Avir At Jefferson
Inspection history, citations, penalties and survey trends for this long-term care facility in Jefferson, Texas.
- Location
- 1307 Martin Luther King Dr, Jefferson, Texas 75657
- CMS Provider Number
- 675241
- Inspections on file
- 32
- Latest survey
- February 22, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Avir At Jefferson during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dysphagia, and multiple comorbidities had a care plan and MD orders requiring monitoring and intervention for poor intake, including use of health shakes when less than half of a meal was consumed. Over an extended period, documentation showed repeated meal refusals and 0–25% intake, yet there was no record that health shakes were provided or that the MD or resident representative were notified. On one occasion, the resident became combative, refused medications, would not allow vital signs to be taken, and would not swallow, but this was not documented as having been reported to the nurse or MD. The MD and resident representatives reported they were not informed of the poor intake or refusals, while facility staff and leadership acknowledged that such changes should have been reported per the facility’s change-in-condition policy, resulting in a deficiency for failure to promptly notify the physician and representative of significant changes in condition.
Surveyors found that the facility did not complete or update comprehensive care plans for two residents and failed to implement a prescribed nutrition order. One resident with multiple CVA-related deficits, pain, incontinence, fall and pressure-ulcer risk, and several high-risk medications had a care plan that only addressed skin integrity and a prior fall, omitting allergies, code status, cognition, incontinence, ADLs, pain, diet, disease processes, and medication-related risks. Another resident with severe cognitive impairment and extensive neuro and medical conditions had an ADL care plan that still stated he could feed himself, despite MDS documentation that he was totally dependent for eating, and staff did not document providing ordered health shakes when he consumed less than 50% of meals, even though intake records repeatedly showed poor or refused intake.
The facility failed to maintain kitchen sanitation and food safety standards, with the Dietary Manager not wearing proper facial coverings and the kitchen having cleanliness issues like food particles on the dishwasher and grease buildup on the stove. Despite policies requiring a cleaning schedule and hair restraints, these were not followed or documented, posing a risk of food contamination.
The facility failed to provide adequate respiratory care for three residents, leading to potential risks of respiratory infections. A resident's oxygen tubing was not changed as ordered, another resident's humidification bottle was found dry, and tracheostomy care for a third resident was not performed using aseptic techniques. These deficiencies were confirmed through observations and staff interviews.
The facility failed to ensure call buttons were within reach for three residents, compromising their ability to request assistance. A resident with pneumonia, dementia, and hypertension had her call button on the floor, out of reach. Another resident with heart conditions had her call button far under her bed, and a third resident with muscular degeneration had her call button behind a dresser. Staff interviews confirmed the responsibility to ensure call buttons are accessible, as per facility policy.
The facility failed to complete and provide baseline care plans within 48 hours of admission for three residents, including an 85-year-old male with multiple health issues, a male with sepsis and heart disease, and a male with heart disease and COPD. The care plans were either outdated, undated, or lacked necessary signatures, and responsible parties were not provided with copies. Staff interviews revealed confusion about responsibilities, contributing to these deficiencies.
The facility failed to update care plans for two residents, one with a reopened Stage IV pressure ulcer and another with a history of falls. The MDS Coordinator and nursing staff did not ensure care plans reflected current conditions, leading to deficiencies in addressing medical and safety needs. Interviews revealed a lack of communication and responsibility among staff, contributing to the oversight.
Two residents at high risk for pressure ulcers were found to have incorrect settings on their pressure-relieving mattresses, with one set at 350 pounds and the other at 50 pounds, despite their actual weights being 203 and 230 pounds. Nursing staff, including RNs and LVNs, were unclear about who was responsible for monitoring these settings, leading to a failure in adhering to the facility's policy on pressure injury prevention. This oversight placed the residents at risk for developing or worsening pressure ulcers.
A resident with an indwelling catheter and a history of urinary tract infections exhibited symptoms such as red-tinged urine and increased confusion. Despite these signs, the nursing staff failed to document or report the red-tinged urine to the physician, delaying necessary medical intervention. This oversight led to the resident being sent to the emergency room with symptoms of septic shock.
