Avir At Grapevine
Inspection history, citations, penalties and survey trends for this long-term care facility in Grapevine, Texas.
- Location
- 1500 Autumn Drive, Grapevine, Texas 76051
- CMS Provider Number
- 675905
- Inspections on file
- 50
- Latest survey
- November 20, 2025
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Avir At Grapevine during CMS and state inspections, most recent first.
Surveyors observed that all four steamtable compartments in the facility's only kitchen contained food and debris while being used to hold various meal items for service. The Dietary Manager confirmed that cleaning of the steamtables was not performed between breakfast and lunch, despite staff training and facility policy requiring cleaning before use.
The facility did not serve the posted lunch menu, substituting cornbread and seasoned okra with sliced bread and capri vegetables due to unavailability. Two residents reported confusion as the menu did not match what was served, and the posted menu was not updated to reflect these changes, contrary to facility policy.
A resident with chronic pain and cognitive impairment was found with two lidocaine patches on her hip, as staff failed to remove the previous patch before applying a new one, despite physician orders and in-service training. Both nursing and medication aide staff did not notice the old patch, and the facility lacked a policy addressing patch removal.
A resident with multiple comorbidities was found unresponsive and not breathing, but staff did not initiate CPR due to confusion over the resident's code status, relying on a hospital DNR that was not valid in the facility. Staff failed to follow policy requiring CPR when code status is unclear, resulting in EMS initiating resuscitation upon arrival after being unable to locate valid DNR documentation.
A resident with severe cognitive impairment was pushed by another resident during an argument, resulting in a fall and pelvic fracture. Staff present were unable to prevent the incident, and initial assessments did not detect the fracture. The administrator did not immediately conduct a full investigation or report the event as abuse, despite facility policy defining resident-to-resident altercations as abuse.
Surveyors found that the Memory Care Unit was not kept free of offensive odors, and several resident rooms contained dead bugs, food particles, dirt, and debris. Housekeeping staff did not routinely move furniture and beds for cleaning unless directed to perform a deep clean, and there was no system to track completion of these deep cleans. These conditions resulted in an environment that was not sanitary or comfortable for residents.
A CNA took a resident's debit card without consent and used it to make unauthorized purchases at multiple businesses. The resident, who had intact cognition and multiple medical conditions, discovered the theft after her family noticed suspicious charges. Facility staff identified the CNA through business camera footage, and the incident was reported to the police. No other residents reported missing property.
A resident with severe cognitive impairment was pushed by another resident during an argument, resulting in a pelvic fracture and loss of mobility. Although staff witnessed the incident and provided immediate care, they did not report it as abuse to the Administrator, who was the Abuse Coordinator. As a result, no investigation or required state reporting occurred, despite facility policies mandating immediate reporting and investigation of abuse.
A resident with severe cognitive impairment was pushed by another resident, resulting in a pelvic fracture and loss of independent mobility. The incident was not immediately reported to the Administrator or the State Survey Agency by the LPN and CNA who witnessed it, and the Administrator did not conduct a full investigation or timely report the event, as required by facility policy.
A resident with severe cognitive impairment was pushed by another resident, resulting in a pelvic fracture and loss of mobility. Although staff assessed the injured resident and notified clinical leadership, the incident was not reported as abuse or investigated according to facility policy. The Administrator was not fully informed of the details and did not initiate an investigation or report the event to authorities.
Four residents did not have full visual privacy in their rooms due to missing or damaged privacy curtains. One resident's curtain could not be extended because of a damaged track, while three others had no curtains at all. Staff interviews indicated that curtain replacement and maintenance were not consistently communicated or addressed, and the responsible staff member was on leave at the time.
Surveyors found that the facility did not maintain an effective pest control program, as evidenced by live and dead cockroaches and other bugs in the rooms of several residents. Despite monthly pest control treatments and ongoing reports of cockroaches, pests continued to be present in resident areas, and the Director of Plant Operations confirmed the issue was persistent due to the building's age and entry points.
A facility failed to maintain the dignity of two residents during mealtime when an RN stood between them, alternately feeding them while standing. The residents, who had severe cognitive impairments, required assistance with eating. The RN was unaware of the importance of sitting while feeding to maintain dignity and had not attended relevant training. The facility's policy emphasizes treating residents with respect and dignity.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, on specific dates. Time Detail Reports showed that RNs worked in shifts that did not meet the required hours. Interviews revealed the absence of a policy addressing RN coverage, contributing to this deficiency.
The facility failed to maintain kitchen sanitation standards, as observed when Cook A placed food in a steamtable with contaminated water and burnt food particles. The Dietary Manager admitted to not cleaning the steamtables, and the facility lacked a policy on kitchen sanitation, leading to potential cross-contamination risks.
