Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Killeen during CMS and state inspections, most recent first.
The facility failed to provide timely ADL assistance, repositioning, toileting, and incontinent care for three dependent residents. One resident with dementia, ESRD on HD, and multiple pressure injuries had delayed care and reports of not being repositioned every 2 hours, while another resident who was incontinent and required x2 Hoyer assistance reported long waits for transfers and toileting, including one incident requiring 911 help. A third resident with bowel and bladder incontinence had delayed response to a call light, reported waiting hours for brief changes, and developed moisture-associated skin damage to the buttocks.
Two cognitively intact residents with significant cardiac, diabetic, renal, visual, and neurologic conditions did not consistently receive scheduled showers or clearly documented hygiene care. One resident, fully dependent for bathing, reported not receiving a shower for over a week and stated staff sometimes cited short staffing, while records showed mixed entries of "Yes," "Not Applicable," and refusals without a care plan focus on shower refusal. Another resident, able to bathe herself with assistance, reported not getting showers as scheduled and having to wash at the sink, despite shower sheets showing irregular documentation and a single recorded refusal without follow-up. A med aide and leadership (ADM, DON) described expectations for showers, refusals, and documentation, but acknowledged that staff often only used paper shower sheets, did not consistently chart refusals in the EHR, and that residents should not go more than a week without a shower, contrary to the facility’s ADL policy requiring support for hygiene in accordance with the care plan.
Surveyors found that the facility failed to provide palatable meals at proper temperatures and in sufficient quantities. During a lunch service, kitchen staff ran out of the planned beef stroganoff entrée and dinner rolls, substituting chopped hamburger patties with gravy over noodles and halved bread slices for the remaining trays, and no test tray was taken due to the shortage. A resident grievance documented complaints that food was cold and that the kitchen did not prepare enough food. The DM acknowledged that more food should have been cooked and that hot plates were not warm, while the cook stated she followed package directions and recipes and denied running out of food. The ADM stated that residents were expected to receive the meal they requested rather than an alternative, and no policy could be produced regarding what to do when insufficient food is prepared.
A resident with diabetes, CHF, CKD, edema, and venous leg ulcers had physician orders for daily and PRN wound care to bilateral leg ulcers using wound cleanser, betadine-moistened gauze, and specific dressings, along with a care plan for impaired skin integrity. Record review showed no wound care was provided on one of the ordered days, despite daily dressing changes being required. The wound care nurse reported she normally provided care Monday through Friday and described the current treatment regimen, while the ADM and DON confirmed that nurses are expected to follow MD/NP orders and that when the wound care nurse is off duty, other nurses are responsible for wound care. The DON acknowledged that wound care was missed on the identified date and stated that failure to perform wound care could lead to worsening of the wound, more drainage, pain, and discomfort.
Surveyors found that the facility did not ensure proper storage and removal of medications when an expired Humalog insulin cartridge remained in a medication room refrigerator for a resident who was now receiving Ozempic, and a medication cart contained two loose pills and a cup with an unidentified pill. Interviews with the DON, ADON, and a med aide confirmed that nurses and med aides were responsible for discarding expired and discontinued medications in designated destruction bins and for auditing carts and medication rooms, but these processes did not prevent expired and unlabeled medications from being left in active storage areas.
Surveyors found that one medication cart and one medication room were not maintained according to medication storage standards. An expired Humalog cartridge remained in the medication room refrigerator for a resident who had been switched to Ozempic, and a medication cart contained two loose pills and a cup with an unidentified pill and no label. A cognitively intact resident with multiple chronic conditions reported receiving her medications and now taking Ozempic. The DON, ADON, and a med aide stated that nurses and med aides were responsible for discarding expired and discontinued medications in designated destruction bins and that narcotics were handled separately with the pharmacy consultant, but they could not explain why the expired insulin and unlabeled pills were still present.
A cognitively intact resident with multiple chronic conditions reported that a former roommate had slapped her on the thigh after a dispute over belongings. The resident stated she informed several CNAs and a family member shortly after the incident and later specifically told one CNA about the prior assault while receiving care. That CNA did not ask for details or timing and did not report the allegation to the abuse coordinator or administration, assuming it was a past event already reported and noting the resident did not appear upset. Facility policy required all suspicions or allegations of abuse or neglect to be reported immediately to the administrator/abuse coordinator within defined time frames, but this did not occur, resulting in a deficiency for failure to timely report an alleged abuse incident.
A resident with multiple chronic conditions developed a persistent rash related to incontinence and hygiene issues. Despite new medical orders for treatment, the care plan was not updated in a timely manner to include all prescribed interventions or measurable objectives. Staff interviews and record reviews confirmed that the care plan did not accurately reflect the resident's current needs until after the deficiency was identified.
A resident who required staff assistance for ADLs did not consistently receive showers according to the facility's established schedule. Documentation and interviews revealed that showers were sometimes missed or provided at unscheduled times, and the resident occasionally received bed baths instead, particularly when there were issues such as cold water. Staff acknowledged the importance of regular bathing for hygiene and skin integrity, and the facility's policy required such care for dependent individuals.
