Avir At Gonzales
Inspection history, citations, penalties and survey trends for this long-term care facility in Gonzales, Texas.
- Location
- 3428 Moulton Rd, Gonzales, Texas 78629
- CMS Provider Number
- 675124
- Inspections on file
- 33
- Latest survey
- January 3, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Avir At Gonzales during CMS and state inspections, most recent first.
A resident with quadriplegia, total dependence for all ADLs, and documented urinary and bowel incontinence remained wet for an extended period after requesting help with toileting and incontinence care. Despite facility policies requiring timely call light response and assistance with ADLs, a CNA turned off the call light, left the room without providing care, and repeatedly delayed changing and bathing the resident while stating she needed a second staff member for a two-person transfer. Observations showed more than 30 minutes elapsed before the CNA secured help from another staff member and began incontinence care and showering, even though staff and leadership acknowledged that waits over 30 minutes for brief changes were excessive and outside facility expectations. This resulted in the resident not receiving necessary services to maintain personal hygiene and grooming in accordance with his care plan and facility policies.
The facility did not ensure RN coverage for at least eight hours daily and lacked a full-time DON for multiple days, as confirmed by staffing records and staff interviews. Leadership acknowledged the importance of daily RN presence for resident assessments, and the facility's policy requires such coverage.
A deficiency was identified when three resident rooms were found to lack a fully functional call light notification system, with dome lights either not activating or missing entirely. Facility staff confirmed that these issues prevented visual notification of care needs, and maintenance records showed no consistent log of call light checks.
A deficiency was cited when a resident's care plan did not address all identified needs and failed to include measurable timetables and specific actions, as observed in the resident's records during the survey.
The facility did not ensure RN coverage for at least 8 consecutive hours each day, as required, with staffing records confirming multiple days without any RN present. The Administrator acknowledged the gaps in coverage and cited challenges in hiring RNs, while the DON noted the absence of a policy addressing this requirement.
A medication error rate of 5 percent or greater was identified during the survey, indicating that the facility did not maintain medication administration accuracy within regulatory standards.
A resident with moderate cognitive impairment and multiple mental health diagnoses was administered several psychoactive medications without signed and dated consents from her POA. The DON confirmed that required consents were missing from both electronic and hard copy records, and the facility's policy did not address the need for obtaining consent for these medications.
A resident admitted with psychotic disorder, major depressive disorder, and anxiety disorder did not have her mental illness diagnoses reflected in the PASRR Level 1 screening due to reliance on incomplete hospital records. The MDS Nurse did not update the PASRR to prompt a Level 2 screening, resulting in mental health services not being coordinated through the local authority, despite the resident receiving psychiatric and counseling services.
An expired controlled medication, Morphine Sulfate oral suspension, was found stored in a locked medication cart for a resident with severe cognitive impairment and chronic lung disease. The LPN using the cart was unaware of the process for removing expired medications, despite having been assessed as competent in this area. The DON confirmed the medication was expired and should not have been present, in accordance with facility policy.
Surveyors found that two residents had unlabeled and undated food items in their personal refrigerators, including an opened jar of Picante Sauce and a Styrofoam cup with an unidentified white liquid. Both residents had cognitive impairments and significant medical conditions. The DON and Administrator were unable to determine how long the items had been stored, and the facility's policy requiring labeling and timely disposal of perishable foods was not followed.
A resident with an order for TED hose had daily MAR entries indicating application, but interviews and observations revealed staff never applied TED hose and instead documented the resident's use of his own compression socks as if they were TED hose. Nursing staff and the unit manager confirmed the discrepancy, and the DON noted that TED hose and compression socks are not interchangeable, resulting in inaccurate and incomplete medical records.
Surveyors found that the facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency related to infection control practices.
Nursing staff did not accurately code a resident's upper extremity functional limitation on the MDS assessment, despite the resident having documented contractures and decreased range of motion due to multiple medical conditions. The omission was confirmed through observation, interviews, and record review, with facility leadership acknowledging the importance of accurate MDS documentation.
Three residents with oxygen equipment in their rooms did not have required physician orders, care plans for oxygen administration, or oxygen safety signage posted, despite facility policy mandating these measures. In two cases, oxygen equipment was present without orders or care plans, and in the third, an order existed but no care plan or signage was in place. Staff interviews confirmed inconsistent adherence to procedures for managing oxygen therapy and safety.