A facility failed to document a resident's advance directive, specifically her preference for a DNR status, in the care plan and physician's orders. The resident, who was cognitively intact, was not asked about her code status upon admission, and her preference was not reflected in the records. Interviews with staff revealed a lack of communication and follow-up, with the Social Worker forgetting to care plan the code status and the ADON and DON unaware of the oversight.
A facility failed to complete a resident's Quarterly MDS Assessment within the required three-month period. The resident, who had moderate cognitive impairment and several medical conditions, did not have an updated assessment since 04/25/2024. The MDS Coordinator mistakenly believed the resident was discharged, and the facility lacked a policy for MDS assessments, leading to the oversight.
A resident's care plan in an LTC facility failed to include her elected code status or advance directive, despite her preference for DNR. Interviews with staff revealed a lack of awareness and communication, with the Social Worker admitting to forgetting to document the code status. The facility's policies on care planning and advance directives were not followed, risking inappropriate care during emergencies.
A facility failed to complete a discharge summary for a resident with bipolar disorder and Alzheimer's disease who left with family and did not return. The Social Worker did not complete the summary, and the facility lacked a policy or monitoring system to ensure discharge documentation. The DON assumed a nurse would document the discharge, but this was not done.
The facility failed to manage pharmaceutical services properly, as expired influenza vaccines and over-the-counter medications were found in storage areas. Staff interviews revealed inconsistent checks and training on removing expired medications. The LVN, ADON, and DON acknowledged lapses in monitoring, and the Central Supply Staff missed identifying expired items. This failure risked residents receiving ineffective medications.
A facility failed to maintain an effective infection prevention and control program when an LVN did not adhere to enhanced barrier precautions for a resident with a gastrostomy tube. Despite signs indicating the need for gown and gloves, the LVN entered the resident's room twice without donning a gown. Interviews revealed the LVN was aware of the requirement but forgot, and training records showed she missed relevant training sessions.
The facility failed to provide consistent wound care and follow physician orders for three residents, leading to potential risks of wound deterioration and infection. A resident with a skin tear did not receive wound care as ordered, and there was no documentation of an antibiotic order. Another resident with a risk for skin damage had inconsistent wound care, with a CNA failing to notify the nurse about a missing dressing. A third resident with a diabetic foot ulcer also experienced lapses in wound care documentation, with a new LVN unaware of the resident's wounds.
A resident with severe cognitive impairments and multiple medical conditions experienced a change in condition when she displayed signs of pain in her left leg. Despite this, the LVN on duty did not notify the physician until the next morning, resulting in a delay in medical intervention. An x-ray later confirmed a left hip fracture. The facility's policy required prompt physician notification, which was not followed, placing the resident at risk for delayed intervention.
A resident with dementia and cognitive deficits experienced a delay in treatment after showing signs of pain in her left leg. The LVN on duty did not notify the physician until the next morning, leading to a delay in diagnosing a hip fracture. The facility failed to follow its policy on changes in resident condition, resulting in an Immediate Jeopardy situation.
Unclean Steamtable Compartments Used During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in its only kitchen. Observations on two separate occasions revealed that all four steamtable compartments contained food and debris floating in them while food was being held for meal service. The specific foods present included sausage jambalaya, capri vegetables, fortified mashed potatoes, mechanical soft sausage jambalaya, brown gravy, pureed vegetables, pureed bread, Salisbury steaks, and pureed jambalaya. These conditions were directly observed prior to and during meal service. Interviews with the Dietary Manager (DM) confirmed awareness of the food and debris in the steamtable compartments before lunch service, with the DM stating that cleaning typically occurred at the end of each shift, not between breakfast and lunch. The DM acknowledged that the expectation was for the steamtable compartments to be cleaned before food was placed in them and that all staff had been trained accordingly. Review of the facility's policy indicated a requirement for a routine cleaning schedule for all cooking equipment and surfaces.
Failure to Serve Posted Menu and Update Menu for Residents
Penalty
Summary
The facility failed to ensure that the posted lunch menu was followed for one reviewed meal. On the observed date, the posted and planned menu listed sausage jambalaya, seasoned okra, cornbread, and a brownie. However, during meal service, residents were instead served sausage jambalaya, sliced bread, and capri vegetables (green beans, carrots, squash, and zucchini). The cornbread was not served because the delivered box appeared to be open and was deemed unusable, and there was no replacement available in time. The seasoned okra was also not served as it had been used earlier in the week, leaving insufficient quantity for the lunch meal. Interviews with two residents revealed that they were unsure of what would be served, as the menu often did not match the actual meal. The Dietary Manager (DM) confirmed the substitutions and acknowledged that the menu should match what is served, and that staff had been trained to ensure this. The facility's policy requires that menus be served as written unless changes are made for preference, unavailability, or special meals, and that menus are posted in relevant areas. In this instance, the posted menu was not updated to reflect the substitutions, leading to confusion among residents.