A resident with moderate cognitive impairment and Alzheimer's disease was financially exploited when a staff member gained access to her bank account and made unauthorized withdrawals totaling over $10,000. The staff member convinced the resident to add her to the account under the guise of providing financial assistance, then withdrew funds without consent. The incident was discovered after another staff member overheard a conversation and reported it to administration.
Two residents with care plans requiring supervision were allowed to smoke without staff present and kept cigarettes and lighters in their rooms, in violation of facility policy. Both residents were cognitively intact but had medical conditions such as muscle weakness and lack of coordination. Staff interviews confirmed that supervision and secure storage of smoking materials were required but not consistently enforced.
A resident with hemiplegia and multiple comorbidities was found in bed with the call light on the floor and out of reach. The resident, who was alert and required assistance for daily living, was unable to call for help due to the call light's placement. Staff confirmed the call light was not accessible and acknowledged the safety concern, in violation of facility policy requiring call systems to be within reach.
A resident with multiple chronic conditions and an indwelling urinary catheter was found with the catheter bag resting on the floor, contrary to facility policy and infection control standards. Staff interviews confirmed awareness of the infection risk, and record review showed the care plan and policy required catheter bags to be kept off the floor.
A facility area contained accident hazards and lacked sufficient staff supervision to prevent accidents, as observed by surveyors during their review of the environment and facility practices.
Three residents requiring oxygen therapy and nebulizer treatments did not have their respiratory equipment changed and documented as ordered, with observations revealing dirty equipment and missing documentation in the EHR. Staff interviews indicated inconsistent practices and uncertainty about responsibilities, while the facility's policy required weekly changes and documentation by nursing staff.
A resident with limited English proficiency and intact cognition was unable to communicate effectively with non-Spanish speaking staff, as the communication board provided was not useful and there were no Spanish-speaking staff available during certain shifts. Staff interviews confirmed ongoing communication barriers, and the facility lacked a specific policy for non-English speaking residents, resulting in unmet communication needs.
A staff member left a facility laptop open and unattended on a medication cart in a hallway, displaying confidential resident medical information. Multiple staff, including a medication aide, RN, DON, and Administrator, confirmed that this action violated HIPAA regulations and facility policy by making sensitive information accessible to unauthorized individuals.
A resident with diabetes and cognitive communication deficits did not receive prescribed doses of Acidophilus on multiple occasions, as confirmed by missing entries in the MAR and staff interviews. Facility policy required timely administration and documentation of medications, but these were not followed, resulting in the resident not receiving the supplement as ordered.
A resident with a history of skin conditions and impaired mobility developed a painful rash under her abdominal fold, which was not assessed or treated in a timely manner by the facility. Despite the resident's complaints and visible symptoms, the facility failed to notify the WCN or implement treatment orders until several weeks later, contrary to their policy on pressure injury prevention.
The facility failed to provide scheduled showers to three residents, leading to poor hygiene and dissatisfaction. A resident with hemiplegia and moderate cognitive impairment received only seven showers in a month, while another with severe cognitive impairment received five. A third resident reported going weeks without a shower, resorting to sponge baths. The DON expected showers thrice weekly, but no ADL policy was provided.
A resident with a non-pressure wound was not provided with proper infection control measures during care. A CNA failed to wear an isolation gown and did not perform hand hygiene after glove removal, while an LVN did not set up a clean field for wound care and used soiled gloves for multiple tasks. Both staff members placed soiled items in an unlined trash can, and the LVN cited the absence of a sanitizer machine as a reason for not performing hand hygiene.
A CNA in a LTC facility failed to perform proper perineal care during a disposable underwear change for a resident with incontinence. The CNA did not follow the facility's policy, which requires washing the perineal area from front to back, and only wiped the resident when soiled with fecal matter. The incident was reported by the resident's representative, and the facility's DON initiated an investigation. The resident was assessed with no injuries noted, and the CNA admitted to not following the procedure.
A resident with a history of cerebral infarction and spastic hemiplegia did not receive scheduled showers and assistance with personal hygiene, leading to deficiencies in care. Despite being scheduled for showers three times a week, the resident reported receiving only five showers and one bed bath over 60 days. Observations confirmed the resident had not been changed into fresh clothing for three days and had dirty dentures and fingernails. Facility documentation and monitoring were inadequate, and staff interviews revealed inconsistencies in understanding and implementing ADL care policies.
A resident with severe cognitive impairment alleged sexual assault by two men. Despite initial assessments showing no signs of assault, a subsequent exam revealed the presence of semen. The facility's investigation did not identify any perpetrators, and the cameras in the area did not record footage. The facility failed to protect the resident from sexual abuse and lacked effective monitoring and investigation procedures.
The facility failed to store, prepare, distribute, and serve food under sanitary conditions, with expired food products found in dry storage and the refrigerator, and food boxes stored on the floor in the walk-in freezer. Interviews confirmed that these practices could lead to contamination and foodborne illness.