Two residents with severe cognitive impairment and fall risk did not have their call lights within reach as required by their care plans and facility policy. Staff interviews confirmed that all staff were responsible for ensuring call lights were accessible, but observations found one resident's call light draped over a nightstand and another's wrapped around a wall plug, both out of reach.
Two residents requiring enhanced barrier precautions did not have care plans reflecting the need for staff to use gowns and gloves during direct care, despite having wounds and infection risks. Although signage was present, care plans were not updated to include these precautions until after surveyor intervention, contrary to facility policy and staff expectations.
The facility failed to distribute mail to residents on Saturdays, as the BOM was the only one responsible for mail distribution and only worked Monday through Friday. Despite department heads having access to the mailbox on weekends, they did not distribute mail, leading to residents expressing dissatisfaction and feeling disrespected. This practice violated the facility's policy on residents' rights to privacy in receiving mail.
The facility did not maintain the required RN coverage for 8 consecutive hours a day, 7 days a week, as evidenced by the absence of RN coverage on ten weekend dates. Interviews with the DON and Regional Nursing Consultant confirmed the lack of coverage and the absence of a policy addressing this CMS standard.
The facility reported a 10% medication error rate due to late administration of medications by a medication aide. Three residents received their medications significantly past the scheduled time, contrary to the facility's policy requiring administration within one hour of the prescribed time. The errors were confirmed through observation and interviews, with the medications marked as late in the electronic record.
The facility's kitchen failed to meet food safety standards, with expired shredded cheese found in the cooler and cleaning supplies improperly stored near food. Additionally, a sack of breadcrumbs was left open and unsealed, risking contamination. The Dietary Manager confirmed these lapses, which contravene the facility's food storage policies.
A LTC facility failed to maintain proper infection control practices, as observed in three separate incidents. A medication aide did not sanitize a blood pressure cuff between residents, a CNA did not properly sanitize her hands during incontinent care, and an LVN failed to wash her hands after touching a potentially contaminated surface before providing enteral feeding. These actions were contrary to the facility's infection control policies.
A resident's right to formulate an advance directive was not honored when her family member executed an OOH-DNR without her consent, despite her intact cognition. The facility failed to reassess her wishes upon her return from hospitalization, and the resident expressed that she did not want anyone signing on her behalf.
Two privacy breaches occurred in the facility: CNAs failed to fully close a privacy curtain during incontinent care, exposing a resident, and an LVN left a computer screen open in a hallway, displaying a resident's protected health information. Both staff members acknowledged the lapses, and the DON confirmed the breaches of privacy.
A resident with severe cognitive impairment and exit-seeking behavior was not provided with a comprehensive care plan addressing these issues. Despite having a physician's order for a wander guard, the care plan did not include this or the resident's tendency to wander. The DON and MDS coordinator acknowledged the oversight, which was contrary to the facility's policy requiring comprehensive care plans.
A resident with intact cognition and complete dependence on staff for transfers did not receive podiatry care despite a physician's order. Observations showed the resident's toenails were severely neglected, and interviews revealed a lack of regular podiatrist visits and difficulty in transporting the resident to an external provider. The facility's nail care policy was not adhered to, resulting in a deficiency in maintaining the resident's foot health.
The facility failed to maintain a safe environment on Hall 300, where a container of Sani-Cloth wipes was left unsecured on a medication cart. This posed a potential hazard, especially to residents with dementia who could access the area. LVN E and the DON confirmed the wipes should have been locked away, as per facility policy, which emphasizes minimizing accident hazards.
A medication cart was left unlocked by an LVN during a blood sugar check, leaving medications accessible and out of sight. The DON confirmed the requirement for carts to be locked, as per facility policy, to prevent drug diversion.
A facility failed to coordinate hospice care for a resident by not having the required Physician Certification of Terminal Illness. The resident, with severe cognitive impairment and COPD, was on hospice care, but the necessary documentation was missing from the facility's records. This lack of documentation could impede communication and coordination between the facility and hospice care teams, affecting the resident's end-of-life care.
