or email from the Agency or Agency nurse prior to performing the skill.
- If a nurse that does not have competency on file is working, and the need for Foley insertion arises, the DON must be notified, and the DON/designee will come to insert the Foley catheter.
- The clinical management team will discuss staffing to include new agency nurses who will be covering the floor during the morning meeting. Any changes in coverage during the day will be discussed with the DON/designee.
- An Ad-Hoc QAPI meeting was held with the Medical Director, Regional Nurse Consultant, Director of Nursing & Assistant Director of Nursing to review the alleged deficiencies, policy and procedure, and the plan of removal of immediacy.
- The policies pertaining to Foley Catheter insertion were reviewed by the RNC, Facility Administrator, and Director of Nursing. No changes were made to the policy.
- The RNC will monitor for compliance on all residents with Foley Catheters and send any trends or issues to the ADHOC QAPI Meeting for review.
- The RNC will ensure this plan is completed.
Dish Machine Temperature Deficiency
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, specifically in the operation of their dish machine. During an observation and interview, it was noted that the dish machine in the kitchen did not reach the required minimum temperature of 120 degrees Fahrenheit for both the wash and rinse cycles. The Dietary Manager, who was temporarily responsible for washing dishes due to a staffing shortage, confirmed that the dish machine was not reaching the necessary temperature, which could lead to cross-contamination and potential illness among residents. Further interviews revealed that the facility had experienced a hot water heater malfunction about a month prior, which had been replaced. However, the dish machine still failed to reach the required temperatures. The Administrator believed there was no risk to residents, citing good sanitation practices. Record reviews of the dishwasher temperature logs for June 2024 confirmed the failure to meet the minimum temperature standards, and the facility's policy aligned with the U.S. Public Health Service, Food Code (2022), which mandates a minimum temperature of 120 degrees Fahrenheit for chemical sanitization in spray-type warewashers.
Deficiencies in Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in personal hygiene and grooming. Resident #28, a female with a history of cerebral infarction and muscle contracture, was found with long fingernails causing indents in her palm and a foul-smelling substance between her fingers, indicating a lack of proper hand hygiene and nail care. Despite the care plan indicating the need for total assistance, staff did not maintain the resident's hygiene, which could lead to skin breakdown or infection. Resident #32, a female with severe cognitive impairment and multiple health issues, was observed with dirty and untrimmed fingernails over consecutive days, despite having a hospice aide for ADL assistance. The facility's failure to ensure nail care was performed, even with the involvement of hospice services, highlights a gap in the coordination of care responsibilities between facility staff and external aides. Resident #43, a male with a stroke and communication deficits, required maximum assistance with ADLs. He was observed with untrimmed fingernails and facial hair, despite expressing a desire to be groomed. The CNA reported that the resident refused care, but subsequent interviews revealed the resident's willingness to receive grooming services. This discrepancy indicates a failure in communication and understanding of the resident's preferences, leading to unmet hygiene needs.
Failure to Maintain RN Coverage on Weekends
Penalty
Summary
The facility failed to ensure the presence of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. This deficiency was identified during a review of the facility's staffing records for a period from March 1, 2024, to June 9, 2024. Specifically, the facility did not have RN coverage on 13 days, all of which were weekends. The absence of RN coverage on these days was confirmed through interviews with the Director of Nursing (DON) and the Administrator, who acknowledged the lack of RN presence on the specified weekends. The facility's policy on Hours of Work, revised in December 2009, mandates staffing in accordance with resident needs and regulatory requirements, which was not adhered to in this instance.
Failure to Address Contractures in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. Specifically, the care plan did not address the resident's contractures, despite the resident having a history of cerebral infarction, muscle wasting, and contracture of muscle, among other conditions. The resident was unable to communicate verbally but could respond to yes or no questions, and was observed with a contracted left hand that emitted a foul odor due to long fingernails creating indents in the palm. Interviews with facility staff, including an LVN, the ADON, and the Social Worker, revealed a lack of clarity and responsibility regarding the updating of care plans. The LVN was unsure if the resident's contractures were care planned and admitted to not knowing who was responsible for updating care plans. The ADON acknowledged that all nursing staff were responsible for updating care plans but was unsure why the resident's contractures were not included. The Social Worker, who was responsible for conducting care plan conferences, was unaware that the resident's contractures were not care planned and noted that the facility was behind on care plans. The DON confirmed that residents with contractures or limited range of motion should be care planned and stated that it was the responsibility of all nursing staff to update care plans. However, the DON was not aware that the resident's contractures were not care planned and believed there was no risk to residents if care plans were not up-to-date due to other communication methods among nursing staff. The facility's policy on comprehensive care plans emphasized the importance of ongoing assessments and updates to care plans when there is a significant change in a resident's condition.