A resident with moderately impaired cognition was left with a dose of Gabapentin at their bedside, contrary to the facility's policy that requires medications to be administered safely and timely. Interviews with staff confirmed that medications should not be left unattended, as it poses a risk of drug diversion and incorrect dosages.
A resident with dementia was administered Quetiapine, an antipsychotic, without an appropriate diagnosis or indication of use. Facility staff expressed confusion over the proper use of antipsychotics, with some stating that dementia is not a suitable diagnosis for such medication. The facility's medication reconciliation process failed to ensure a justified use of Quetiapine, despite pharmacy recommendations for alternative therapy.
A resident in the facility experienced significant medication errors due to improper scheduling of Levothyroxine and Pantoprazole. Despite the need for specific timing to ensure therapeutic effects, these medications were administered at suboptimal times, as confirmed by staff interviews and record reviews. The facility lacked a process to review medication administration times, leading to ineffective treatment and potential adverse reactions.
A facility failed to report a drug diversion incident involving a resident's hydromorphone medication to the State Survey Agency. The medication was tampered with, and the ADM did not report it, believing the hospice company would handle it. The resident, who had Parkinson's, COPD, and diabetes, was not harmed as he had additional medication available. The facility's policy required reporting such incidents within 24 hours, which was not followed.
A resident with Alzheimer's and osteoporosis was improperly handled by staff, who failed to follow facility policy for safe repositioning. Video evidence showed staff pulling the resident by the wrist and arms, contrary to the policy requiring two staff members and a draw sheet. Staff cited the resident's combative behavior and personal limitations as reasons for not following proper procedures.
A resident with a history of diabetes and muscle wasting experienced pain during wound care treatment, but the facility failed to provide appropriate pain management. Despite the resident's complaints and visible signs of pain, the treatment nurse did not offer pain medication or hold the procedure, and the resident's physician orders did not include PRN pain medications.
The facility failed to maintain an infection prevention program, leading to potential infection risks for four residents. The Treatment Nurse did not wash her hands or change gloves appropriately during wound care procedures, as observed and confirmed through interviews and record reviews. The DON and ADON acknowledged the nurse's incomplete training and misunderstanding of hand hygiene protocols.
Failure to Notify Physician and Representative of Resident’s Poor Intake and Medication Refusals
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and resident representative (RP) of significant changes in the resident’s condition, including poor oral intake, refusal of meals, and refusal of medications, as required by facility policy. The resident was an older adult with multiple serious diagnoses, including cerebral infarction, dysphagia, cerebrovascular disease, chronic kidney disease, right eye blindness, vascular dementia, malignant brain neoplasm, repeated falls, depression, and hypertension. A quarterly MDS showed severe cognitive impairment (BIMS score of 7), total dependence for all ADLs including eating, wheelchair use, and complete bowel and bladder incontinence. The care plan identified a nutritional problem or risk and directed staff to monitor, document, and report to the MD as needed for signs and symptoms of dysphagia, including refusing to eat. Record review showed an order for a health shake to be given if the resident consumed less than 50% of a meal, with instructions to encourage intake and notify the nurse. The MAR and order summary contained this order, but there was no documentation that the resident ever received a health shake during the review period. Nutrition intake records documented repeated days where the resident ate 0–25% of meals, refused entire meals, or had missing documentation for some meals over multiple days. Despite this pattern of poor intake and refusals, nurses’ notes from the beginning to the middle of the month did not show that the physician or the resident’s RP were notified about the resident’s refusal of meals or poor eating. On one date, a medication aide documented that the resident was resistant to medication administration, swinging and swatting, not allowing blood pressure to be taken, and not swallowing anything, but there was no documentation that the nurse was notified of this behavior. In interviews, the resident’s RPs stated they had not been informed of the resident’s refusal to eat or take anything by mouth and indicated they would have intervened had they known. The physician reported he did not recall being notified that the resident was not eating well or that the resident was combative and refusing medications, and stated he would have expected notification so he could implement interventions. Facility staff, including an LVN, the DON, and the ADM, acknowledged in interviews that such changes in condition, including meal refusals, medication refusals, and abnormal behaviors, should have been reported to the nurse, the physician, and the RP, in accordance with the facility’s written policy on change in condition, which requires prompt notification of the physician and representative for significant changes and for refusal of treatment or medications three or more consecutive times. The facility’s policy titled "Change in a Resident's Condition or Status" required the nurse to notify the attending or on-call physician when there was a significant change in the resident’s physical, emotional, or mental condition, and when there was refusal of treatment or medications three or more consecutive times. It also required notification of the resident’s representative when there was a significant change in the resident’s physical, mental, or psychosocial status, with notifications to be made within 24 hours of the change, except in emergencies. Despite these requirements, the record and interview evidence showed that the physician and RPs were not notified of the resident’s ongoing poor oral intake, repeated meal refusals, and the episode of combative behavior and medication refusal, leading to the cited deficiency for failure to promptly notify the physician and resident representative of changes in condition.