Failure to Provide Timely Toileting and Hygiene Assistance to a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with toileting and incontinence care to a dependent resident, as required by the resident’s care plan and facility policies. The resident was an adult male with cerebral infarction, quadriplegia, and muscle wasting/atrophy, admitted with total dependence for all ADLs, including toileting hygiene, transfers, and personal hygiene. His MDS and care plan documented that he was cognitively intact (BIMS 14), used a wheelchair, was always incontinent of urine and frequently incontinent of bowel, and required two-person assistance and a mechanical lift for transfers and toileting. The care plan also identified him as at risk for impaired skin integrity and pressure ulcers due to moisture, with goals for intact skin and interventions including assistance with movements/tasks and total dependence for toilet use. On the day of the incident, the resident reported that he had been wet for about an hour and stated that a CNA did not want to change or bathe him. At 12:48 PM, he was observed in his wheelchair, appropriately dressed, holding his call light, and expressing anger about being left wet. At 12:50 PM, CNA A entered his room in response to the call light, turned it off, told him she was waiting for additional staff to help with his brief change, and left the room quickly without allowing him to fully explain his needs. At 1:06 PM, the resident stated he was still waiting to be changed. CNA A entered again, placed wipes, gloves, and changing pads on the bed, commented that the resident was impatient, and left the room, stating she needed another staff member to assist, but did not provide care at that time. Subsequent observations showed that CNA A did not secure a second staff member and initiate care until more than 30 minutes after the resident’s request. At 1:19 PM, CNA A was observed asking a Med Tech to assist with a two-person brief change, and at 1:21 PM they entered the room to provide incontinence care, then exited quickly. At 1:24 PM, CNA A wheeled the resident to the shower area, again stating that the resident was impatient and that she needed another staff member to help clean, change, or bathe him. At 1:28 PM, the Med Tech entered the shower area to assist with toileting hygiene and showering. Interviews with CNAs, an LVN, the Regional Nurse Consultant, and the Administrator confirmed facility expectations for call light response (generally within 5–10 minutes), two-hour rounding, and that waiting more than 30 minutes for a brief change was considered excessive and unacceptable. CNA A acknowledged that the resident waited more than 30 minutes for toileting hygiene, that a 40-minute wait was excessive, and that she had difficulty obtaining help from other staff, resulting in the resident remaining soiled for an extended period despite being totally dependent for ADLs. Facility policies on Resident Rights, ADL support, and the call system required that residents be treated with respect and dignity, receive necessary services to maintain grooming and personal hygiene when unable to perform ADLs independently, and have calls for assistance answered timely. The resident’s documented dependence for toileting and hygiene, combined with his incontinence and risk for skin breakdown, required prompt assistance with elimination and hygiene. Despite these requirements, the resident remained wet for more than 40 minutes after his second verbal request to CNA A, with delays attributed by staff to difficulty obtaining a second person for transfer and care. Staff interviews consistently described that more than 30 minutes for toileting hygiene was outside facility protocol and could be considered neglectful, and leadership confirmed that a wait time exceeding 35 minutes for a total-care, alert resident to have his brief changed was unacceptable. These observations and interviews demonstrate that the facility did not ensure the resident received timely assistance with ADLs necessary to maintain good grooming and personal hygiene as outlined in his care plan and facility policies.
Failure to Provide Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was on duty for at least eight hours each day and did not have a full-time Director of Nursing (DON) present for eight specific days in November 2025. Record review showed that on these days, there was no RN or DON working at the facility during the 24-hour period. The absence of RN coverage was confirmed by both the Corporate RN and the Human Resources Director, who stated that the previous DON, who had provided daily RN coverage, was last employed on October 31, 2025. After this date, the Corporate RN attempted to visit the facility as much as possible but was not present daily, resulting in gaps in required RN coverage. Interviews with facility leadership, including the Administrator and Assistant Director of Nursing (ADON), acknowledged the necessity of having a DON or RN present to provide licensed nursing assessments of resident care needs and behaviors on a daily basis. The facility's own policy requires that an RN provide services at least eight hours every 24 hours, seven days a week. The deficiency was identified through observation, interviews, and record review, with no mention of specific residents or their medical conditions at the time of the deficiency.
