Avir At Grand Saline
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Saline, Texas.
- Location
- 1638 Vz Cr 1803, Grand Saline, Texas 75140
- CMS Provider Number
- 675878
- Inspections on file
- 22
- Latest survey
- March 22, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Avir At Grand Saline during CMS and state inspections, most recent first.
The facility failed to ensure safe food handling by not consistently monitoring and documenting cooking and holding temperatures, and by lacking effective dietary oversight. Review of temperature logs showed many missing or incomplete entries for multiple meals, and on numerous days no logs were available at all, despite written standards specifying required internal cooking and holding temperatures. A complaint alleged that a resident was served raw chicken, and a family member reported that chicken had been served undercooked. The new DM acknowledged that she had not verified that cooks were completing temperature logs and had not trained a newly hired cook on the logging process. The cook stated he was unaware of the temperature log, did not document temperatures, and knew only the poultry temperature requirement, not other food or holding standards. These actions and inactions conflicted with the facility’s own dietary policies and job descriptions, which required temperature control, recordkeeping, and investigation of food quality complaints.
A resident with severe cognitive impairment and a Wanderguard bracelet exited the facility unsupervised after staff failed to conduct a proper census check when a door alarm sounded. The resident was not discovered missing until contacted by police, who found him over a mile away. Staff had received training and had protocols in place, but these were not followed at the time of the incident.
The facility did not consistently develop or implement baseline care plans within 48 hours of admission for three residents with complex medical needs. In some cases, care plans were incomplete, lacked required signatures, or were not made available to nursing staff, resulting in inadequate documentation and communication about residents' immediate care needs.
A resident with diabetes and her responsible party were not informed in advance about changes to her insulin dosing and blood glucose monitoring orders after re-admission. The nurse practitioner altered the orders without documented notification to the resident or her representative, and the responsible party only learned of the changes after questioning staff. Facility staff confirmed that notification should have occurred, but it was missed in this case.
A resident with multiple chronic conditions and moderate cognitive impairment, along with her representative, was not informed of or included in the development or review of her person-centered care plan. There was no documentation of invitations to care plan meetings or provision of care plan summaries, and the representative confirmed she was not consulted or given a copy of the care plan, contrary to facility policy.
A comprehensive MDS assessment was not completed within the required 14-day timeframe for a newly admitted resident with multiple complex medical conditions. Key sections of the assessment remained incomplete, and the MDS Coordinator acknowledged the delay, citing inexperience and workload as contributing factors.
A resident with severe cognitive impairment and multiple medical conditions was admitted, but the facility did not complete a comprehensive, person-centered care plan within the required 21-day period. Staff interviews revealed that the MDS Coordinator, DON, and ADON shared responsibility for care planning, but due to new staff and organizational challenges, the care plan was not developed on time as required by policy and federal regulations.
The facility did not report to the state agency an allegation of physical abuse made by a resident against two CNAs, nor did it report a serious injury involving a subdural hematoma following an unwitnessed fall by another resident. In both cases, the required notifications were not made despite facility policy and regulatory requirements.
A resident at risk for pressure injuries developed a DTI to the right heel after staff failed to consistently perform required skin assessments and follow the care plan, particularly during a period without a treatment nurse. Nursing staff did not regularly inspect the resident's skin, and the injury was only identified after it had developed, despite facility policy and care plan directives.
Staff failed to perform proper hand hygiene between glove changes and after handling contaminated materials during incontinent care for two residents. In both cases, CNAs did not follow hand hygiene protocols as outlined in facility policy, despite having received training. Interviews revealed inconsistent understanding of hand hygiene requirements among staff and leadership.
The facility's kitchen failed to maintain sanitary conditions, with a scoop left in a flour bin, raw cabbage stored on the floor, and several food items unlabeled or undated. The dietary manager acknowledged the issues, noting that new staff were still learning procedures. These actions violated facility policy and FDA guidelines, potentially risking foodborne illness for residents.
A long-term care facility failed to maintain an effective infection control program, as staff did not adhere to Enhanced Barrier Precautions (EBP) and proper PPE disposal protocols. An LVN did not wear a gown while administering medication to a resident with a gastrostomy tube, and rooms of residents on contact isolation lacked bio-hazard containers for PPE disposal. These lapses in infection control practices could increase the risk of cross-contamination and disease spread.
