Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Grapevine during CMS and state inspections, most recent first.
RN coverage was not maintained for 8 consecutive hours on multiple days reviewed, including days with no RN present and days when RN shifts totaled only about 5.5 to 6.5 hours. The Staffing Coordinator, DON, Administrator, and ADON C all acknowledged the 8-hour RN requirement, but the schedule review showed the facility did not consistently meet it, despite the facility policy requiring an RN at least 8 hours every 24 hours, 7 days a week.
Medication administration errors resulted in a 17.95% error rate during a med pass. An MA gave the wrong eye drop to a resident with glaucoma and missed an ordered cough medication for another resident because it was not in the cart and the nurse was not notified. An LPN also failed to verify G-tube placement, flush between meds, and give enteral meds by gravity for a resident with a feeding tube.
Expired medications were found in the nurses' medication cart for Hall 200, including Midodrine, Ibuprofen, Nitroglycerin, and Meclizine with past use-by or expiry dates. The LVN stated he did not check the whole cart that morning, while the ADON and DON stated nurses were expected to check carts every shift and nursing management was responsible for auditing, but the DON still missed the expired meds during his last check.
Resident council meetings were held in an open dining room next to the kitchen and main entrance hall instead of a private space. During the meeting, staff walked through the area and kitchen staff stepped out to move tray carts, and there were no signs posted to indicate a council meeting was in progress. Seven residents reported their monthly meetings had been moved from the conference room because it was too cold, and the Activity Assistant and Administrator both acknowledged the meetings were being held in the dining room without privacy.
Failure to care plan resident weight loss: A resident with Alzheimer’s disease, malnutrition, dysphagia, and other diagnoses had documented weight loss and was receiving a mechanical soft diet plus House shakes, but the care plan did not address weight loss or include related interventions. Staff interviews confirmed the resident was slowly losing weight and that weight loss should have been care planned, yet the care plan remained incomplete despite the resident’s nutritional risk.
Care Plan Not Updated for Tube Feeding Water Flush Order: A resident with PEG tube feeding, dysphagia, malnutrition, and total dependence for ADLs had a physician order for Nutren 2.0 and a 70 mL/hr water flush, but the care plan was not revised to reflect the updated flush order. Staff interviews showed the LVN, ADON, DON, and MDS Coordinator each expected care plan updates when feeding orders changed, yet the resident’s plan still contained older tube feeding and water flush information. Observations also showed the feeding equipment and bags were not consistently labeled with date, time, initials, or rate.
Failure to provide nail care and grooming for a resident dependent on staff for personal hygiene. The resident, who had dementia and bipolar disorder, was observed with nails about half an inch long and black debris under and around the nail beds. His care plan directed staff to check, trim, and clean nails on shower days and as needed, but staff acknowledged the nails were dirty and needed to be trimmed, and the DON stated the assigned CNA task had not been continued after the CNA went on maternity leave.
Wound care for a resident with a left foot post-surgical wound was not provided as ordered. The dressing was observed loosely wrapped, not properly supporting the wound, and later noted to be soiled through, while the resident reported the dressing had not been changed as expected. The wound care nurse, ADON, and DON stated wound treatments were to follow the MD order and be initialed and dated after completion, but this was not consistently done.
Unlabeled tube feeding and water bags for a resident receiving enteral nutrition. A resident with a PEG tube, dysphagia, malnutrition, and total dependence for eating had ordered Nutren 2.0 and water flushes, but staff observed the feeding bags without the resident’s name, date, time, flow rate, or nurse initials. An LVN confirmed the required information was not written on the bags, and the ADON and DON stated nursing staff were responsible for labeling the formula and water bags during administration.
Failure to Disinfect Blood Pressure Cuff Between Residents: An MA checked the blood pressure of two residents back-to-back without disinfecting the BP cuff in between. The MA stated she knew the cuff should be disinfected between residents but forgot, and the DON stated staff were expected to disinfect cuffs between each resident. The facility’s standard precautions policy stated reusable equipment is not used for more than one resident until it has been appropriately cleaned and reprocessed.
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.