Failure to Develop and Implement Comprehensive Care Plans and Nutrition Orders for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive, person-centered care plans addressing all identified needs for two residents, as required by facility policy and the MDS assessments. For one resident with cerebrovascular disease, hemiplegia/hemiparesis following cerebral infarction, adult failure to thrive, polyneuropathy, hypertension, atherosclerotic heart disease, and nutritional deficiency, the admission MDS showed moderate cognitive impairment (BIMS 12), functional limitations in range of motion, wheelchair use, partial to substantial assistance with most ADLs, frequent urinary incontinence and occasional bowel incontinence, frequent pain requiring scheduled pain medication, a history of falls, risk for pressure ulcers, and use of antidepressant, diuretic, opioid, antiplatelet, and anticonvulsant medications. Despite this, the resident’s care plan, with an admission date of 1/18/26, contained only two problem areas: risk for impaired skin integrity/wound and an actual fall, and did not include problem areas or interventions for allergies, discharge plans, code status, cognitive status, incontinence status, activities, pain management, diet, ADL assistance, fall risk, pressure ulcer risk, bleeding risk, preferences, disease processes, or the listed medications. Observation and interview with this resident showed he was sitting in a wheelchair and reported he could not use his right arm or leg and had previously been very independent and active before his stroke. He stated he was continent of urine but needed assistance to use a urinal because he could not manage his clothing and hold the urinal with one hand, and he expressed reluctance to ask for help while also not wanting to soil himself. He also stated he was angry about his current health situation, that his whole life had changed, and that he did not feel the facility realized that. The MDS Coordinator acknowledged that the comprehensive care plan was her responsibility along with another MDS Coordinator, that it should include areas such as code status, diet, allergies, assistance needed, skin, bowel and bladder, medications, fall and pressure ulcer risk, and health conditions, and that the comprehensive care plan for this resident was not completed within the required 21 days from admission. For the second resident, who had diagnoses including cerebral infarction, dysphagia, cerebrovascular disease, chronic kidney disease, right eye blindness, vascular dementia, malignant neoplasm of the brain, cognitive symptoms following cerebral infarction, repeated falls, depression, and hypertension, the quarterly MDS indicated severe cognitive impairment (BIMS 7), wheelchair use, dependence on staff for all ADLs including eating, and continuous bowel and bladder incontinence. However, the resident’s ADL care plan, with an admission date of 12/27/25, still described an ADL self-care performance deficit related to confusion and impaired balance and stated that the resident was able to feed himself with meal and tray set-up, last revised on 8/20/25, and was not updated to reflect dependence on staff for eating. Additionally, there was a physician order, present on the order summary and MAR, for the resident to receive a health shake if less than 50% of a meal was consumed, with encouragement of intake and notification of the nurse, but there was no documentation that the resident ever received a health shake during the review period, despite multiple documented meals where intake was 0–25%, 26–50%, or refused. Nursing notes did not indicate that health shakes were offered or refused. Facility staff, including LVNs, the MDS Coordinator, the DON, the physician, and the administrator, stated that the comprehensive care plan is intended to direct resident care, should be complete and accurate, and that physician orders, including the health shake order, should have been followed.