A facility failed to ensure proper EBP training and implementation, as observed when an LVN did not don a gown while administering medication to a resident with a gastrostomy tube. Despite EBP signage and available PPE, the LVN only wore gloves, indicating a lack of training upon hire. Interviews confirmed that new hires were not trained on EBP, and observations showed other rooms with EBP signage lacked PPE supplies, highlighting systemic issues in infection control measures.
Failure to Monitor and Document Food Temperatures and Oversee Safe Food Handling
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the only kitchen reviewed. Surveyors’ record review of March 2026 food temperature logs showed that on multiple dates where logs were available, the facility did not document final internal cooking temperatures for breakfast, lunch, and dinner meals. For those same dates, required holding temperatures for breakfast and lunch had multiple blank or slashed entries, indicating that required temperature monitoring was not performed or recorded. On numerous additional dates in March 2026, there were no food temperature logs available at all, indicating that required temperature monitoring was not conducted or maintained on those days. The facility’s own temperature log form contained reference standards for safe food handling, including internal cooking temperatures and hot and cold holding parameters, but these standards were not consistently documented as being followed. A complaint investigation intake documented an allegation that the facility’s food was of poor quality and that a resident was served raw chicken on a specific date, which the resident did not eat. During dinner meal service observation and interview, a resident’s family member reported that kitchen staff had served chicken that was not fully cooked. The Dietary Manager (DM), who had been in her position for about one month and had previously worked as a cook for about one year, stated that cooks were responsible for obtaining and documenting food temperatures for all meals and that logs were kept on a clipboard in the kitchen. However, she acknowledged that several March 2026 food temperature logs were incomplete or not completed and that she could not confirm whether food temperatures were consistently taken. She also stated she was not aware that cooks were not completing the logs until the survey interview and that she had not followed up to ensure the logs were being completed. A cook who began working in the last week of February 2026 reported that he knew food temperatures were to be taken but said he was not instructed to document them and was unaware of the existence of a food temperature log. He stated that no one had shown or reviewed the temperature log with him, and while he knew poultry must reach 165°F, he could not identify required temperatures for other foods or the minimum holding temperatures for hot or cold items. The DM confirmed she had not trained or reviewed the food temperature log process with this cook and had assumed another cook had done so. The DM reported that she was notified on a specific date about residents’ complaints regarding uncooked chicken and received a picture showing chicken that was not fully cooked; she stated it was possible food temperatures were not taken that day and did not check the temperature log at that time. The cook initially denied but later admitted he was the cook who prepared the chicken on the date in question, stated he took the temperature but did not document it, and acknowledged that some chicken may not have been properly prepared. The DM’s job description and the facility’s Food Preparation and Service Policy both required oversight of dietary operations, investigation of food quality complaints, maintenance of dietary records, and adherence to specific cooking and holding temperatures, but the documented practices and interviews showed these requirements were not consistently implemented or monitored. The facility’s written Food Preparation and Service Policy, revised in November 2022, defined the temperature danger zone, identified potentially hazardous foods, and specified required internal cooking temperatures and holding parameters for various food items, including poultry and reheated foods. It also required that food thermometers be clean, sanitized, and calibrated, and that food and nutrition services staff monitor temperatures of foods held in steam tables throughout meal service. The policy further required that proper hot and cold temperatures be maintained during food distribution and service, and that foods held in the danger zone beyond specified time limits be discarded. Despite these detailed policy requirements, the lack of complete temperature logs, the absence of logs on multiple days, the DM’s lack of verification of staff practices, and the cook’s lack of training and knowledge about documentation and holding temperatures collectively demonstrate that the facility did not ensure that food was prepared and served in accordance with its own professional standards and safe food handling practices. The DM’s job description, signed earlier in the year, required her to evaluate and monitor all aspects of dietary operations, maintain high-quality food, plan and conduct training and in-service education for dietary personnel, investigate and resolve food quality and service complaints, and prepare routine reports and maintain all dietary records in accordance with policies and procedures. The cook job description required inspection of food and food preparation to maintain quality standards, temperature standards, and sanitation regulations. Interviews with the DM and the cook, combined with the incomplete and missing temperature logs and the complaint about undercooked chicken, show that these responsibilities were not fully carried out. The Administrator confirmed that the DM and the cook were both new and that the DM was responsible for training dietary staff and ensuring adherence to facility policies and procedures, but the evidence in the report shows that this oversight and training did not occur as required, contributing to the identified deficiency in food safety practices.
Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple psychiatric diagnoses, who was wearing a Wanderguard bracelet, was able to leave the facility unsupervised. The resident was last seen by staff in the morning, and although the front door alarm sounded, the charge nurse assumed it was triggered by other residents accompanied by family members and did not conduct a facility-wide check to account for all residents with Wanderguard devices. The resident was not discovered missing until the local police contacted the facility after finding him approximately 1.3 miles away. The resident's care plan had previously identified a risk for wandering, and a Wanderguard had been placed after a prior incident where the resident was found outside the facility. Despite this, staff did not follow procedures to verify the whereabouts of all residents at risk when the door alarm was activated. Interviews with staff revealed that although they had received training on elopement procedures and the use of a binder listing residents with Wanderguards, the protocol was not followed at the time of the incident. The charge nurse did not initiate a sweep or census check to ensure all at-risk residents were present after the alarm sounded. The facility's failure to provide adequate supervision and to respond appropriately to the door alarm resulted in the resident leaving the premises undetected for approximately one hour. The resident was eventually located by law enforcement and returned to the facility without injury. The incident demonstrated a lapse in the implementation of established elopement prevention protocols, specifically in monitoring and accounting for residents identified as being at risk for wandering or elopement.
Failure to Develop and Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, as required by policy. For one resident with Alzheimer's disease, dementia, aortic stenosis, and osteoporosis, the electronic baseline care plan was completed but lacked signatures from the resident, the resident's representative, and the staff who developed the plan. The document was not properly signed or made available to the nursing staff, and the process for obtaining signatures was inconsistently followed. Another resident with a principal diagnosis of COPD, emphysema, dementia, and diabetes mellitus did not have their baseline care plan updated to address the principal diagnosis or the identified risks for hypoglycemia and hyperglycemia. The care plan was a revision of a previous stay's plan and did not include goals or interventions for the current admission's primary health concerns. Additionally, there was no documentation that the resident or their representative had been informed or included in the care planning process. A third resident with multiple diagnoses, including cerebral atherosclerosis, major depression, diabetes, and dysphagia, had an incomplete and undated baseline care plan in the electronic record, and the signed paper copy was not scanned into the electronic health record. As a result, the baseline care plan was not accessible to nursing staff and could not be updated to reflect changing needs. The facility's process for managing baseline care plans was inconsistent, leading to incomplete documentation and lack of communication among staff regarding residents' immediate care needs.
Failure to Notify Resident and Representative of Changes in Insulin Orders
Penalty
Summary
The facility failed to inform a resident with diabetes mellitus and her responsible party in advance about changes made to her physician orders regarding insulin dosing and blood glucose monitoring. Upon re-admission from the hospital, the resident's orders were changed by the nurse practitioner from a sliding scale insulin regimen with blood glucose checks four times daily to a reduced frequency of two times daily and discontinuation of the sliding scale insulin. There was no documented evidence that either the resident or her responsible party was notified of these changes, as required by facility policy and regulatory standards. The responsible party only became aware of the changes several days after admission when the resident reported not receiving her insulin shots. Upon inquiry, the responsible party learned of the order changes from nursing staff and subsequently had the original orders reinstated after discussing with the nurse practitioner. Interviews with staff, including the charge nurse and DON, confirmed that notification of such changes is expected practice, but in this instance, the notification was missed. Facility policy also requires prompt notification of residents and their representatives regarding changes in care or treatment.
Failure to Include Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and her representative were informed of and included in the development and implementation of a person-centered care plan. Record review showed that during the resident's stay, there was no documentation indicating that either the resident or her representative had been invited to participate in care planning meetings, had been consulted about the care plan, or had received a copy of the care plan. The resident, who had a history of COPD, emphysema, dementia, and diabetes mellitus, was moderately cognitively impaired and ambulatory with a walker. Despite these needs, there was no evidence in the medical record of any communication or invitation to the care planning process for the resident or her representative. Interviews with the resident's representative confirmed that she was not consulted or included in the care planning process, was never asked to attend a care plan meeting, and was not provided with a copy of the care plan. The DON, who was not employed at the facility during the resident's stay, was unable to find any documentation of care plan meetings or invitations for the resident or her representative. Facility policy required that residents and/or their representatives be provided with a written summary of the baseline care plan and be informed of their right to participate in care planning, but this was not followed in this case.