Failure to Maintain Functional Call Light System in Resident Rooms
Penalty
Summary
The facility failed to ensure that a fully functional call light notification system was available in three resident rooms across three hallways. During observation rounds with the Maintenance Director and Activity Director, it was found that the dome lights outside the entrances to two rooms did not activate when the call light was engaged, and the dome light apparatus was missing from the entrance of another room. The Maintenance Director, who had been in the position for about a month, was unaware of how long these issues had persisted and had not maintained a written log of call light checks, only checking them as needed. Record review indicated that maintenance repairs, including call light notification repairs, had been completed previously, but these deficiencies were still present at the time of the survey. Interviews with facility staff confirmed that the lack of an operating dome light hindered staff's ability to receive visual notifications of residents' care needs. The facility's policy required that the resident call system remain functional at all times, but this standard was not met in the identified rooms. The deficiency was identified through observation, interview, and record review, and it was acknowledged by both the Maintenance Director and Activity Director that the absence of a working call system could impede timely staff response to resident needs.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the survey process and was based on a review of the resident's records, which did not contain a comprehensive or measurable care plan as required.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. Review of RN staffing records showed that there was no RN coverage on thirteen specific dates between March and July 2025. During interviews, the Administrator confirmed the lack of RN coverage on these dates and attributed the issue to difficulties in hiring enough RNs, particularly for weekend shifts in a rural setting. The Director of Nursing (DON) also confirmed that there was no facility policy addressing the requirement for 8-hour daily RN coverage, stating that this was a CMS standard.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
A medication error rate of 5 percent or greater was identified during the survey. This indicates that the facility failed to ensure that the administration of medications was performed with an acceptable level of accuracy, resulting in a higher than permitted rate of medication errors. The deficiency was based on direct observation and calculation of medication error rates during the survey process.
Failure to Obtain Informed Consent for Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident's right to be informed in advance of the risks and benefits of proposed care, treatment alternatives, and to choose preferred options was upheld. Specifically, for one resident with a history of psychotic disorder, major depressive disorder, and anxiety disorder, there were no signed and dated consents from the resident's Power of Attorney (POA) for the use of multiple psychoactive medications, including Seroquel, Buspar, Zoloft, Trazodone, and Depakote. Record review showed that the resident had moderate cognitive impairment and was prescribed these medications for her mental health conditions. The resident was not aware of the medications she was taking, and the electronic health record did not contain any consents for these psychoactive medications. During interviews, the DON confirmed that no consents were found in the electronic or hard copy records, except for an unsigned and undated consent for Seroquel. The DON acknowledged responsibility for ensuring medication consents were obtained prior to administration and was unable to explain why the consents were missing. Additionally, the facility's policy on antipsychotic medication use did not include information regarding the need to obtain consent for psychoactive medications.
Failure to Coordinate PASRR Assessments for Resident with Mental Illness
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for a resident admitted with multiple mental health diagnoses, including Psychotic Disorder with delusions, Major Depressive Disorder, and Anxiety Disorder. Upon admission, the resident's PASRR Level 1 screening did not reflect her mental illness diagnoses, as the MDS Nurse relied primarily on hospital records, which did not indicate mental illness or dementia. The MDS Nurse later acknowledged that she used poor judgment by not updating the PASRR to reflect the resident's mental health conditions, which would have triggered a Level 2 PASRR screening by the local mental health authority. The resident was admitted with moderate cognitive impairment and was receiving antipsychotic, antianxiety, and antidepressant medications. Despite being seen by a mental health counselor and psychiatric provider shortly after admission, the lack of a Level 2 PASRR referral meant that these services were not coordinated through the local authority as required. The DON confirmed that the resident's PASRR should have indicated her mental illness diagnoses upon admission and acknowledged the absence of a facility policy regarding PASRR services, relying instead on state guidelines.
Expired Controlled Medication Found in Medication Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled and stored in accordance with professional standards, as evidenced by the presence of an expired controlled medication, Morphine Sulfate 20mg/5ml oral suspension, in the Hall 300 Nurse's medication cart. The medication, prescribed for a female resident with chronic obstructive pulmonary disease and severe cognitive impairment, had an expiration date of 12/28/2024 but was still found in the locked controlled medication storage during an observation. The nurse present at the time, who had been working at the facility for three weeks, acknowledged the medication was expired but was unaware of whose responsibility it was to remove expired medications from the cart. The Director of Nursing confirmed that the expired medication should not have been stored in the medication cart and stated that it was the responsibility of the nurse using the cart to remove expired medications. Review of the nurse's competency checklist indicated she had been assessed as competent in areas including checking medication expiration dates. The facility's policy required contacting the dispensing pharmacy for instructions regarding the return or destruction of discontinued or outdated medications.