The facility failed to address and follow up on grievances raised during Resident Council meetings, including issues with staff behavior, call lights, and food quality. Despite documenting these grievances, the Activity Director did not follow up or report back to the residents, leading to a deficiency in resident care and life quality.
A social worker verbally abused a resident by calling him 'stupid' in a moment of agitation, which was witnessed by the ADON and reported immediately. The resident, who had multiple diagnoses including Vascular Dementia and Anxiety, was reassured by staff and felt safe in the facility. The social worker was suspended during the investigation.
The facility failed to provide necessary grooming and personal care for six residents, leading to long, dirty nails, unkempt appearances, and potential infection risks. Staff interviews revealed inconsistencies in responsibilities and lack of training regarding nail care.
The facility failed to provide scheduled one-on-one activities for three residents with severe cognitive impairments and physical disabilities, as required by their care plans. This deficiency was identified through observations, interviews, and record reviews, revealing that the residents did not receive necessary in-room activities for January and February 2024, potentially impacting their mental and social well-being.
The facility failed to provide proper respiratory care for two residents by not dating, bagging, or replacing nebulizer and oxygen tubing every seven days, and not cleaning the air filter for an air concentrator. Observations and staff interviews confirmed that the equipment was not properly maintained, which could lead to respiratory infections.
The facility failed to ensure that residents' call lights were within reach, affecting five residents who needed assistance with activities of daily living. Observations revealed that call lights were on the floor or out of reach, posing potential risks for unmet needs and falls. Staff interviews confirmed the expectation for call lights to be accessible to residents.
The facility failed to complete a resident's admission assessment within the required 14-day period. The resident, admitted with multiple complex medical conditions, had an incomplete MDS assessment, and staff interviews revealed confusion about responsibility for Medicaid MDS assessments.
The facility failed to develop a comprehensive care plan within seven days after the required comprehensive assessment for a resident with multiple diagnoses. Interviews revealed that the care plan was expected to be completed within 21 days of admission, but it was not completed on time, potentially leading to improper care methods.
A resident with severe cognitive impairment and a history of falls was moved by the Director of Therapy without necessary assessments after a fall, despite instructions from an LVN to wait. This action was against the facility's protocol, which required a nurse to complete pain assessments, vital signs, and other evaluations before moving the resident.
The facility failed to ensure that all drugs and biologicals were labeled and not expired in the Pod 2 medication storage room, medication cart, and nurse treatment cart. Staff were unaware of policies regarding the checking and removal of expired medications, and the ADON confirmed that expired medications could be ineffective in treating residents' conditions.
The facility failed to make the most recent survey results easily accessible to residents, with the survey book not located in common areas and unclear signage. Staff were unaware of the book's location, and residents expressed they did not know how to access the survey results.
Delayed ADL Assistance, Repositioning, and Incontinent Care
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living received timely assistance with hygiene, repositioning, toileting, and incontinent care. The deficiency involved three residents who were dependent on staff for care and who had documented needs for substantial or maximal assistance. Facility records, observations, and interviews showed delayed responses to call lights, delayed brief changes, and inconsistent assistance with ADLs and repositioning. One resident had multiple serious medical conditions, including vascular dementia, end-stage renal disease on hemodialysis, bacterial pneumonia, and a myoneural disorder, and was documented as incontinent of bowel and bladder with a care plan requiring substantial to maximal assistance for personal hygiene. Records showed pressure-related skin problems, moisture-associated skin damage, excoriation, and later hospital records documenting multiple pressure injuries, including unstageable and deep tissue injuries to the heels, sacrum, buttocks, toes, and elbows. The resident’s representative stated staff often took 45 minutes to an hour to respond and that the resident was not repositioned every two hours during visits. Staff interviews reflected that the resident required total assistance for repositioning and ADLs, and that she had developed heel pressure injuries while in bed. A second resident was documented as incontinent of bowel and bladder, required x2 max assistance with ADLs and transfers using a Hoyer lift, and had a care plan addressing ADL self-care deficits and incontinence. Toileting hygiene documentation showed assistance recorded only once a day on several dates during the review period. The resident reported waiting 45 minutes to 2 hours for help, waiting to get up in the wheelchair, and waiting to be returned to bed and assisted with the bedpan and cleaning. The resident also stated that on one occasion the Hoyer lift batteries were dead throughout the facility and she had to call 911 for help getting back to bed. A third resident was documented as always incontinent of bowel and bladder and had a care plan calling for staff assistance with personal hygiene and oral care. Nursing documentation identified new moisture-associated skin damage and incontinence-associated dermatitis to the buttocks, with the area being cleaned and dried throughout the shift. Observation showed the resident’s call light on for 48 minutes while staff passed by without responding, and the resident stated she had been wet for part of the night and waited hours for the correct brief size. Staff interviews acknowledged that residents needed rounding every two hours and prompt incontinent care, while the DON and administrator stated residents should be checked regularly and repositioned per orders.