Deficiencies in Kitchen Sanitation and Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. The Dietary Manager was repeatedly seen without proper facial hair covering, which is a requirement for maintaining hygiene in food preparation areas. Despite acknowledging the need for facial coverings, the Dietary Manager reported that the provided coverings did not fit properly and had informed the previous manager and the ADM about this issue. However, no corrective action was taken to address the ill-fitting facial coverings. Interviews with dietary staff confirmed that all kitchen staff, including those with facial hair, were expected to wear appropriate hair restraints to prevent contamination of food. Additionally, the facility's kitchen was found to have cleanliness issues, including food particles on top of the dishwasher and grease buildup on the gas stove. The Dietary Aide responsible for cleaning the dishwasher admitted to not having a checklist to mark completed tasks, leading to uncertainty about when the dishwasher was last cleaned. The Dietary Manager also acknowledged the presence of food particles and grease buildup, stating that there was no documentation or checklist for cleaning these areas. The lack of a structured cleaning schedule and verification process contributed to these sanitation lapses. The facility's policies, dated October 2018, outlined the need for a cleaning schedule and employee sanitation practices, including the use of hair restraints. However, the cleaning schedule was not being followed or documented as required. The ADM and DON both expressed expectations for a cleaning checklist to be in place and initialed upon task completion, but this was not being enforced. The absence of proper documentation and oversight in the kitchen cleaning process posed a risk of food contamination, potentially leading to foodborne illnesses among residents.
Inadequate Respiratory Care for Residents
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to potential risks of respiratory infections. For Resident #8, the facility did not change the oxygen tubing as per the physician's order, which required weekly changes every Friday. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that it was the responsibility of the nursing staff to ensure the oxygen tubing was changed and labeled with the new date, as failure to do so could place residents at risk for respiratory infections. Resident #48's care was compromised as the humidification bottle attached to her nasal cannula was found to be without water. The resident, who was on oxygen therapy due to congestive heart failure and ineffective gas exchange, was observed with a dry humidification bottle, which could lead to a dry nose and potential nosebleeds. The resident was unable to recall how long the bottle had been dry, and the nursing staff failed to ensure the bottle was filled, as confirmed by interviews with LVN Q and LVN R. For Resident #190, the facility did not adhere to aseptic techniques during tracheostomy care. LVN Q performed the procedure without using the prescribed sterile water and prepared solution, instead using normal saline. The trach care kit was contaminated when LVN Q used non-sterile gloves to handle items, and the tracheostomy cannula was not removed and cleaned as required. Additionally, the trach tube holder was changed without the assistance of a second staff member, contrary to the facility's policy. These actions placed the resident at risk for infection, as acknowledged by LVN Q and the DON during interviews.
Failure to Ensure Call Buttons Within Reach for Residents
Penalty
Summary
The facility failed to ensure that the call buttons for three residents were within reach while they were in bed, which is a violation of their right to reasonable accommodation of needs and preferences. Resident #7, a female with pneumonia, dementia, and hypertension, was found with her call button on the floor, out of reach, while her bed was in a high position. She reported that the call button had been on the floor all night and morning, leaving her unable to request assistance. Resident #17, a female with systolic heart failure, hypertensive heart disease, and a history of myocardial infarction, also had her call button out of reach, far under her bed. She expressed that she never used her call button because she could not reach it and needed someone to hand it to her. Her care plan indicated that staff should anticipate and meet her needs, ensuring the call light was within reach. Resident #50, a female with muscular degeneration, hyperlipidemia, and hypertension, had her call button several feet away behind a dresser, making it inaccessible. Interviews with staff, including a CNA, the DON, and the ADM, confirmed that it was the responsibility of all staff to ensure call buttons were within reach. The facility's policy on answering call lights emphasized the importance of making call lights accessible to residents.
Failure to Complete and Distribute Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan was completed and provided to residents and/or their representatives within 48 hours of admission for three residents. Resident #36, an 85-year-old male with multiple diagnoses including a fracture, vascular dementia, and diabetes, did not have a baseline care plan completed for his admission on 09/04/24. The facility provided a care plan dated from a previous admission, indicating a failure to update and complete a new plan for the current admission. Resident #2, a male with a history of sepsis, megaloureter, and atherosclerotic heart disease, had an undated baseline care plan that lacked signatures from the resident, representative, and staff. This indicates that the care plan was not properly completed or communicated to the responsible party. Attempts to contact the responsible party were unsuccessful, and no documentation was provided to show that the care plan was shared with them. Resident #190, a male with conditions such as atherosclerotic heart disease and COPD, also had an undated baseline care plan without necessary signatures. The responsible party for Resident #190 reported not receiving a copy of the care plan, which would have been helpful in understanding the resident's care needs. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion and distribution of baseline care plans, contributing to the deficiencies observed.