Failure to Follow Physician Orders for Lidocaine Patch Administration
Penalty
Summary
The facility failed to ensure that medication aides (MAs) and nurses followed physician orders for the administration and removal of a lidocaine patch for a resident with chronic pain and moderately impaired cognition. The resident, who had a diagnosis of age-related osteoporosis and was on a scheduled pain medication regimen, was observed to have two lidocaine patches on her right hip, one dated two days prior and another from the current day. Record review showed that staff had signed off on the removal and application of patches, but the old patch was not removed before the new one was applied, contrary to the physician's order. Interviews with staff revealed that both the MA and RN involved were aware of the requirement to remove the old patch before applying a new one, and both had attended in-service training on medication administration. However, neither noticed the previous patch during their respective shifts. The facility's policy on pharmacy services did not address the specific procedure for patch administration and removal, and the DON confirmed there was no policy in place for patch removal. The failure to remove the old patch before applying a new one was not identified until it was observed by surveyors.
Failure to Initiate CPR Due to Code Status Confusion
Penalty
Summary
A deficiency occurred when facility personnel failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident, a male with a history of stroke, heart failure, hypertension, diabetes, aphasia, substance abuse, and cerebral ischemia, was found unresponsive on the floor with a reddish-purple face, weak pulse, and no obvious respirations. The resident's care plan indicated full code status, requiring initiation of CPR if the resident was without a heartbeat or not breathing. However, LVN A did not initiate CPR, instead placing the resident on oxygen and attempting to arouse him while checking the code status in the electronic chart. Staff believed the resident was a DNR based on information in the electronic chart and a hospital DNR form, but there was no valid Out of Hospital DNR or state-recognized advance directive on file. The facility's policy required CPR to be initiated if the code status was unclear, but staff did not apply the AED or begin resuscitation efforts. When EMS arrived, they found the resident pulseless and apneic, and began CPR after being unable to locate valid DNR documentation. The confusion over the resident's code status and the lack of appropriate paperwork led to a delay in life-saving interventions. Interviews with facility staff, including the DON, ADON, and Administrator, confirmed that CPR should have been initiated in the absence of a valid Out of Hospital DNR. The EMS Captain and the facility's physician also stated that, according to state requirements, the resident was a full code and resuscitation should have been performed. The incident revealed that staff were not adequately trained to distinguish between hospital and Out of Hospital DNRs, and did not follow facility policy regarding initiation of CPR when code status was unclear.
Removal Plan
- Complete a code status audit of all residents residing in the facility to ensure appropriate documentation in the chart listed as advanced directives or out of hospital DNRs.
- Complete a chart audit to double-check that no code statuses were missed.
- Start education on Code Status and CPR, with education ongoing.
- Educate the director of nursing and administrator on Code Status, Out of Hospital DNRs, when to initiate CPR, and when to apply the AED.
- Initiate new training for all nurses on identifying the appropriate code status including out of hospital DNR vs. Hospital DNR, when to initiate CPR, and how to use the AED correctly.
- Nursing staff checks all residents for orders and appropriate paperwork on code status upon admission/readmission to the facility.
- Nurse management team checks code status in the morning meeting, and the social worker in weekly audits.
- Continue to audit code statuses weekly.
- Discuss all audit results in QAPI.
- Notify the Medical Director of the deficiency (F678).
- Complete education for all staff, and remove any staff unable to be educated from the schedule until training is provided.
Failure to Protect Resident from Abuse Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was free from abuse, specifically when one resident pushed another, resulting in a fall and a pelvic fracture. The incident took place during a period when staff were present in the dining area, and both residents involved had severe cognitive impairment and a history of delusions. The resident who was pushed had previously been independently ambulatory and had recently completed physical therapy. After the incident, she experienced significant pain, was unable to ambulate as before, and required hospitalization, where imaging confirmed a pelvic fracture. Staff interviews revealed that the altercation was preceded by an argument between the two residents, with one becoming agitated and physically pushing the other. Although staff were nearby and attempted to intervene, they were unable to prevent the push. Initial assessments and x-rays did not reveal a fracture, but persistent pain led to further evaluation and the eventual diagnosis. Documentation and interviews confirmed that the staff recognized the event as a resident-to-resident altercation, which is considered abuse under facility policy. The facility's administration did not immediately conduct a thorough investigation into the incident. The administrator relied on secondhand accounts and did not interview all witnesses, including a CNA who directly observed the event. The administrator was initially unaware of the full details and did not report the incident as abuse to the appropriate authorities. The lack of immediate and comprehensive investigation and reporting contributed to the deficiency, as the facility did not ensure the resident's right to be free from abuse was upheld.