Failure to Provide and Document Scheduled Hygiene Care for Two Cognitively Intact Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate hygiene care and services to maintain or improve residents’ ability to perform activities of daily living (ADLs), specifically bathing, for two cognitively intact residents. Resident #1, an older female with multiple diagnoses including type 2 diabetes with circulatory complications, combined systolic and diastolic heart failure, chronic kidney disease stage 3B, and edema, was care planned for an ADL self-care performance deficit related to limited mobility, with a goal to maintain current function and an intervention stating she was totally dependent on one staff member for bathing/showering and would receive a sponge bath when a full bath or shower could not be tolerated. Her care plan did not address a history of refusing showers. Shower documentation for March showed multiple entries of "Not Applicable," one entry of "No," and several refusals, with gaps in clear evidence that scheduled showers were consistently provided. During interview, Resident #1 stated she had not had a shower since the prior Tuesday and reported that staff sometimes told her they were short-staffed and could not give her a shower, and that she only refused when in too much pain or when she had appointments. Resident #2, an older female with acute systolic heart failure, type 2 diabetes with kidney complications, legal blindness, and epilepsy, had a quarterly MDS indicating she was cognitively intact and able to bathe herself except for washing her back and hair. Her care plan identified an ADL self-care performance deficit related to limited range of motion and noted she was non-compliant with showers at times, with an intervention stating she could bathe herself. Shower records for March showed numerous "Yes" entries but also multiple "Not Applicable" entries and one documented refusal, with no clear documentation that she consistently received showers on her scheduled days. In interview, Resident #2 stated she was not getting showers as scheduled, that only one night staff member reliably ensured she received showers and hair washing, and that when she once refused a shower due to an appointment and agreed to take it upon return, no one followed up to offer the shower. She reported that she washed herself at the sink when showers were not provided. Staff interviews further demonstrated issues with implementation and documentation of hygiene care. A medication aide stated that CNAs gave showers and were supposed to inform nurses so refusals could be charted, but acknowledged that staff sometimes only marked paper shower sheets or wrote "resident refused" and were not consistently entering refusals into the electronic health record. The Administrator stated residents could not be forced to shower, that refusals were care planned, and that the goal was to provide at least one shower per week, with attempts by preferred staff and family involvement if needed. The DON stated her expectation was that aides provide showers and ADL care and chart it, acknowledged that many residents refused showers, and stated residents should not go more than a week without a shower due to risks of skin breakdown, odor, and infection. She also stated she did not know why staff were not charting refusals in the electronic system, despite the existence of shower sheets. The facility’s ADL policy required provision of care and services to maintain grooming and personal hygiene, including appropriate support and assistance with hygiene in accordance with the plan of care, which was not consistently carried out for these residents.
Failure to Provide Adequate, Palatable Meals at Proper Temperature
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature, and that sufficient quantities of the planned meal were prepared. During a lunch meal observation in the kitchen, the Surveyor noted that the cook had not documented food temperatures prior to tray preparation and only stated she remembered them. The planned lunch consisted of beef stroganoff over egg noodles, green beans with pimento, a dinner roll, and a gooey butter bar. As staff prepared trays, they ran out of the main entrée and dinner rolls before all resident trays were completed. To finish the last five trays, the dietary manager and other staff chopped hamburger patties, mixed them with gravy, and placed this mixture over noodles instead of the planned beef stroganoff. There were also not enough dinner rolls, so staff substituted by cutting bread in half for residents who did not receive a roll. A test tray was not requested because there was not enough of the planned food prepared. Grievance records showed that a resident had previously complained that the food was cold and that the kitchen did not prepare enough food. In interviews, the dietary manager acknowledged that more food should have been cooked and stated that hot plate temperatures should be at least 130 degrees, noting that the hot plates were not warm or hot to the touch and that staff were expected to take food temperatures on the line about 15 minutes before serving. The cook reported that she was responsible for preparing meals for different diets and maintaining food temperatures, that she took temperatures when placing food on the steam table, and that she measured food amounts based on packaging and recipes. She denied running out of food, stating she had hamburger meat to add to what was already prepared and that she normally had leftovers. The administrator stated her expectation that residents receive the meal they requested rather than an alternative unless they specifically asked for it and indicated her understanding that more of the base meal could be made if needed. As of the date of the survey, the dietary manager and administrator were unable to provide a policy addressing situations when insufficient food is prepared for residents.