RN Coverage Not Maintained for Required 8 Consecutive Hours
Penalty
Summary
The facility failed to use the services of an RN for at least eight consecutive hours a day, seven days a week on 12 of 74 days reviewed during the look-back period. Record review of the RN coverage schedule showed no RN coverage on 01/12/25 and 03/08/25, and on multiple other dates the RN coverage totaled only about 5 hours and 30 minutes to 6 hours and 33 minutes, with shifts ending before eight consecutive hours were completed. The dates identified included 01/25/25, 01/26/25, 02/22/25, 02/23/25, 03/01/25, 03/02/25, 03/09/25, 03/15/25, 03/16/25, and 05/18/25. During interviews, the Staffing Coordinator stated she was responsible for completing the nursing schedules and was aware there should be an RN for 8 consecutive hours, but she was not aware of any RN coverage issues when she was hired. The DON stated he was aware of the 8 consecutive hour requirement but was not aware the facility had no 8 consecutive hours of RN coverage on the identified days. The Administrator stated she was aware of the requirement and that the facility had problems with RN coverage, though not consistently. ADON C also stated she was aware of the requirement but was not aware of an issue with RN coverage. The facility policy stated that a registered nurse provides services at least eight hours every 24 hours, seven days a week.
Medication administration errors during pass
Penalty
Summary
The facility failed to keep the medication error rate below 5 percent during a medication pass observation, with 7 errors in 39 opportunities for a 17.95% error rate involving three residents and two staff members. During the observation, MA E administered the wrong eye drop to a resident with glaucoma and severe cognitive impairment, giving latanoprost eye drops at the time when brimonidine tartrate was ordered, and she stated she did not compare the MAR with the medication on hand. MA E also failed to administer Dextromethorphan-Guaifenesin to another resident who had hypertension, heart failure, and intact cognition. The medication was ordered every 12 hours for cough, but the morning dose was not given because it was not in the cart. She stated she did not notify the nurse that the medication was missing. The charge nurse later stated he had not been notified of the missing dose. LVN B failed to follow physician orders for a resident with anemia, dysphagia, and a feeding tube when administering medications through the gastrostomy tube. He did not check tube placement before administration, did not flush the tube with water between medications, and did not administer the medications by gravity as ordered. He crushed the medications, mixed them with water, and administered them through the tube by plugging, then flushed after all medications were given. He stated he knew the ordered procedure but forgot to flush between medications and assumed the tube placement had already been checked earlier.
Expired Medications Found in Medication Cart
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with currently accepted professional principles, and expired medications were found in the nurses' medication cart for Hall 200. During observation of the cart with LVN K, surveyors found 1 packet of Midodrine 2.5 mg tablets with a use-by date of 07/23/25, 1 packet of Ibuprofen 400 mg tablets with a use-by date of 09/05/25, 1 bottle of Nitroglycerin 0.4 mg tablets with an expiry date of 07/20/25, and 1 packet of Meclizine 25 mg with a use-by date of 07/16/25. During interview, LVN K stated it was the responsibility of all nurses to check carts for expired medications every shift, but he did not check the whole cart that morning. He stated that if expired medications were administered, they would not be effective. The ADON stated her expectation was that all nurses check their carts every shift for expired medication, and that nursing management was responsible for auditing carts, but she had not been auditing them. The DON stated nurses were responsible for checking their carts every shift and nursing management was responsible for auditing afterward, but he missed the expired medications when he last checked the carts. The facility policy dated February 2021 stated that discontinued, outdated, or deteriorated medications or biologicals are to be returned to or destroyed by the dispensing pharmacy.
Resident Council Meetings Held Without Privacy
Penalty
Summary
The facility failed to provide a private meeting space for the residents' monthly council meetings for 7 of 7 confidential residents reviewed for resident council. During a confidential resident group interview on 09/17/25 at 1:45 PM, the meeting was held in an open dining room next to the facility kitchen and main entrance hall. The area had no doors that could be closed to ensure privacy, and there were no signs indicating that a resident council meeting was in progress. While the meeting was underway, staff were observed walking through the main hall and kitchen staff stepped out to retrieve tray carts. All seven residents in attendance stated that their monthly resident council meetings were being held in this open dining room area. The residents reported that the meetings had been held in the conference room, but the room was too cold. On 09/18/25, the Activity Assistant stated resident council meetings had been moved to the dining room since June 2025 because residents complained about the conference room being cold, and she was not aware the meetings needed to be held in a private setting. The Administrator stated the meetings had been held in the dining room since the Activity Director left around May or June 2025 and acknowledged awareness of the requirement for a private area, though she was not sure why it was not done.