Removal Plan
- Notify the medical director of the Immediate Jeopardy (IJ).
- Care plan new behavior of aggressiveness towards other residents for Resident #7, with interventions of a psych consult and redirection when agitated.
- Provide education on de-escalation techniques to all staff.
- Call a psychiatric consult by the medical director for Resident #7 to review medications and behaviors.
- Educate the Administrator and Director of Nursing on abuse and neglect, resident-to-resident altercations, and de-escalation of resident behaviors.
- Train staff on abuse and neglect as well as de-escalation of resident behaviors by the administrator and DON and through facility training software.
- Continue education for new staff as they are hired.
- Start new education on abuse and neglect, resident-to-resident altercations, and de-escalation of resident behaviors for all staff prior to the start of their next shift.
- Hold an Ad Hoc QAPI meeting to inform all the management team.
- Review resident behaviors daily in morning clinical meetings while viewing the 24-hour report/EMR and then weekly in IDT; monitor this monthly in QAPI.
- Complete staff education; remove any staff member unable to be educated from the schedule until training has been provided.
Failure to Maintain Sanitary and Odor-Free Environment in Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, as evidenced by persistent urine odors throughout the Memory Care Unit and unsanitary conditions in the rooms of five residents. Observations revealed dead bugs, food particles, dirt, and debris at the head of beds and between beds and walls in these rooms. Despite the presence of two housekeepers assigned daily to the unit, these issues were not addressed during routine cleaning. Interviews with housekeeping staff indicated that while high-touch surfaces, floors, trash, and bathrooms were cleaned regularly, furniture and beds were not routinely moved for cleaning unless a deep clean was specifically requested. The Housekeeping Supervisor confirmed that each housekeeper was expected to perform a deep clean in one room per day, which involved moving all furniture and beds, but there was no tracking system in place to ensure this was completed. The facility's Resident Rights policy emphasized the importance of a dignified existence, including a clean environment.
Misappropriation of Resident's Debit Card by CNA
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) took a resident's debit card without consent and used it to make purchases at three different businesses. The resident, a female with diagnoses including diabetes, multiple sclerosis, and anxiety disorder, had an intact cognitive status as indicated by a BIMS score of 14. The resident typically kept her debit card in her purse, stored in the top drawer of her nightstand, and discovered it missing after her family noticed suspicious charges and contacted her. Additionally, $20 was reported missing from her purse. The facility's investigation revealed that the CNA, who had only been employed for about two weeks, was identified through business camera footage as the individual who used the stolen debit card. The administrator and other staff confirmed the CNA's identity after reviewing the footage provided by one of the businesses. The CNA was asked to provide a statement but refused and denied the allegations, despite being confronted with the evidence. The incident was reported to the police, and the resident's family took steps to freeze the debit card and press charges. Interviews with other alert and oriented residents and staff indicated that there were no additional concerns or reports of misappropriation or theft. The facility's policy strictly prohibits exploitation, theft, and misappropriation of resident property, defining misappropriation as the wrongful use of a resident's belongings or money without consent. The incident was limited to the single resident, and no other missing property was reported among other residents.
Failure to Implement Abuse Prevention and Reporting Policies After Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse and misappropriation, specifically in the case of a resident-to-resident altercation that resulted in significant injury. On the date of the incident, one resident with severe cognitive impairment and a history of delusions was pushed by another resident, also with severe cognitive impairment, during an argument in the dining area. The push caused the first resident to fall and sustain a pelvic fracture, which led to a significant decline in mobility and increased pain. Documentation and interviews confirmed that the incident was witnessed by staff, and the injured resident was assessed, given pain medication, and later sent to the hospital after continued complaints of pain, where the fracture was diagnosed. Despite the facility's policies requiring immediate reporting of suspected abuse, neglect, or exploitation to the Administrator (the designated Abuse Coordinator), the staff involved did not report the incident as abuse at the time. Both the LVN and CNA present during the incident acknowledged in interviews that they were aware of the reporting requirements but did not immediately notify the Administrator, either due to uncertainty about whether the incident constituted abuse or lack of experience. The Administrator was not made aware of the full details of the incident, including the intentional nature of the push, and therefore did not initiate an investigation or report the event to the appropriate state authorities as required by policy. The lack of immediate reporting and investigation meant that the incident was not properly classified or addressed as abuse, and the required notifications to the state health agency were not made. The Administrator only became aware of the full circumstances after the fact and acknowledged that, had she known the details, she would have conducted an investigation and reported the incident. The facility's failure to follow its own policies and procedures in this case resulted in a deficiency related to the prevention, identification, and reporting of abuse.