Failure to Provide Ordered Daily Wound Care for Venous Leg Ulcers
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment and services consistent with professional standards of practice for one resident with venous leg ulcers. The resident, a cognitively intact female with multiple comorbidities including type 2 diabetes with circulatory complications, congestive heart failure, chronic kidney disease stage 3B, edema, and a history of lower leg fracture, was identified as at risk for pressure ulcers on her MDS. Her comprehensive care plan for impaired skin integrity to the right anterior leg, right medial leg, and left second toe included interventions such as skin observation, keeping skin clean and dry, hydrating skin with lotion as needed, and reporting skin alterations to the nurse. Physician orders directed that a left medial leg venous ulcer (wound #5) and a right leg venous ulcer (wound #6) be cleansed with wound cleaner, treated with betadine-moistened gauze to the wound base, and secured with appropriate dressings, to be changed daily and as needed; however, the orders did not document the stages of the wounds. Record review of the electronic health record showed no documentation that wound care was provided on 03/28/2026, despite daily dressing changes being ordered. The wound care nurse reported that she provided wound care Monday through Friday, that the resident’s leg wounds began as blisters, and that current treatment involved betadine-moistened gauze and daily dressing changes, including after showers when staff could wrap the legs with gauze, ABD, Kerlix, and an ace bandage. She stated the last dressing change had been performed on 03/30/2026 and acknowledged that if wound care was not changed properly, infection could occur, although she described the wounds as healing with no oozing or blisters at that time. Observation on 03/31/2026 confirmed the wound care nurse performing wound care to the resident’s legs per physician orders. The ADM stated her expectation that nurses follow MD/NP orders and facility policy, and the DON stated that when the wound care nurse is not on duty, it is the responsibility of other nurses to provide wound care, acknowledging that wound care was not done on 03/28/2026 and that failure to perform wound care could result in worsening of the wound, increased drainage, pain, and discomfort.
Improper Medication Storage and Failure to Remove Expired Drugs
Penalty
Summary
Surveyors identified a deficiency in the facility’s pharmaceutical services related to improper medication storage and failure to remove expired medications. During an observation of a medication room refrigerator, an expired Humalog 100 units/mL cartridge labeled with a best-by date of 12/25/2024 and dated 12/26/2024 for a specific resident was found still stored. The DON later stated that this resident no longer used Humalog and was currently taking Ozempic instead. The facility’s policy on Medication Labeling and Storage, revised February 2023, required that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, and that nursing staff maintain medication storage areas in a clean, safe, and sanitary manner. Additional observations on a medication cart at nursing station/pod 2 revealed two loose pills in the bottom drawer and a cup containing a single unknown pill. The DON, when interviewed, stated she did not know what the pill was or why it was left there and discarded the medications. The DON also stated that staff should not keep medication in the cart in a cup with no label or have loose pills in the cart, and that medication carts should be clutter-free with expired medications removed. The facility’s policy required medications and biologicals to be stored in locked compartments under proper conditions, with nursing staff responsible for maintaining safe and sanitary storage and preparation areas. Interviews with the ADON, DON, and a med aide showed that responsibility for discarding expired medications and auditing medication carts and rooms was assigned to nurses and medication aides. The ADON stated that expired medications and medications for discharged residents were to be discarded in a designated destruction box in the medication rooms, and that narcotics were stored in a lock box in the DON’s office until destroyed with the pharmacy consultant. The DON and med aide each confirmed that nurses and med aides were responsible for throwing away expired medications and that everyone should receive their medications as ordered. Despite these stated expectations and procedures, the presence of an expired Humalog cartridge in the refrigerator and unidentified loose and cup-held pills in the medication cart demonstrated that the facility did not ensure all drugs and biologicals were stored properly and that expired or unidentified medications were removed as required.
Improper Storage and Failure to Discard Expired and Unidentified Medications
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage and labeling practices involving one of four medication carts and one of two medication rooms. During an observation of the medication room refrigerator, an expired Humalog 100 units/mL cartridge labeled with a best-by date of 12/25/2024 was found for a resident who was no longer using that medication and was currently taking Ozempic instead. The facility’s own policy, revised February 2023, required that discontinued, outdated, or deteriorated medications be returned or destroyed per pharmacy instructions, and that medications be stored in a clean, safe, and sanitary manner. Record review showed the involved resident was an older female with multiple diagnoses, including major depressive disorder, mixed hyperlipidemia, unspecified polyneuropathy, gout, and an unspecified muscle disorder. Her MDS indicated she was cognitively intact with a BIMS score of 14 and required partial to moderate assistance with several ADLs, while being dependent on staff for showers. She reported receiving her medications and not missing doses, and stated she was now taking Ozempic instead of her prior diabetic medication, though she did not recall the previous medication’s name. Additional observations on the medication cart at nursing station/pod 2 revealed two loose pills in the bottom drawer and a cup containing a single unknown pill, with no label or resident identification. The DON, who did not know what the pill was or why it was left there, discarded the medications. In interviews, the ADON, DON, and a med aide each stated that nurses and medication aides were responsible for discarding expired medications into designated destruction bins, and that narcotics were handled separately with the pharmacy consultant. They acknowledged that medications should not be left loose or in unlabeled cups in the cart and that expired medications should have been discarded, but they were unable to explain why the unknown pill and loose pills were present in the cart or why the expired Humalog remained in the refrigerator.