Failure to Maintain Proper Kitchen Sanitation Due to Lack of Hot Water
Penalty
Summary
The facility failed to ensure there was hot water in the kitchen to supply the dish machine and three-compartment sink, leading staff to boil water to wash, rinse, and sanitize dishes. This issue persisted for about 1 1/2 months, during which time the staff used Styrofoam plates and plastic utensils for serving meals. The lack of hot water was reported to the Dietary Director, but proper logging of water temperatures and sanitation levels ceased once the hot water was shut off. This failure could place residents at risk for food contamination and foodborne illness. The Dietary Director and kitchen staff were aware of the hot water issue, which began due to a pipe bursting and subsequent damage to the motherboard of the hot water heater. Despite this, the staff continued to use boiling water for washing, rinsing, and sanitizing dishes without taking or documenting the water temperatures or sanitation levels. Observations revealed that the sanitizer level in the three-compartment sink exceeded the recommended 200 ppm, reaching 400 ppm, which was the darkest color on the test strip bottle. Interviews with the Dietary Director and Administrator confirmed that the kitchen had been without hot water since the pipe burst. The Dietary Director stated that vendors had been contacted, and they were waiting for a part to repair the hot water heater. The Administrator acknowledged that the lack of proper documentation and over-sanitizing were issues that could place residents at risk for foodborne illnesses. The facility's sanitization policy required specific water temperatures and sanitation levels, which were not being met during this period.
Failure to Accommodate Resident's Call Light Needs
Penalty
Summary
The facility failed to ensure that a resident with quadriplegia had a call light that accommodated his needs. The resident, who was cognitively intact and totally dependent on staff for all activities of daily living (ADLs), had requested his call light be placed near his right shoulder. Despite this, the resident was unable to activate the call light due to his paralysis. He reported that staff had tried various placements for the call light, but none were effective, leading him to often yell for help and wait several hours for assistance. This situation was observed during an interview and room inspection, where the resident demonstrated his inability to use the call light. Interviews with staff revealed that they were aware of the resident's inability to use the call light and attempted to check on him more frequently. However, due to the resident being on isolation for COVID-19 and the busy nature of the hall, staff were not always able to check on him as often as needed. One CNA mentioned that it was sometimes difficult to check on the resident every two hours, as required by protocol. Another CNA, who had only been at the facility for a week, confirmed that she was instructed to keep the call light near the resident's shoulder but acknowledged the challenges in providing frequent checks. The RN in charge, who had been at the facility for only four days, was unaware that the resident could not use his call light even when it was placed near his shoulder. The RN and the Regional Director of Operations (RDO) both stated that the expectation was for all residents to have access to a call light they could use. The RDO mentioned that the facility was in the process of looking for a different type of call light to better accommodate the resident's needs. The facility's policy on answering call lights emphasized the importance of ensuring residents could operate the system and checking on those who could not use their call lights frequently.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, addressing their specific medical needs. Resident #1, a female with multiple diagnoses including heart failure and a pacemaker, did not have interventions for her pacemaker included in her care plan. Despite being at the facility for almost a year, she had not seen an oncologist or cardiologist, and her pacemaker had not been reset since admission. The ADON and PA were unaware of the need for these follow-ups, and the ADON had not scheduled the necessary appointments due to a lack of communication and personal illness. The PA acknowledged the need for annual pacemaker monitoring but had not ensured it was done for Resident #1. Resident #2, a male with diagnoses including vascular dementia and gastrointestinal issues, did not have his vomiting/nausea or gastrointestinal issues addressed in his care plan. He was observed unresponsive and could not be interviewed. The RDO, who was temporarily assisting at the facility, was aware of some follow-up appointments but could not provide records for them. The RDO mentioned difficulties in scheduling appointments due to the resident's insurance and refusal of care. The RQC stated that the ADON/DON should check clinical documents for follow-up treatments, but there was no clear process for reviewing clinical records to catch missed appointments. The facility's failure to include specific medical interventions in the care plans for these residents could lead to missed diagnoses or worsening of existing conditions. The lack of communication and coordination among staff members contributed to the deficiencies, as evidenced by the interviews with the ADON, PA, RDO, and RQC. The facility's policy on comprehensive person-centered care plans was not obtained at the time of the survey exit.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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