Failure to Timely Report and Investigate Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were immediately reported, as required, to the Administrator and the State Survey Agency within two hours of the incident. Specifically, an incident occurred in which one resident pushed another, resulting in a fall and a pelvic fracture. Both the LVN and CNA who witnessed the event did not immediately report the incident to the Administrator, who also served as the Abuse Coordinator. The Administrator was not made aware of the full details of the incident in a timely manner and did not report the event to the appropriate authorities within the required timeframe. The resident who sustained the injury was an elderly female with severe cognitive impairment and a history of delusions, but no prior behavioral issues. She was previously independently ambulatory but, following the incident, required the use of a wheelchair due to the pelvic fracture. Documentation and interviews confirmed that the resident was assessed after the fall, pain medication was administered, and an x-ray was ordered. However, the initial x-ray did not reveal a fracture, and the resident was later sent to the hospital due to ongoing pain, where the fracture was diagnosed. The resident's responsible party was not initially aware of the circumstances of the fall and reported a significant decline in the resident's mobility following the incident. Interviews with staff revealed a lack of understanding regarding the definition of abuse, particularly in cases involving residents with cognitive impairment. The LVN and CNA both acknowledged knowing the reporting protocol but did not recognize the incident as abuse at the time, resulting in a delay in reporting. The Administrator did not conduct a thorough investigation or report the incident to the State Survey Agency, as she was not fully informed of the details. Facility policy required immediate reporting and investigation of all suspected abuse, including resident-to-resident incidents, but these procedures were not followed in this case.
Failure to Investigate and Report Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to investigate and report an allegation of abuse after an incident in which a resident with severe cognitive impairment was pushed by another resident, resulting in a pelvic fracture. The incident occurred in a common area while staff were present, and was witnessed by both a CNA and an LVN. The LVN assessed the injured resident, administered pain medication, notified the DON, MD, and responsible party, and ordered a STAT x-ray. Despite these actions, the incident was not reported as abuse to the Administrator, who was the designated abuse coordinator, nor was a formal investigation initiated at that time. The resident who sustained the injury had a history of severe cognitive impairment, delusions, and depression, and was previously independently ambulatory. Following the incident, she experienced significant pain, was unable to ambulate, and was ultimately sent to the hospital, where a pelvic fracture was diagnosed. The resident's responsible party confirmed that the resident was pushed by another resident and that her mobility was significantly reduced as a result of the injury. The resident who pushed her also had severe cognitive impairment and a history of delusions but no prior physically aggressive behaviors toward other residents. Interviews with staff revealed that both the LVN and CNA present at the time of the incident did not immediately recognize the event as abuse, partly due to the cognitive status of the aggressor. The DON was notified of the incident but did not ensure that it was reported as abuse or that an investigation was conducted. The Administrator did not conduct an investigation or report the incident to the appropriate authorities, as required by facility policy, because she was not made aware of the full details. The facility's policy required immediate reporting and thorough investigation of all abuse allegations, but this was not followed in this case.
Failure to Provide Visual Privacy Due to Missing or Damaged Curtains
Penalty
Summary
The facility failed to ensure full visual privacy for four residents in the Memory Care Unit, as observed during a survey. One resident's room had a privacy curtain that could not be fully extended around the bed due to a damaged track, while three other residents' rooms lacked privacy curtains entirely. At the time of observation, the residents were not present in their rooms and were being kept in the dining area for observation, and were unable to be interviewed. Interviews with the Housekeeping Supervisor revealed that the Floor Tech, responsible for changing privacy curtains, was on leave, and that maintenance would address damaged tracks if notified. The Director of Plant Operations stated that curtain issues were typically communicated verbally and was unaware of any current problems. Review of facility policy confirmed residents' rights to privacy and dignity.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live and dead cockroaches and other bugs in the rooms of five residents. Observations revealed two live cockroaches in one resident's bathroom and dead cockroaches and other bugs at the head of beds between the bed and the wall in four other residents' rooms. The pest control log indicated that cockroaches had been reported every month since May 2024, with monthly treatments conducted by the pest control company, including the most recent treatment a week prior to the observation. During an interview, the Director of Plant Operations acknowledged that bugs in the facility were an ongoing problem, attributing it to the age of the building and multiple entry points for pests. He stated that the pest control company treated the entire facility and sealed any openings found during their visits. However, he was unaware of a specific pest control policy beyond the requirement to have a pest control program. The facility's Resident Rights policy emphasized the right to a dignified existence, which includes a pest-free environment.