Failure to Label and Date Resident Food Items in Personal Refrigerators
Penalty
Summary
The facility failed to ensure proper labeling and dating of food items stored in personal refrigerators in residents' rooms, as required by facility policy. During observations, one resident's refrigerator contained an opened glass jar of Picante Sauce with a 'Best Use By' date but no indication of when it was opened. Another resident's refrigerator contained a Styrofoam cup with a white liquid, possibly milk, covered with plastic wrap, but lacking any label or date to identify its contents or when it was placed there. Both items were not labeled or dated as required for safe storage and handling. Record reviews revealed that one resident had severe cognitive impairment and the other had mild cognitive impairment, with both having significant medical conditions such as dementia, muscle wasting, chronic kidney disease, and diabetes. Interviews with the DON and Administrator confirmed that they could not determine how long the food items had been in the refrigerators and acknowledged that outdated food should be discarded. The facility's policy required that food brought by family or visitors be labeled and stored appropriately, and that nursing staff are responsible for discarding perishable foods by their use-by or expiration dates. However, these procedures were not followed for the residents in question.
Failure to Accurately Document and Administer Ordered TED Hose
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who had a physician's order for TED hose to be applied in the morning and removed at bedtime for edema. Review of the Medication Administration Record (MAR) for the month showed that staff documented the application of TED hose every morning, but night shift documentation was inconsistent, with most entries indicating to 'see progress note' and only two entries marked as 'off' or 'N/A.' Interviews with the resident and a family member revealed that staff had never applied TED hose, and the resident always wore his own black compression knee-high socks, which he put on himself daily. The family member confirmed never seeing staff apply TED hose. Further interviews with nursing staff and the unit manager confirmed that the resident wore compression socks, not TED hose, and that day shift staff were documenting the use of compression socks as if they were TED hose on the MAR. The DON clarified that TED hose and compression socks are not the same and should not be substituted for each other. The facility's policy requires that treatments and services performed be documented objectively, completely, and accurately in the medical record, which was not followed in this case.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection prevention and control measures were not established or maintained as expected. The report specifically notes the absence of a comprehensive program designed to prevent and control infections within the facility.
Failure to Accurately Reflect Resident's Functional Limitation in MDS Assessment
Penalty
Summary
Nursing staff failed to accurately code Section GG of the MDS Comprehensive assessment for a resident with multiple diagnoses, including myopathy, rheumatoid arthritis, osteoarthritis, osteoporosis, osteopenia, contractures, chronic pain, and muscle atrophy. Despite documentation in the care plan and physician's progress notes indicating the resident had contractures and decreased range of motion in the upper extremities, the MDS assessment did not reflect any impairment in the resident's upper extremity function. Observations and interviews confirmed the resident had visible hand contractures and required staff assistance for transfers. The MDS Coordinator acknowledged that the assessment did not capture the resident's limited range of motion due to contractures. Both the DON and Administrator stated that accurate MDS records are essential for proper care planning and regulatory compliance. Facility policy requires comprehensive assessments to be conducted according to established criteria and timeframes.
Failure to Ensure Safe and Appropriate Respiratory Care and Oxygen Safety Measures
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who had oxygen equipment in their rooms. For two residents, there were no physician orders for oxygen administration, no care plans addressing oxygen use, and no oxygen safety signs posted on their room doors, despite the presence of oxygen concentrators or cylinders. In both cases, the oxygen equipment was not in use at the time of observation, but staff interviews confirmed that the equipment was available for use as needed, particularly for residents on hospice care. For the third resident, although there was a physician order for oxygen to be administered as needed for shortness of breath, there was no care plan addressing oxygen administration and no oxygen safety sign on the room door. The oxygen cylinder was present in the room but had not been used since admission. Staff interviews indicated that hospice provided the oxygen equipment for potential use, and that nursing staff were responsible for obtaining orders, updating care plans, and ensuring appropriate signage. Facility policy required a physician order, review of the care plan, and placement of 'No Smoking/Oxygen in Use' signs when oxygen equipment is present. However, these procedures were not followed for the three residents identified. Staff and administration interviews confirmed that the required orders, care plans, and safety signage were not consistently in place for residents with oxygen equipment in their rooms, regardless of whether the oxygen was actively being used.