Deficiencies in Care Plan Implementation for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in addressing their medical and safety needs. For one resident, the care plan did not address a Stage IV sacral pressure ulcer that had reopened. Despite the ulcer being noted in the resident's medical records, the MDS Coordinator did not update the care plan to reflect the current condition, which was acknowledged as an oversight. Interviews with the MDS Coordinator, DON, and ADM confirmed that the responsibility for updating care plans was shared among nursing management, but the necessary updates were not made. Another resident's care plan failed to incorporate new interventions and updates for fall prevention, despite a history of multiple falls. The resident had been readmitted with several diagnoses, including protein-calorie malnutrition, dysphagia, COPD, Parkinson's disease, and epilepsy. The care plan had not been updated to reflect recent falls or to implement effective interventions. Interviews with various staff members, including CNAs, LVNs, and the DON, revealed a lack of awareness and communication regarding the resident's fall risk and the necessary interventions. The facility's policy on fall risk management was not effectively implemented, as evidenced by the absence of updated care plans and fall risk assessments. The facility's failure to update and implement care plans for these residents highlights a breakdown in communication and responsibility among the staff. The MDS nurse, DON, and other nursing staff were responsible for ensuring that care plans were current and reflective of each resident's needs. However, the lack of updated care plans and the failure to conduct timely fall risk assessments contributed to the deficiencies identified by the surveyors. The facility's policies on comprehensive care planning and fall risk management were not adequately followed, leading to potential risks for the residents involved.
Failure to Ensure Correct Pressure-Relieving Mattress Settings
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #36 and Resident #187, received appropriate care to prevent pressure ulcers. Both residents were at high risk for pressure ulcers, as indicated by their Braden scale scores and medical conditions. Resident #36 had a history of vascular dementia, Type 2 diabetes, and multiple wounds, while Resident #187 had a history of myocardial infarction and Type 2 diabetes. Despite these risks, the pressure-relieving mattresses for both residents were set incorrectly, with Resident #36's mattress set at 350 pounds and Resident #187's at 50 pounds, which did not correspond to their actual weights of 203 pounds and 230 pounds, respectively. Observations and interviews revealed a lack of clarity and responsibility among the nursing staff regarding the monitoring and adjustment of the pressure-relieving mattress settings. RN G, RN S, LVN Q, and LVN R all expressed uncertainty about who was responsible for ensuring the correct settings. RN S, the wound care nurse, acknowledged the importance of correct settings to prevent pressure ulcers and admitted that the settings for both residents were incorrect. The Director of Nursing (DON) and the Administrator (ADM) also confirmed that the nursing staff was responsible for checking and adjusting the mattress settings. The facility's failure to maintain the correct settings on pressure-relieving mattresses placed the residents at risk for developing or worsening pressure ulcers. The facility's policy on the prevention of pressure injuries emphasized the importance of selecting appropriate support surfaces based on residents' risk factors, but this was not adhered to in practice. The incorrect settings could lead to unnecessary pressure ulcers, skin breakdown, and discomfort for the residents.