Failure to Maintain Resident Dignity During Mealtime
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents during mealtime. RN D was observed standing between two residents, alternately feeding them while standing, which did not promote a dignified environment. This action was contrary to the facility's policy and expectations, which require staff to sit at the same level as residents when assisting them with eating. The residents involved had severe cognitive impairments and required assistance with eating due to conditions such as Alzheimer's disease and dysphasia. Interviews with RN D revealed a lack of awareness regarding the importance of sitting while feeding residents to maintain their dignity. RN D admitted to not having received training on dignity, which was confirmed by the Director of Nursing (DON) who noted that RN D's name was absent from the in-service training record on dignity. The facility's policy on resident rights emphasizes the importance of treating residents with respect and dignity, which was not adhered to in this instance.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least eight consecutive hours a day, seven days a week, during specific dates within the review period from May 25, 2024, to August 25, 2024. This deficiency was identified for five specific days: May 25, May 26, June 1, June 8, and June 15, 2024. On these days, the facility's Time Detail Reports showed that the RNs worked in shifts that did not meet the required eight consecutive hours. For instance, on May 25, 2024, RN C worked a total of 5.5 hours, RN E worked 5.5 hours, and RN D worked 5.5 hours, none of which met the eight-hour requirement. Interviews conducted on August 29, 2024, with the Director of Nursing (DON) and the Administrator revealed that the facility did not have a policy addressing RN coverage. The DON acknowledged that RNs usually doubled up on weekend shifts and expressed an expectation for RNs to work eight consecutive hours on weekends for coverage reasons. The Administrator confirmed the absence of a policy regarding RN coverage, which contributed to the failure to meet the regulatory requirement of having an RN on duty for the specified hours.
Failure to Maintain Kitchen Sanitation Standards
Penalty
Summary
The facility failed to maintain proper kitchen sanitation standards, specifically in the storage, preparation, distribution, and serving of food. During an observation, it was noted that Cook A placed food containers into a steamtable that contained contaminated water with burnt food particles. The steamtable compartments were not cleaned, and the water was tinted with various colors, indicating contamination. This was observed in multiple compartments where different food items were placed, including hamburger steaks, pinto beans, cabbage, and pork loin. Interviews revealed that Cook A was aware of the dirty steamtable compartments but proceeded to use them due to being rushed. The Dietary Manager admitted to forgetting to clean the steamtables the previous night and acknowledged that the compartments should be cleaned after each meal to prevent cross-contamination. The facility lacked a specific policy addressing kitchen sanitation, which contributed to the oversight. The Federal Food Code 2022 was referenced, highlighting the requirement for cleaning equipment and utensils to prevent food contamination.
Failure to Document Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was honored, specifically for a resident who was cognitively intact and had expressed a preference for a Do Not Resuscitate (DNR) status. Upon review, it was found that the resident's code status was not accurately documented in the facility's records, and there was no care plan addressing the resident's advance directives. The resident had not been asked about her code status upon admission, and her preference for DNR was not reflected in the physician's orders or the care plan. Interviews with facility staff, including the LVN, Social Worker, ADON, and DON, revealed a lack of communication and follow-up regarding the resident's code status. The admission nurse was responsible for obtaining and documenting the code status, while the Social Worker was expected to follow up and include it in the care plan. However, the Social Worker admitted to forgetting to care plan the resident's code status, and the ADON and DON were unaware of the oversight until it was brought to their attention. This deficiency placed the resident at risk of not having her end-of-life wishes honored.
Failure to Complete Quarterly MDS Assessment
Penalty
Summary
The facility failed to update a resident's assessment using the quarterly review instrument as required by state and CMS guidelines. Specifically, the facility did not complete the Quarterly MDS Assessment for a resident within three months of their most recent comprehensive assessment. This oversight was identified during a review of the resident's records, which showed that the last MDS Assessment was submitted on 04/25/2024, and no subsequent assessment was completed by the due date of 07/25/2024. The resident in question was an elderly female with moderate cognitive impairment and several medical conditions, including diabetes, hypothyroidism, and dysphagia. Interviews with facility staff revealed a lack of awareness and oversight regarding the missed assessment. The MDS Coordinator, responsible for completing the assessments, mistakenly believed the resident had been discharged and did not realize the assessment was due. The Director of Nursing confirmed the assessment was missed but was unsure of the reason. Additionally, the facility lacked a policy addressing MDS assessments, contributing to the oversight. The MDS Coordinator relied on a consultant to alert her to overdue assessments, which did not occur in this instance.