Failure to Care Plan Resident Weight Loss
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident #16 that addressed weight loss and included measurable objectives and timeframes. Resident #16 was a male resident with diagnoses including Alzheimer's disease, malnutrition, hypothyroidism, GERD without esophagitis, dysphagia, and hypertension. His quarterly MDS dated 06/26/25 reflected that he had lost 5% or more in the last month or 10% or more in the last 6 months, and the record also showed physician orders for a regular diet, mechanical soft texture, regular liquids, and House shakes three times daily for risk of malnutrition. The care plan dated 06/06/25 did not reflect that Resident #16 was at risk for weight loss. Weight records showed 155.8 pounds on 03/04/25, 147.2 pounds on 08/05/25, 143.3 pounds on 09/03/25, and 149.0 pounds on 09/18/25. Observation and interview showed the resident in the dining room, smiling, playing cards, and later eating about 75% to 100% of meals and drinking House shakes. Staff interviews confirmed that the resident was slowly losing weight, was receiving shakes, and that weight loss should have been care planned, but the care plan did not address it. Interviews with the LVN, ADON, DON, Dietitian, and MDS Coordinator showed awareness that residents at risk for weight loss should be care planned, but they also confirmed Resident #16's care plan did not include weight loss or related interventions. The DON stated an IDT meeting had been held and interventions were in place, and the Dietitian stated the resident's weight loss was not significant and may have been related to age, diagnosis, thin body habitus, and muscle loss. The facility policy on Comprehensive Person-Centered Care Plans stated that a comprehensive care plan with measurable objectives and timetables is to be developed and implemented for each resident.
Care Plan Not Updated for Tube Feeding Water Flush Order
Penalty
Summary
The facility failed to revise and review the care plan for one resident to include the physician-ordered 70 mL water flush during tube feedings. Resident #10 was a male admitted and readmitted to the facility, with an MDS dated 08/07/25 showing a BIMS score of 00 and indicating he was unable to complete the interview. His diagnoses included paraplegia, bilateral lower leg contractures, unspecified protein-calorie malnutrition, dysphagia, and gastrostomy status. The MDS also reflected that he was dependent on staff for eating and all activities of daily living skills. Record review showed Resident #10’s care plan included tube feeding interventions and multiple revisions related to Nutren 2.0 and water flushes, but the care plan did not reflect the physician order for a 70 mL water flush during tube feedings. The physician order for feeding directed Nutren 2.0 at 44 mL/hr via PEG and FWF 70 mL/hr x 22 hrs, with a total fluid volume of 1540 mL. During observation, the resident was seen without his tube feeding machine connected while it remained in his room, and later the feeding machine was observed running with formula and water flush settings documented on the machine. The formula bag and water bag did not indicate the date, time, initials, or rate. Interviews with the LVN, ADON, DON, and MDS Coordinator showed that staff expected care plan updates when tube feeding orders or water flush rates changed, and that nursing staff, the ADON, DON, and MDS Coordinator all had roles in reviewing or updating care plans. The ADON stated she was not aware the care plan had not been updated with accurate water flushing, and the MDS Coordinator stated she was not aware the care plan was not updated with the new water flush orders. The facility’s Comprehensive Person-Centered Care Plan policy stated that a comprehensive, person-centered care plan is developed and implemented for each resident.
Failure to Provide Nail Care and Grooming
Penalty
Summary
Facility staff failed to provide grooming and nail care for Resident #67, a [AGE]-year-old male with non-Alzheimer's dementia and bipolar disorder who was dependent on staff for showering/bathing and personal hygiene. His quarterly MDS reflected intact cognition with a BIMS score of 99, and his care plan directed staff to check nail length and trim and clean nails on shower days and as needed as part of his personal hygiene care. During observation, Resident #67 was sitting in his wheelchair in his room with nails at least half an inch long and black debris underneath and around the nail beds on both hands. He stated he was unsure when staff last assisted with trimming or cleaning his nails and said he would not mind help cutting them down, though he was not bothered by them being dirty. The Staffing Coordinator acknowledged the nails were dirty and needed to be trimmed, and stated nail care was expected on shower days. The DON and ADON stated they expected residents to have hand hygiene including nail care, and the DON said no one had continued the nail-care task after the CNA assigned to it went on maternity leave.