Failure to Ensure Call Lights Accessible to Residents
Penalty
Summary
The facility failed to ensure that two residents had access to their call lights, as required by their care plans and facility policy. For one resident with severe cognitive impairment and a high risk for falls, observations revealed that both his push button and soft touch call lights were draped over a nightstand and not within his reach while he was seated in his recliner. This resident was unable to answer questions about his call light due to his cognitive status and was observed attempting to get up from his recliner without assistance. Another resident, also with severe cognitive impairment and a history of falls, was found asleep in bed with her call light cord wrapped around the call light plug on the wall behind her bed, making it inaccessible. Staff interviews confirmed that call lights should be within reach of residents at all times, and that all staff members, including CNAs, nurses, housekeeping, and the Administrator, were responsible for ensuring proper placement. The resident denied moving the call light herself and stated that she relied on it to call for assistance. Both residents had care plans specifying that call lights should be kept within reach and that staff should educate and encourage their use. Facility policy also required that call lights be within easy reach of residents in bed or confined to a chair. Interviews with staff and administration revealed uncertainty about recent training on call light placement and issues with broken call light clips, but confirmed the expectation that call lights be accessible to residents at all times.
Failure to Develop and Implement Care Plans for Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans addressing enhanced barrier precautions for two residents. For one resident with chronic obstructive pulmonary disease and severe cognitive impairment, there was no care plan in place to address the need for staff to use gowns and gloves during direct care, despite the presence of a wound requiring dressing and an enhanced barrier precautions sign posted outside the room. The resident's care plan only addressed a laceration from a fall, omitting the required infection control measures. Another resident, who had chronic venous hypertension, a colostomy, and no cognitive impairment, also lacked a care plan for enhanced barrier precautions at the time of review. This resident was dependent on staff for multiple activities of daily living and had active wound care and colostomy management orders. Although an enhanced barrier precautions sign was posted, the care plan was not updated to reflect these precautions until after surveyor intervention. Interviews with staff, including an LVN, a CNA, the Administrator, and the DON, confirmed that care plans should include enhanced barrier precautions to inform staff of required infection control measures. The facility's policy requires comprehensive care plans with measurable objectives and timetables, and ongoing assessment and revision as resident conditions change. The lack of timely care plan updates for enhanced barrier precautions constituted the identified deficiency.
Failure to Distribute Mail on Saturdays
Penalty
Summary
The facility failed to uphold residents' rights to receive mail in a timely manner, as observed during a survey. It was found that the facility staff did not distribute mail received on Saturdays to the residents. This practice was confirmed during a confidential group meeting with residents, who expressed their dissatisfaction and confusion about not receiving mail on Saturdays. They felt that this practice was disrespectful and diminished their quality of life. Interviews with facility staff, including the Business Office Manager (BOM) and the Administrator, revealed that the BOM was solely responsible for distributing mail from Monday to Friday, leaving Saturday's mail undelivered until the following Monday. Despite department heads rotating as managers on duty during weekends and having access to the mailbox, they did not distribute the mail. The facility's policy on resident rights, which includes the right to privacy in sending and receiving mail, was not adhered to, as the practice of not distributing mail on Saturdays had been in place since 2018.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to comply with the requirement of having a registered nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week. This deficiency was identified during a review of the facility's RN hours record, which revealed a lack of RN coverage on ten specific dates, all of which were weekends, between March 1, 2024, and May 31, 2024. Interviews with the Director of Nursing (DON) and the Regional Nursing Consultant confirmed the absence of RN coverage on these dates. The facility had two RNs, one full-time and one part-time, who worked different shifts, but there was no RN coverage on the specified dates. Additionally, the Regional Nursing Consultant acknowledged that there was no nursing policy in place to address the requirement for RN coverage for 8 hours per day, as it was a CMS standard.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10% error rate based on 3 errors out of 30 opportunities. These errors involved three residents who did not receive their medications within the prescribed time frame. Medication Aide D administered hydrocodone to a resident 1 hour and 20 minutes late, duloxetine to another resident 1 hour and 42 minutes late, and metoprolol to a third resident 1 hour and 55 minutes late. These delays were observed and confirmed during interviews, and the medications were marked in red in the electronic medication administration record, indicating they were administered past the allowable time window. The residents involved had various medical conditions, including myopathy, atrial fibrillation, depression, rheumatoid arthritis, hypertension, chronic obstructive pulmonary disease, anxiety disorder, type 2 diabetes mellitus, major depressive disorder, hyperlipidemia, hypokalemia, dementia, osteoarthritis, and chronic venous hypertension. The facility's policy requires medications to be administered within one hour of their prescribed time, which was not adhered to in these instances. The Director of Nursing confirmed that medications should be administered within one hour of the scheduled time, either one hour before or after, and acknowledged the errors.