Failure to Complete Timely Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a newly admitted resident within the required 14-day timeframe, as specified by the CMS Resident Assessment Instrument (RAI) User Manual. Record review showed that the resident, a male with multiple diagnoses including cerebral atherosclerosis, major depression, diabetes mellitus, anxiety, sleep apnea, atrial fibrillation, dysphagia, arthritis, ataxia, and a history of repeated falls, was admitted to the facility and had an incomplete admission MDS assessment. Key sections of the MDS, such as identification information, preferences, functional abilities, health conditions, special treatments, participation in assessment, and care area assessment summary, were not completed, and the assessment was not signed as completed by the required date. During an interview, the MDS Coordinator acknowledged the assessment was overdue and could not provide a reason for the delay. She stated she was still learning the process and had not completed the assessment within the regulatory timeframe. The facility's policy, based on the RAI Version 3.0 Manual, requires comprehensive assessments to be completed by the end of day 14 following admission, but this was not met for the resident in question.
Failure to Complete Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident within the required timeframe. Specifically, a female resident with diagnoses including Alzheimer's disease, dementia, aortic stenosis, and osteoporosis was admitted, and her records showed a severely impaired cognitive status with a BIMS score of 6. Despite these needs, a comprehensive care plan had not been completed within 21 days of admission, as required by both federal regulations and the facility's own policy. The MDS Coordinator confirmed that the comprehensive MDS assessment and subsequent care plan were not completed on time, attributing the delay to efforts to get caught up with new admissions. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that responsibility for care plan development was shared among the MDS Coordinator, DON, and ADON. The DON and other key staff were new to the facility and acknowledged they were still organizing processes and were unaware that the resident's care plan was overdue. Review of the facility's policy and the CMS RAI Manual confirmed the requirement for care plan completion within 21 days of admission, which was not met in this case.
Failure to Timely Report Alleged Abuse and Serious Injury
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse and serious injury to the state agency as required by regulations. In one instance, a male resident with dementia and physical impairments reported to the DON that two CNAs were rough with him during care, including an allegation that one CNA struck him with a rolled-up rag and knocked a scab off his foot. Although the Administrator conducted an internal investigation and determined the accused CNAs were not present at the time of the alleged incident, the facility did not report the allegation to the state agency as required, since the Administrator believed reporting was unnecessary if the accused staff were not present. In a separate case, another male resident with dementia and a history of falls experienced an unwitnessed fall resulting in a head injury. The resident was found on the floor with a hematoma and was transported to the hospital, where he was diagnosed with a subdural hematoma. Despite the serious nature of the injury, the facility did not report the incident to the state agency. The DON, who was present at the time of the fall, confirmed that the Administrator was responsible for reporting such incidents, but the required report was not made. Review of the facility's own policy confirmed that all allegations of abuse, neglect, exploitation, or injuries of unknown source must be reported immediately to the Administrator and to authorities, with specific timelines based on the severity of the incident. The facility's failure to report both the abuse allegation and the serious injury was not in accordance with their policy or regulatory requirements.
Failure to Prevent Pressure Injury Due to Inconsistent Skin Assessments
Penalty
Summary
A deficiency occurred when a resident, who was at risk for pressure injuries due to conditions such as dementia, diabetes, incontinence, and limited mobility, developed a deep tissue injury (DTI) to her right heel. The resident's care plan required skin assessment and inspection every shift, with particular attention to the heels, but this was not consistently implemented. The facility's policy also required daily skin inspections during personal care and weekly risk assessments, but these were not reliably performed. Nursing staff interviews revealed that skin assessments were primarily the responsibility of the treatment nurse, and when the facility was without a treatment nurse, other nurses did not assume this responsibility. Several staff members, including RNs and LVNs, stated they had not recently assessed the resident's feet or performed skin assessments, despite the care plan's requirements. The DON confirmed that skin assessments should be performed on admission and weekly, and that if a care plan called for assessments every shift, this should be done, but was unaware of any such care plans being in place. Documentation showed that the resident had no skin issues noted in assessments prior to the discovery of the DTI. The injury was first identified by an RN who noticed a dark area with surrounding redness on the resident's right heel and subsequently notified the physician and responsible party. Observations at the hospital confirmed the presence of a DTI on the right heel. The facility's failure to ensure consistent skin assessments and adherence to the care plan led to the development of the pressure injury.