Failure to Report Changes in Resident's Condition Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in preventing urinary tract infections. The resident, who had a history of urinary tract infections and other medical conditions, exhibited symptoms such as red-tinged urine, increased confusion, and an elevated white blood cell count. Despite these symptoms, the nursing staff did not document or report the red-tinged urine to the physician, which was a critical oversight given the resident's medical history and current symptoms. The report highlights that LVN Q observed the resident's pink-tinged urine but failed to document it or notify the physician, MD T, about this significant change. Although LVN Q communicated the elevated white blood cell count to the physician, the omission of the red-tinged urine was a crucial lapse. This lack of communication and documentation was compounded by the fact that the resident had been previously noted to have increased confusion, a symptom that could indicate a urinary tract infection. Further interviews revealed that the nursing staff, including LVN M and the DON, acknowledged the importance of notifying the physician about changes in the resident's condition. However, the failure to report the pink-tinged urine delayed the necessary medical intervention, ultimately leading to the resident being sent to the emergency room with symptoms of septic shock. The facility's policies on catheter care and acute condition changes were not adhered to, contributing to the deficiency in care provided to the resident.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications for a resident. Specifically, staff left a dose of Gabapentin at the bedside of a resident who was not care planned to self-administer medications. The resident, who had a moderately impaired cognition as indicated by a BIMS score of 12, was unaware of the missed dose until informed by the surveyor. This oversight was observed during a survey, highlighting a lapse in the medication administration process. Interviews with facility staff, including a Certified Medication Aide (CMA), the Director of Nursing (DON), and the Administrator (ADM), confirmed that the medication aide is responsible for ensuring residents take or refuse their medications before leaving the room. The facility's policy on administering medications, dated April 2019, requires that medications be administered safely and timely, and any refused medication should be discarded. The failure to adhere to these procedures could lead to residents taking medications not prescribed to them, posing a risk of drug diversion and incorrect therapeutic dosages.
Inappropriate Use of Antipsychotic Medication for Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident, who had not previously used psychotropic drugs, was not given these drugs unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified for one resident who was administered Quetiapine, an antipsychotic medication, without an appropriate diagnosis or indication of use. The resident, an elderly female with a history of dementia, heart failure, atrial fibrillation, hypothyroidism, atherosclerotic heart disease, anxiety, and depressive episodes, was taking Quetiapine for unspecified dementia with psychotic disturbances, which was not adequately justified in her clinical records. Interviews with facility staff revealed inconsistencies and misunderstandings regarding the appropriate use of antipsychotic medications. LVN F stated that a resident with dementia should not be prescribed antipsychotic medication and emphasized the importance of clarifying diagnoses before administration. RN G and MDS Nurse H also expressed concerns about the appropriateness of using antipsychotics for dementia, indicating that diagnoses such as schizophrenia or bipolar disorder would be more suitable. The ADON and DON provided conflicting views, with the DON asserting that the medication was appropriate for unspecified dementia with psychotic disturbances, while the ADON acknowledged the need for proper diagnosis verification. The facility's medication reconciliation process was found to be lacking, as evidenced by the absence of a clear diagnosis supporting the use of Quetiapine for the resident. The pharmacy consultation had previously recommended considering alternative therapy due to the lack of an approved indication for the medication. Despite these recommendations, the facility did not provide a copy of their policy for psychotropic medication use, and there was no documentation of a comprehensive review or resolution of the medication discrepancy.
Medication Administration Timing Deficiency
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Levothyroxine and Pantoprazole. The resident, an 85-year-old male with diagnoses of hypothyroidism and gastro-esophageal reflux disease, was admitted to the facility with a medication regimen that required specific timing for optimal therapeutic effect. However, the medications were not scheduled appropriately, with Levothyroxine being administered at 8 a.m. and Pantoprazole at 9 a.m., contrary to the recommended times for these medications. Interviews with various staff members, including registered nurses and medication aides, revealed a lack of adherence to proper medication administration protocols. The staff acknowledged that thyroid medications like Levothyroxine should be given on an empty stomach and not with other medications, ideally before breakfast. Similarly, Pantoprazole should be administered at least 30 minutes before meals to be effective. The staff admitted that the medications were not scheduled at optimal times, which could render them ineffective and potentially lead to adverse reactions. The Director of Nursing confirmed that the medications were not scheduled therapeutically and that there was no process in place to review medication administration times. The facility's policy on administering medications emphasized the importance of timing for optimal therapeutic effect and preventing interactions, but this was not followed in practice. The deficiency was identified through a combination of record reviews and staff interviews, highlighting a systemic issue in medication scheduling and administration within the facility.