Food Safety Violations in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. A bag of shredded Cheddar cheese was found in the reach-in cooler, past its use-by date, which was not discarded as per the facility's food storage policy. The Dietary Manager (DM) confirmed that the cheese had been opened on 05/07/2024 and should have been discarded to prevent potential foodborne illness. Additionally, cleaning supplies, including a broom, plunger, and mop heads, were improperly stored in the dry storage area alongside food staples, which is against the facility's storage guidelines. Furthermore, a 25-lb. sack of Japanese-style breadcrumbs was found open and unsealed in the dry storage room, lacking a label and use-by date, which could lead to contamination from pests. The DM acknowledged that the breadcrumbs should have been properly sealed and labeled. The facility's dietary policies are based on the Texas Food Establishment Rules, 2015 edition, and the U.S. FDA Food Code, 2022, which require proper labeling, dating, and storage of food to prevent contamination and ensure safety.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. A medication aide did not sanitize a blood pressure cuff between using it on two residents, despite being aware of the need to prevent cross-contamination. This oversight occurred during medication administration for residents with various medical conditions, including hypertension and diabetes. The aide admitted to not having sanitizing wipes available on her cart and acknowledged the lapse in protocol. Another deficiency was observed when a CNA did not properly sanitize her hands while providing incontinent care to a resident with severe cognitive impairment and multiple health issues, including Alzheimer's disease and diabetes. The CNA used hand sanitizer but failed to rub it between her fingers, which is necessary to ensure complete hand hygiene. The CNA recognized the mistake and confirmed having received training on proper hand hygiene techniques. Additionally, an LVN failed to sanitize her hands after touching a potentially contaminated surface before providing enteral feeding to a resident with brain cancer and other serious health conditions. The LVN moved a bedside table without sanitizing it and then proceeded to provide care without washing her hands. This action was contrary to the facility's hand hygiene policy, which requires hand sanitization after contact with objects in the resident's environment. The LVN acknowledged the error and confirmed having received infection control training.
Failure to Honor Resident's Advance Directive Rights
Penalty
Summary
The facility failed to honor a resident's right to request, refuse, and/or discontinue treatment and to formulate an advance directive. A resident, who was cognitively intact with a BIMS score of 14, was unable to make her wishes known regarding her code status. Her family member executed an Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) order without her consent or knowledge, following a physician's recommendation during a hospitalization when the resident was near death. The facility did not reassess the resident's cognitive status or her wishes regarding the DNR upon her return to the facility. Interviews revealed that the resident was not informed about the DNR status and expressed that she did not want anyone signing documents on her behalf. The family member, who signed the DNR, wished to respect the resident's wishes and have the DNR removed, restoring her status to full code. The facility's policy required the Interdisciplinary Care Planning Team to review advance directives with residents during quarterly care planning sessions, which was not adhered to in this case.
Privacy Breaches During Resident Care
Penalty
Summary
The facility failed to ensure personal privacy for two residents during care activities. For one resident, CNAs did not completely close the privacy curtain while providing incontinent care, leaving the resident exposed and visible from the room's door. The curtain rods were too far apart, preventing the curtains from closing fully. Both CNAs acknowledged the issue and confirmed they had received training on resident rights but had not reported the malfunctioning curtain rods. The Director of Nursing (DON) confirmed that privacy should have been maintained and that staff had received training on resident rights. In another instance, an LVN left a computer screen open on a medication cart in the hallway, displaying a resident's protected health information, including their medication administration record and insulin order. This information was visible to other staff and residents. The LVN admitted the oversight and confirmed she had received training on resident rights. The DON also confirmed that the medication administration record is protected information and should have been secured. The facility's policy requires staff to have in-service training on resident rights, including confidentiality of protected health information.