Failure to Perform Proper Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene practices among staff during incontinent care for two residents. In one instance, a CNA performed multiple glove changes while providing care, including opening a wet brief, wiping the resident's vaginal area and bottom, applying lotion, and putting on a clean brief, but did not perform hand hygiene between glove changes. Although the CNA had previously been checked off on proper handwashing techniques, she stated that hand hygiene was not necessary between glove changes. In another instance, a CNA disposed of a dirty wipe after receiving it from another CNA during incontinent care, but did not change gloves or perform hand hygiene before handing over clean wipes and a clean brief. The CNA acknowledged the lapse, attributing it to nervousness. Interviews with the DON and Administrator revealed differing expectations regarding hand hygiene, with the DON expecting hand hygiene before care, between dirty and clean tasks, after care, and between glove changes, while the Administrator emphasized hand hygiene before and after glove use and when hands are visibly soiled. The facility's policy indicated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and outlined specific indications for hand hygiene.
Sanitation Deficiencies in Kitchen Food Storage and Labeling
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. A scoop was left inside a bulk flour bin in the dry pantry, which was later removed by the dietary manager (DM) who acknowledged that new kitchen staff had not yet learned all procedures. Additionally, a box of raw cabbage was improperly stored on the floor in front of a reach-in cooler, and several food items in the coolers were not labeled or dated, including a resealable bag of breadsticks, a large plastic container with an unknown orange-brown substance, and various nectar-thickened juices. The DM admitted to not knowing the contents of the plastic container and confirmed that thickened liquids should be dated when opened. The facility's policy on food storage, dated 12/01/11, requires that scoops be stored in a protected area near food containers, all items be stored at least six inches above the floor, and refrigerated foods be dated, labeled, and tightly sealed. The Food and Drug Administration Code, 2013, also mandates that food be stored in a clean, dry location, protected from contamination, and at least six inches above the floor. The facility's failure to adhere to these standards could place residents at risk of foodborne illness.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of personal protective equipment (PPE) by staff. Specifically, LVN A did not wear the required gown while administering medication to a resident with a gastrostomy tube, despite the presence of signage indicating the need for Enhanced Barrier Precautions (EBP). LVN A admitted to forgetting to don a gown and acknowledged that she had not received training on EBP at the facility. Interviews with other staff, including LVN B and the Director of Nursing (DON), confirmed that the facility's policy required the use of gloves and gowns for residents with indwelling devices, such as feeding tubes, to prevent cross-contamination and the spread of infections. Additionally, the facility failed to provide appropriate containers for the disposal of contaminated PPE in the rooms of residents requiring contact isolation. Observations revealed that rooms of residents on contact isolation did not have lined bio-hazard containers for doffed PPE. Staff interviews indicated that PPE was improperly disposed of in regular trash cans or removed from the room in plastic bags. The DON confirmed that bio-hazard boxes should have been placed in the rooms for proper disposal of PPE, and it was the responsibility of medical services to ensure their presence. The facility's policies and CDC guidelines emphasize the importance of using PPE, including gloves and gowns, for high-contact resident care activities and proper disposal of PPE to contain pathogens. The lack of adherence to these protocols and the absence of necessary disposal containers highlight significant lapses in the facility's infection control practices, potentially increasing the risk of cross-contamination and the spread of communicable diseases among residents.
Deficiency in EBP Training and Implementation
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care, specifically in the context of Enhanced Barrier Precautions (EBP). This deficiency was observed when LVN A did not don a gown before administering medication to a resident with a gastrostomy tube, who was under EBP due to the presence of an indwelling device. Despite the presence of EBP signage and available personal protective equipment (PPE) at the resident's room, LVN A only wore gloves and neglected to wear a gown, which is a requirement for EBP to prevent cross-contamination and the spread of infections. Interviews with LVN A revealed that she was aware of the EBP requirements but admitted to forgetting to don a gown during the procedure. Further investigation showed that LVN A had not received any EBP training upon her hire at the facility, which was confirmed by the Director of Clinical Operations (DCO) and the Director of Nursing (DON). The lack of initial EBP training was a systemic issue, as the Business Office Manager (BOM) also confirmed that new hires were not trained or checked off on EBP, and the facility's new hire orientation and training checklists did not address EBP. Additionally, observations indicated that other rooms with EBP signage lacked PPE supplies at or near the entrances, suggesting a broader issue with the facility's implementation of EBP protocols. The facility's policy on EBP, which aligns with CDC guidelines, mandates the use of gowns and gloves for high-contact resident care activities, such as those involving feeding tubes. However, the absence of training and proper PPE setup compromised the facility's ability to adhere to these infection control measures.
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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