Failure to Document Resident's Code Status in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically neglecting to address the resident's elected code status or advance directive. The resident, a female with intact cognition and a BIMS score of 15, was admitted with diagnoses including multiple sclerosis, anxiety disorder, and hyperkalemia. Despite these conditions, the care plan did not include her code status, and there was no active physician's order for it. The resident expressed a preference for DNR, but this was not documented or reflected in her care plan. Interviews with facility staff, including an LVN, the Social Worker, the ADON, and the DON, revealed a lack of awareness and communication regarding the resident's code status. The Social Worker admitted to forgetting to include the code status in the care plan, and the ADON and DON were not informed of the oversight until it was brought to their attention. The facility's policies on care planning and advance directives were not followed, leading to the omission of the resident's code status in her care plan, which could result in inappropriate care during an emergency.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a final summary of a resident's status at the time of discharge was available for release to authorized persons and agencies, with the consent of the resident or resident's representative. This deficiency was identified for one resident who was reviewed for discharge summary. The resident, a male with diagnoses of bipolar disorder and Alzheimer's disease, was taken out of the facility on pass with his family and did not return. The facility did not complete a discharge summary after the resident left, and there was no documentation concerning the resident's discharge in the progress notes or assessments. Interviews with the Social Worker and the Director of Nursing (DON) revealed that the discharge was not planned, and the facility did not have a policy or a uniform discharge assessment (UDA) for discharge summaries. The Social Worker admitted to not completing the discharge summary and was unsure why it was not done. The DON assumed that a nurse would at least add a progress note related to the discharge, but this was not done. The Administrator confirmed the absence of a policy addressing discharge summaries, and there was no monitoring to ensure that discharge summaries or notes were being completed.
Expired Medications and Vaccines Not Removed
Penalty
Summary
The facility failed to ensure the proper management of pharmaceutical services, specifically in the storage and removal of expired medications and vaccines. During an observation, expired influenza vaccines were found in the medication room refrigerator, and expired over-the-counter medications were discovered in the Central Supply medication cabinet. The Licensed Vocational Nurse (LVN) acknowledged that it was the responsibility of all nurses to check and remove expired medications, but this was not consistently done. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) also admitted to lapses in monitoring and training regarding the removal of expired medications. Interviews with the staff revealed a lack of consistent checks and training on the removal of expired medications. The Central Supply Staff, responsible for ensuring medications were not expired, missed identifying expired items during her checks. The DON and ADON were responsible for overseeing the process but could not recall specific dates of their last checks. The facility's policy required expired medications to be removed and destroyed, but this was not adhered to, placing residents at risk of receiving ineffective medications.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN L, who did not adhere to enhanced barrier precautions while providing care to a resident. The resident, a male with severe cognitive impairment and a gastrostomy tube, was on enhanced barrier precautions due to his medical condition. Despite the presence of a sign on the resident's door indicating the need for gown and gloves, LVN L entered the room on two separate occasions to administer a bolus feeding and medications without donning a gown, although she performed hand hygiene and wore gloves. Interviews with LVN L and the Director of Nursing (DON) revealed that LVN L was aware of the requirement to wear PPE but forgot to do so. The DON confirmed that staff were expected to wear PPE for residents on enhanced barrier precautions, which was indicated by signs on the residents' doors. A review of the facility's training records showed that LVN L did not attend the training sessions on infection control and enhanced barrier precautions. The facility's policy on enhanced barrier precautions outlined the necessity of wearing gowns and gloves during high-contact care activities, such as device care involving feeding tubes.
Failure to Provide Consistent Wound Care
Penalty
Summary
The facility failed to provide appropriate wound care treatment and follow physician orders for three residents, leading to potential risks of wound deterioration and infection. Resident #1, a cognitively intact female with a skin tear on her left elbow, did not receive wound care as per physician orders from 07/15/24 to 07/23/24. Additionally, there was no documentation of an antibiotic order for Bactrim tablets. The lack of communication and documentation among staff members, including the Treatment Nurse, Charge Nurse, and Medical Records Coordinator, contributed to the oversight in wound care management. Resident #2, a female with moderate cognitive impairment and a risk for moisture-associated skin damage, did not receive consistent wound care as ordered. The August 2024 TAR showed missing documentation for several dates, and during an observation, the resident's wound was found uncovered. The CNA assigned to Resident #2 did not notify the nurse about the missing dressing, assuming it was intentional. The Charge Nurse was unaware of the situation, indicating a breakdown in communication and adherence to wound care protocols. Resident #3, a female with moderate cognitive impairment and a diabetic foot ulcer, also experienced lapses in wound care documentation. The August 2024 TAR lacked entries for multiple dates, and during an observation, the resident's wound was uncovered. LVN E, who was new to the hall, was unaware of the resident's wounds, highlighting a lack of proper handover and training. The facility's failure to ensure consistent wound care and documentation for these residents reflects a systemic issue in following professional standards and physician orders.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to immediately consult with a resident's physician when there was a change in the resident's condition, specifically when the resident displayed signs and symptoms of pain in her left leg. The resident, who had a history of end-stage renal disease, arthritis, hip fracture, Alzheimer's disease, and other conditions, was non-verbal and had severe memory and decision-making impairments. On the evening of the incident, a CNA noticed the resident yelling out in pain during peri care, which was unusual for her. Despite this, the LVN on duty did not notify the physician until the following morning. The LVN assessed the resident's left leg but did not observe any visible abnormalities such as bruises or swelling. The LVN reported the resident's discomfort to the oncoming nurse but did not contact the physician, as she believed the resident was not in pain and had slept comfortably throughout the night. However, when the RN arrived the next morning, she assessed the resident and noted that the resident expressed pain through facial grimacing when her left leg was moved. The RN then contacted the physician, who ordered an x-ray that confirmed a left hip fracture. The delay in notifying the physician resulted in a delay in the resident receiving appropriate medical intervention. The facility's policy required prompt notification of the physician in the event of a change in a resident's condition, which was not adhered to in this case. This failure placed the resident at risk for delayed physician intervention and was identified as an Immediate Jeopardy situation, although it was later removed after corrective actions were initiated.