Failure to Address Exit-Seeking Behavior in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and a history of exit-seeking behavior. The resident, who was admitted with diagnoses including diabetes mellitus, cognitive communication deficit, dementia with psychotic disturbance, and heart failure, had a BIMS score indicating severe cognitive impairment. Despite having a physician's order for a wander guard to be checked every shift, the resident's care plan did not address his exit-seeking behavior or the use of the wander guard. Observations and interviews revealed that the resident had a wander guard taped to his wheelchair, but this was not reflected in his care plan. The Director of Nursing acknowledged the care plan's inaccuracy, and the MDS coordinator admitted that the resident's wandering behavior was overlooked in the care plan. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan with measurable objectives and timeframes, which was not adhered to in this case.
Failure to Provide Podiatry Care
Penalty
Summary
The facility failed to provide proper foot care for a resident, leading to a deficiency in maintaining mobility and good foot health. The resident, who had intact cognition and was completely dependent on facility staff for transfers, had not received podiatry care since admission. Despite a physician's order indicating the need for podiatry care, there was no documentation of such care being provided. Observations revealed the resident's toenails were overgrown, thick, curved, ragged, chipped, uneven, cracked, and yellowish, with a thick growth underneath some toenails. Interviews with the resident, a CNA, the Ombudsman, the DON, and the regional nurse consultant highlighted the lack of podiatry care. The CNA incorrectly stated that the podiatrist had attended to the resident's feet, while the Ombudsman had previously reported the issue to the administrator. The DON acknowledged the absence of a regular visiting podiatrist and the difficulty in transporting the resident to an external provider. The facility's policy on nail care emphasized regular cleaning and trimming, with specific instructions for residents with circulatory impairments, but these guidelines were not followed for the resident in question.
Unsafe Storage of Hazardous Materials on Hall 300
Penalty
Summary
The facility failed to ensure the resident environment on Hall 300 was free from accident hazards, as observed on 06/06/2024. A container of Sani-Cloth, a germicidal wipe with precautionary statements indicating potential eye damage, was found on the medication cart in the open. This was confirmed by LVN E, who acknowledged that the wipes could pose a hazard if handled improperly, especially since there were multiple residents with dementia who could access the area. The facility's policy emphasizes making the environment as free from accident hazards as possible, yet this incident demonstrated a lapse in maintaining a safe environment. During an interview with the DON on 06/07/2024, it was confirmed that the Sani-Cloth containers should be kept out of residents' reach, particularly for those with dementia, as they could pose a risk of injury. The DON also confirmed that staff had been trained in handling hazardous products, indicating a failure in adherence to the facility's safety protocols. The facility's policy on safety and supervision of residents highlights the importance of identifying safety risks and environmental hazards through employee training and monitoring, yet this incident revealed a gap in the implementation of these safety measures.
Medication Cart Security Breach
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with one of the medication carts (Hall 300 Medication Cart). During a medication administration session, LVN C left the medication cart unlocked on one occasion while checking a resident's blood sugar in their room. This oversight left blister packs, bottles, and vials of medications accessible and out of sight, which could lead to misappropriation or accidental ingestion of medications. In an interview, LVN C acknowledged leaving the cart unlocked and admitted to forgetting the requirement to keep it locked. The Director of Nursing (DON) confirmed that the medication cart should have been locked and that the nursing staff had been trained on drug diversion prevention, including the importance of keeping medication carts locked. The facility's policy mandates that medication carts must be securely locked when out of the nurse's view, which was not adhered to in this instance.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for a resident receiving hospice services. This deficiency was identified during a review of records and interviews, where it was found that the facility did not have the most recent Physician Certification of Terminal Illness for a resident. The absence of this critical document could hinder the communication and coordination of care between the facility's care team and the hospice care team, potentially affecting the quality of end-of-life care provided to the resident. The resident in question was admitted to the facility with multiple diagnoses, including a cognitive communication deficit and chronic obstructive pulmonary disease (COPD), and was on hospice care. Despite the resident's care plan indicating hospice care due to COPD, the facility's clinical records and hospice binder lacked the necessary physician certification from the time of admission. During an interview, the nurse consultant acknowledged the absence of the document, which should have been included in the hospice binder to ensure proper coordination of care. The facility's policy on hospice care coordination, revised in July 2017, mandates obtaining such documentation to facilitate effective communication and care planning.
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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