Failure to Timely Report Resident’s Allegation of Abuse to Abuse Coordinator
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all alleged violations involving abuse and neglect were reported immediately, but no later than 24 hours, to the administrator/abuse coordinator and proper authorities. A cognitively intact female resident with a history of type 2 diabetes, mild protein-calorie malnutrition, hypertension, prior stroke with upper limb monoplegia, muscle weakness, unsteadiness, and lack of coordination reported that her former roommate had slapped her on the thigh several weeks earlier after a dispute over food items. The resident stated she told multiple CNAs within a few days of the incident, as well as her family member the day after it occurred, but she could not recall the staff members’ names. She later specifically recalled informing one CNA (CNA A) about the incident several days after it happened. Record review showed that during a later counseling session, the licensed professional counselor (LPC) learned of the allegation and relayed it to the social worker (SW), who then reported it to the administrator/abuse coordinator. The facility’s investigation documented that the resident had previously told CNA A on an earlier date that she did not like her roommate because the roommate had hit her in the past. During interview, CNA A confirmed that, while providing care a few weeks prior, the resident reported that her roommate had hit her at some point in the past. CNA A did not ask when the incident occurred or obtain further details, and she did not report the allegation to the abuse coordinator or other facility leadership at that time. CNA A stated she took the report lightly because the resident was talking about other topics and laughing, and because the resident said she had already told other CNAs when it happened. CNA A acknowledged that she recognized the administrator as the abuse coordinator but chose not to report the allegation, believing it was a past event and that the resident did not appear upset. The facility’s written policy on abuse, neglect, exploitation, and misappropriation required that any suspicion of abuse or related violations be reported immediately to the administrator and appropriate officials, defining “immediately” as within two hours for allegations involving abuse resulting in serious bodily injury and within 24 hours for allegations that do not involve abuse or do not result in serious bodily injury. The failure of CNA A to report the resident’s allegation in accordance with this policy led to the cited deficiency for not ensuring that all alleged violations involving abuse and neglect were reported immediately, but no later than 24 hours.
Failure to Update and Implement Comprehensive Care Plan for Resident with Rash and Incontinence Issues
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including COPD, hypertension, dementia, diabetes, and mobility difficulties. Despite the resident being cognitively intact, the care plan was not updated in a timely manner after new orders were received from a nurse practitioner regarding a rash. The care plan did not initially include all prescribed treatments, such as oral doxycycline and fluconazole, and lacked measurable objectives and timeframes to address the resident's medical, nursing, and psychosocial needs. Interviews and observations revealed that the resident experienced a persistent rash under the breast and torso, which was associated with incontinence and hygiene challenges. Staff reported that the resident often refused to wear briefs or use the bathroom, resulting in prolonged exposure to moisture and contributing to the skin condition. Multiple staff members, including CNAs, LVNs, and the DON, noted that the care plan was not promptly updated to reflect the new interventions and that this could hinder the delivery of appropriate care. Record reviews and staff interviews confirmed that the care plan was only revised after questions were raised, and prior to that, it did not accurately reflect the resident's current needs or the interventions required. The facility's policy requires ongoing assessment and timely revision of care plans as residents' conditions change, but this was not followed in this case, leading to a gap in care planning and implementation for the resident.
Failure to Provide Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs), specifically bathing, received showers as scheduled. According to the electronic shower schedule, the resident was to receive showers on Tuesdays, Thursdays, and Saturdays during the 2pm-10pm shift. However, record review showed inconsistencies in the dates and times showers were provided, with some showers occurring outside the scheduled days and times, and gaps in adherence to the established schedule. The resident, who was cognitively intact and required partial to moderate assistance with personal hygiene, lower body dressing, transfers, bed mobility, and toileting hygiene, was observed to be clean and without foul odors during the survey. She reported that her showers depended on which staff member was assigned and that she sometimes received bed baths instead, particularly when there were issues such as cold water. The resident stated she refused bed baths with cold water and would escalate concerns to facility staff or the Ombudsman if needed. Staff interviews confirmed that the resident was vocal about her care preferences and that missed showers could lead to hygiene and skin issues. Facility staff, including the DON, CNA, Med Aide, LVN, and ADM, acknowledged the importance of regular showers for residents to prevent skin breakdown and maintain hygiene. They also confirmed that the resident did not typically refuse showers and was proactive in communicating her needs. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene, but the observed inconsistencies in shower provision indicated a failure to fully meet these requirements for the resident in question.
Failure to Prevent Misappropriation of Resident Funds by Staff
Penalty
Summary
The facility failed to protect a resident from misappropriation of property by allowing an assistant (AC) to access the resident's bank account, resulting in four unauthorized transactions totaling $10,250. The resident, an elderly female with a history of cerebral infarction and Alzheimer's disease, had moderate cognitive impairment as indicated by a BIMS score of 12. The resident reported that the assistant convinced her to add the assistant to her bank account under the pretense of helping with finances, but subsequently withdrew funds without the resident's knowledge or consent. Only a portion of the funds was returned to the resident. Staff interviews revealed that a certified medication aide overheard the assistant instructing the resident not to disclose information about the money and reported this to the administrator. The administrator confirmed that the assistant's name appeared on the resident's bank account and that multiple large withdrawals were made. The facility's policy required protection of residents from misappropriation and mandated background checks, but the misappropriation occurred without the facility's awareness until after the funds were taken.