Failure to Report Drug Diversion Incident
Penalty
Summary
The facility failed to report an alleged drug diversion involving a resident's medication to the State Survey Agency and other officials as required by state law. The incident involved a bottle of hydromorphone that was tampered with, which was reported by a Licensed Vocational Nurse (LVN) to the Administrator (ADM) after receiving it from a hospice nurse. The ADM was informed of the tampering but did not report it as a drug diversion, believing it was the responsibility of the hospice company to do so. This oversight was identified during a complaint investigation by a Health and Human Services (HHS) nurse, who advised the ADM to report the incident. The resident involved was an elderly male with Parkinson's disease, COPD, and diabetes mellitus, who had cognitive impairment and required assistance with activities of daily living. Despite the tampering, the resident was not harmed as he had additional sealed bottles of hydromorphone available. The ADM acknowledged the failure to report the incident, stating he did not consider it a drug diversion since it was not his staff involved. The facility's policy required reporting all allegations of drug theft within 24 hours, which was not adhered to in this case.
Improper Resident Handling and Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision to prevent avoidable accidents for a resident. The resident, who had Alzheimer's Disease, dementia, and osteoporosis, required assistance with activities of daily living (ADLs) and was sometimes understood and sometimes understood others. The resident's care plan noted a behavior problem where she would call out that she was being hurt when no one was touching her. Video evidence revealed improper handling of the resident by staff members. In one instance, a staff member pulled the resident by the wrist into a sitting position, causing the resident to express pain. In another instance, a staff member pulled the resident up in bed by her upper arms. Interviews with staff members indicated that the proper procedure was not followed, as the resident should have been repositioned using a draw sheet or pad with the assistance of two staff members. The facility's policy on repositioning, revised in May 2013, emphasized the use of two people and a draw sheet to avoid shearing while moving a resident. Despite this policy, staff members admitted to not following the correct procedures, citing reasons such as the resident's combative behavior and personal physical limitations. The Director of Nursing and the Administrator both acknowledged that the improper handling could lead to injuries, such as skin tears or fractures.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident who required such services. The resident, who was cognitively intact and had a history of diabetes, muscle wasting, and difficulty walking, complained of pain in her heel prior to and during wound care treatment. Despite her complaints and visible signs of pain, such as saying 'ouch' and grimacing, the treatment nurse did not offer any pain medication or hold the wound care procedure. The resident's physician orders did not include any PRN pain medications, and the treatment nurse did not take steps to address the resident's pain during the procedure. The resident's pain assessment indicated mild pain in the last five days, but there was no detailed documentation of the frequency or impact on activities. During an interview, the treatment nurse acknowledged hearing the resident's complaints of pain but did not think to ask if she wanted pain medication. The Director of Nursing (DON) was unaware of the resident's pain until the day of the observation. The facility's Pain Assessment and Management Policy emphasizes the importance of assessing and managing pain, but this was not followed in the case of this resident, leading to her experiencing pain during wound care.
Infection Control Deficiency Due to Improper Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment, leading to potential infection risks for four out of five residents reviewed. The Treatment Nurse did not wash her hands while providing wound treatments for Residents #1, #3, #4, and #5. Additionally, the nurse did not change her gloves between dirty and clean wounds for Resident #1 and did not change gloves from one wound to the next during Resident #5's wound treatments. These actions were observed during wound care procedures and were confirmed through interviews and record reviews. Resident #1, a [AGE]-year-old female with diagnoses including diabetes and muscle wasting, had a wound on her right heel. The Treatment Nurse did not wash her hands before or after the treatment and failed to change gloves after removing a soiled bandage. Resident #3, a [AGE]-year-old with Parkinson's disease and anxiety, received skin prep on her heels without the nurse washing her hands before or after the procedure. Resident #4, a [AGE]-year-old with heart failure and a pressure injury, had her wound treated without the nurse washing her hands, although gloves were changed appropriately. Resident #5, a [AGE]-year-old with dementia, had multiple wounds treated without the nurse changing gloves between different wound sites. During an interview, the DON and ADON acknowledged that the Treatment Nurse was new and had not completed her full training. They also mentioned that the nurse was in school to receive her RN license and would be sent to wound care classes upon completion. The ADON incorrectly stated that hand sanitizer was as effective as soap and water, contrary to the facility's policy. The facility's Wound Care Policy, dated October 2010, requires washing and drying hands thoroughly at multiple stages of the wound care process, which was not followed in these instances.
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.