Removal Plan
- The following in-services were initiated by COMPLIANCE NURSE DON: Any nursing staff member not present or in-service will not be allowed to assume their duties until in-serviced and expectations acknowledged.
- Licensed Nurses: Promptly and accurately assessing a resident when change of condition has been identified / reported.
- Assessing a resident's change in condition using SBAR, so that all necessary information is communicated to the physician or Nurse Practitioner.
- Reporting changes of condition to the physician or nurse practitioner based on Change of Condition Form.
- Non-licensed nursing staff: Reporting changes in a resident's condition to a nurse immediately.
- If the nurse does not assess timely, the DON/Designee must be notified.
- The Administrator, DON and ADON were in-serviced regarding ensuring all staff applicable to the in-service receive the training, to use online resources and / or in person training, to ensure all trained staff have attested that they have received the training by a signed acknowledgement.
- An ADHOC QAPI meeting was conducted regarding this plan and monitoring.
- The Medical Director was notified of this plan and monitoring.
- The DON/Designee will monitor all kiosk (dashboard) alerts a minimum of 4 times per week to ensure any potential change of condition has been addressed timely.
- The DON/Designee will randomly ask nurses per week what they would do if a resident had a change of condition, or it was reported to them that a resident had a change of condition.
- The QAPI committee will review the findings and make any needed changes.
Failure to Provide Timely Treatment for Resident's Change in Condition
Penalty
Summary
The facility failed to provide timely treatment and care to a resident who experienced a change in condition. The resident, a female with multiple diagnoses including dementia and cognitive communication deficit, showed signs of pain when her left leg was touched. Despite these signs, the Licensed Vocational Nurse (LVN) on duty did not notify the physician until the following morning, resulting in a delay in treatment. An x-ray later confirmed a left hip fracture, and the resident was sent to the hospital for evaluation and treatment. The resident's care plan, which included monitoring for physical and nonverbal indicators of discomfort, was not adequately followed. The LVN noted the resident's discomfort but did not perceive it as pain and failed to contact the doctor. The resident's condition was not reassessed until the next shift, when the Registered Nurse (RN) on duty identified the issue and took appropriate action by notifying the physician and ordering an x-ray. The facility's policy on changes in resident status or condition was not adhered to, as the nurse did not promptly notify the physician of the resident's change in condition. This oversight led to an Immediate Jeopardy situation, indicating a serious risk to the resident's health and safety. The facility's failure to act in accordance with professional standards of practice and the resident's care plan resulted in a significant delay in necessary medical intervention.
Removal Plan
- In-service training for nursing staff on assessing a resident when a change of condition is identified or reported.
- Education for licensed nurses on assessing a resident's change in condition using SBAR to ensure all necessary information is communicated to the physician or Nurse Practitioner.
- Training for licensed nurses on reporting changes of condition to the physician or nurse practitioner based on the Change of Condition Form.
- Education for non-licensed nursing staff on reporting changes in a resident's condition to a nurse.
- Instruction for non-licensed nursing staff to notify the DON/Designee if the nurse does not assess.
- In-service training for the Administrator, DON, and ADON to ensure all staff applicable to the in-service receive the training, using online resources and/or in-person training, and ensuring all trained staff have attested to receiving the training by a signed acknowledgment.
- Monitoring by the DON/Designee of all kiosk alerts to ensure any potential change of condition has been addressed.
- Random questioning by the DON/Designee of nurses on what they would do if a resident had a change of condition, or it was reported to them that a resident had a change of condition.
- Review by the QAPI committee of the findings and making any needed changes.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