Failure to Enforce Smoking Supervision Policy
Penalty
Summary
The facility failed to follow its established smoking policy for two residents who were reviewed for smoking. Both residents were observed or reported to have smoked without staff supervision and to have kept cigarettes and lighters in their rooms, contrary to facility policy. Specifically, one resident was observed smoking in the designated area without staff present, and she stated that she kept her smoking materials in her purse in her room and smoked whenever she wanted. The other resident also reported keeping cigarettes and a lighter in her room and smoking at her discretion, noting that staff were not always present during smoking times. Both residents had care plans indicating the need for staff supervision or adaptations when using tobacco products. Medical records showed that both residents were cognitively intact but had diagnoses including muscle weakness, lack of coordination, and other conditions that could increase their risk during unsupervised smoking. Despite these care plans and diagnoses, the facility did not ensure that staff were present during smoking or that smoking materials were secured as required by policy. Interviews with facility staff, including the HRD, CN, and ADM, confirmed that the policy required staff supervision during smoking and that residents were not to keep smoking materials in their rooms. Staff acknowledged that unsupervised smoking could pose safety hazards, but were unaware of any injuries or incidents resulting from these lapses. The facility's written smoking policy also specified that residents requiring monitoring must be under direct supervision at all times while smoking and may not keep smoking articles except under supervision.
Call Light Not Accessible to Resident with Hemiplegia
Penalty
Summary
A deficiency occurred when a male resident with hemiplegia, chronic kidney disease, heart failure, obstructive uropathy, and atrial fibrillation was found in bed with his call light on the floor behind the head of his bed, out of his reach. The resident, who was alert and had no cognitive impairment, stated he was unaware the call light was on the floor and could not reach it due to his partial paralysis. He expressed that he required the call light to request staff assistance for activities of daily living and would not be able to call for help if needed. The resident did not know how the call light ended up on the floor and confirmed he did not place it there. Staff interviews confirmed that the call light was not within the resident's reach at the time of observation, and staff acknowledged that this posed a safety concern, as the resident would not be able to summon help and could potentially fall if attempting to retrieve it. The facility's policies require that residents have access to a call system from their bed and guarantee residents' rights to a dignified existence and the ability to communicate their needs. The failure to ensure the call light was accessible was observed and confirmed by multiple staff members, including nursing and administrative personnel.
Catheter Bag Found on Floor Violates Infection Control Policy
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with an indwelling urinary catheter. On the date of observation, the resident’s catheter bag was found hanging off the side bed rail with the bottom of the bag resting on the floor. The resident, who had diagnoses including hemiplegia, chronic kidney disease, heart failure, obstructive uropathy, and atrial fibrillation, was unable to see the catheter bag from his position and was unaware it was on the floor. Multiple staff interviews confirmed that the catheter bag being on the floor was an infection control issue, as it could expose the bag and tubing to bacteria and create a risk for infection, especially given the resident’s immunocompromised status. Record review showed that the resident’s care plan included monitoring for signs and symptoms of urinary tract infection and that the facility’s policy required catheter bags and tubing to be kept off the floor. Staff, including RNs, LVNs, and the administrator, acknowledged during interviews that the catheter bag on the floor was a violation of infection control practices and could lead to contamination. The facility’s own policy, updated in July 2024, specifically stated that catheter tubing and drainage bags must be kept off the floor to prevent catheter-associated urinary tract infections.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and there was insufficient oversight by staff to mitigate these risks. The deficiency was identified based on direct observation and review of facility practices related to accident prevention.
Failure to Document and Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for three residents who required oxygen therapy and nebulizer treatments. Specifically, the facility did not ensure that nebulizer masks and oxygen cannulas were changed and documented according to physician orders and facility policy. Observations revealed that one resident's nasal cannula appeared dirty and there was no documentation in the electronic health record (EHR) indicating when it had last been changed. Interviews with the resident and her roommate provided conflicting accounts of when the cannula was last replaced, and staff interviews confirmed that the process for changing and documenting respiratory equipment was inconsistent. Record reviews for the three residents showed active orders for regular changing of oxygen and nebulizer tubing, masks, and cannulas, with specific instructions for weekly changes and documentation in the EHR. However, there was no evidence in the records that these changes were consistently performed or documented. Staff interviews revealed a lack of clarity regarding responsibility and routine for changing respiratory equipment, with some staff stating it should be done weekly, typically on Sundays, and others unsure of the exact process. The facility was also in the process of transitioning to a new EHR system, which contributed to gaps in documentation. The facility's own policy required weekly changing and documentation of oxygen and nebulizer tubing and masks by the nursing department. Despite this, the required documentation was missing, and direct observation confirmed that at least one resident was using respiratory equipment that had not been changed as required. This failure to follow established protocols and document care placed residents at risk for infection, as noted by staff during interviews.