Wound Care Not Completed Per Physician Orders
Penalty
Summary
The facility failed to ensure that Resident #52’s surgical wound care was provided in accordance with physician orders and the resident’s care plan. Resident #52 was a cognitively intact male with a history of amputation, chronic osteomyelitis, lack of coordination, and unsteadiness on feet. His care plan identified a left forefoot amputation related to gangrene and a post-surgical wound of the left distal foot, with interventions to monitor the wound daily and apply lodosorb, gauze roll, and kerlix. Physician orders directed cleansing the left distal foot wound with normal saline, applying iodosorb, covering with alginate, and wrapping with kerlix on a Monday/Wednesday/Friday schedule. On observation, Resident #52’s right foot had no dressing even though there was an order for treatment, and the resident stated staff were no longer wrapping it because it had healed. The left foot dressing was observed to be loosely wrapped around the foot and ankle, with a deep red area at the toes, gauze not in place, and the wrap not supporting the wound. The resident stated the dressing had last been changed two days earlier and had not been changed since. Later observation showed the left foot fully wrapped, but the toe area had soiled through the dressing and onto the top sheet. The wound care nurse stated he had only been in the position for two days, was responsible for wound care, and that charge nurses would complete care if he was not in the building. He stated the dressing on the left foot had last been changed the prior day and that the way it was dressed when he saw it was not acceptable. He also stated staff initials and the date must be identified on the wound after care was provided. The ADON and DON both stated wound care was expected to be completed according to physician orders and that staff were to initial and date the dressing after treatment; they also stated failure to do so placed residents at risk of infection and missed treatments.
Unlabeled tube feeding and water bags for a resident receiving enteral nutrition
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident who received enteral feeding through a PEG tube. Resident #10 was a male resident with paraplegia, bilateral lower leg contractures, protein-calorie malnutrition, dysphagia, and gastrostomy status. His MDS reflected that he was dependent on staff for eating and all activities of daily living, and his care plan identified tube feeding and water flushes as part of his nutritional support. Physician orders directed Nutren 2.0 at 44 mL/hr via PEG with water flushes, and the resident required staff assistance with tube feeding and water flushes. During observation, the resident was seen without his tube feeding machine connected while it remained in his room. Later, staff checked tube placement and residual and connected the feeding. When the feeding machine and bags were observed, the formula bag and water bag were not labeled with the date, time, initials, or rate. On a later observation, the resident’s formula and water bags again did not indicate the date, time, initials, or rate. The resident’s tube feeding was being managed by nursing staff, but the bags were not consistently marked to show when the feeding had been started. Interview with an LVN confirmed that each feeding and water bag should have the resident’s name, date, time, flow rate, and nurse initials, but he had not written that information on the bags and believed it should be done for each administration. The ADON and DON also stated that nursing staff were responsible for labeling the formula and water bags with the required clinical information and acknowledged that failing to do so placed the resident at risk of feeding errors and not following physician orders. The facility policy required enteral orders to specify the type of feeding, amount, frequency, and flush amount, and the enteral nutrition policy addressed use of enteral nutrition based on nutritional assessment.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program when MA E did not disinfect a blood pressure cuff between checking the blood pressure of two residents. Resident #52’s quarterly MDS reflected diagnoses of hypertension and a BIMS score of 14, indicating intact cognition. Resident #4’s quarterly MDS reflected diagnoses of hypertension and heart failure, with a BIMS score of 13, also indicating intact cognition. During observation on 09/17/25 at 7:58 AM, MA E checked Resident #52’s blood pressure and then went directly to Resident #4’s room and checked Resident #4’s blood pressure without disinfecting the cuff in between. In interview, MA E stated she knew she was supposed to disinfect between residents but forgot because she was nervous. The DON stated his expectation was for staff to disinfect blood pressure cuffs between each resident, and the facility’s standard precautions policy stated reusable equipment is not used for the care of more than one resident until it has been appropriately cleaned and reprocessed.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,294 citations issued within 25 miles in the last 12 months — including the 49 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Grapevine
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grapevine Medical Lodge | 1 mi | ★★★★★ | 0 | 0 |
| Bear Creek Nursing And Rehabilitation | 2.9 mi | ★★★★★ | 14 | 2 |
| The Carlyle At Stonebridge Park | 5.6 mi | ★★★★★ | 14 | 1 |
| Keller Oaks Healthcare Center | 6 mi | ★★★★★ | 2 | 0 |
| Discovery Village At Southlake | 6 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.