Failure to Provide Effective Communication for Non-English Speaking Resident
Penalty
Summary
The facility failed to ensure the right to a dignified existence, self-determination, and effective communication for a resident with limited English proficiency. The resident, a Spanish-speaking male with diagnoses including diabetes mellitus, diabetic arthropathy, and a cognitive communication deficit, was unable to communicate effectively with staff who did not speak Spanish. The care plan identified the resident's communication needs and included interventions such as the use of visual cues, gestures, flash cards, and a communication board, as well as contacting family or friends for assistance. However, observations revealed that these interventions were not effectively implemented, as the communication board was not accessible or useful to the resident, and staff frequently relied on ad hoc methods such as sign language or seeking out Spanish-speaking staff when available. Multiple staff interviews confirmed that most staff, including those on evening and night shifts, did not speak Spanish and found the communication board ineffective. Staff reported difficulty in assessing the resident's needs, including pain levels, and often depended on non-verbal cues or attempted to find a Spanish-speaking colleague, which was not always possible. The Director of Rehabilitation, who was a Spanish speaker, acknowledged concerns about the lack of Spanish-speaking staff during certain shifts and the resulting communication barriers. The Director of Nursing and Administrator also recognized the importance of communication but indicated that the primary tools available were the communication board and the ability to call a Spanish-speaking staff member by phone, which was not consistently utilized. Review of facility policy confirmed the right of residents to communication and access to services, but no specific policy for non-English speaking residents was provided when requested. Observations and interviews demonstrated that the resident was unable to reliably communicate his needs or understand staff instructions, and the interventions outlined in the care plan were not effectively supporting his communication needs.
Unattended Laptop with Resident Information Left Accessible
Penalty
Summary
A staff member left a facility laptop open and unattended on a medication cart in a hallway, with confidential resident medical information visible on the screen. This occurred while the medication aide was in a resident's room, leaving the laptop accessible to anyone passing by. The observation was confirmed on the specified date, and interviews with multiple staff members—including medication aides, an RN, the DON, and the Administrator—acknowledged that leaving the laptop open and unattended constitutes a violation of HIPAA regulations and facility policy regarding the security of resident information. Staff interviewed stated that leaving the laptop open could allow unauthorized individuals to view or alter resident information. All interviewed staff, including the DON and Administrator, confirmed awareness of the policy and acknowledged that such an action is a breach of confidentiality and resident rights. The report did not mention any specific residents affected or provide details about their medical history or condition at the time of the incident.
Failure to Administer and Document Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident by not ensuring that Acidophilus, a prescribed supplement, was administered as ordered on multiple occasions. Specifically, the medication was not given on several documented dates and times, as evidenced by gaps in the Medication Administration Record (MAR). Interviews with staff confirmed that if a medication is not documented as given in the MAR, it is considered not administered. The staff responsible for administering and documenting the medication did not record its administration, and attempts to interview the medication aide responsible were unsuccessful. The resident involved was an adult male with a history of diabetes mellitus with diabetic arthropathy, cognitive communication deficit, and a need for assistance with personal care. His care plan included interventions for pain management and required medications to be administered as ordered. The facility's policy required medications to be administered and documented in a timely manner, with oversight by nursing leadership. Review of the MAR and staff interviews confirmed that the required documentation and administration did not occur for the specified dates and times.
Failure to Timely Address Resident's Skin Condition
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident who developed a rash under her abdominal fold, causing her significant pain. The resident, who was moderately cognitively impaired and at risk for pressure ulcers due to impaired mobility, reported that a CNA had torn off her brief too quickly, causing the Velcro to scrape her skin. Despite the resident's complaints of pain and the visible rash, the facility did not assess or implement treatment orders in a timely manner. The resident's skin assessment conducted on 11/19/24 by LVN A and the ADON did not note any new skin issues, and no treatment orders were in place until 11/22/24, when Nystatin powder was applied. The resident and a CNA reported that the rash had been present for at least two weeks, and the resident's RP confirmed that the redness had been present for at least a week. The WCN and WCD were not notified of the skin issue, contrary to the facility's procedure, which required nurses to report new skin integrity issues. Interviews with facility staff revealed a lack of communication and follow-through in addressing the resident's skin condition. The DON acknowledged that the redness should have been reported to the WCN for assessment and potential treatment orders. The facility's policy on pressure injury prevention emphasized the importance of regular skin assessments and timely reporting of changes, which were not adhered to in this case.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain good hygiene. Specifically, three residents did not receive showers in compliance with their scheduled shower times. Resident #3, a female with hemiplegia and moderate cognitive impairment, was observed with messy and greasy hair, oily face, and crusty eyes. She reported going long periods without showers, which made her feel sad. Her records indicated she received only seven showers over a month, despite requiring extensive assistance with ADLs. Resident #4, a male with severe cognitive impairment, was observed with a greasy face and stubble, and he reported not receiving regular showers, with the last one being a week prior. His records showed he received only five showers in a month. Resident #5, a female with moderate cognitive impairment, reported going 2-3 weeks without a shower and resorted to sponge baths due to feeling dirty. Her records indicated she received only one shower in nearly a month. The Director of Nursing (DON) stated that residents should receive showers at least three times a week, and any refusals should be documented. However, a policy on ADLs was not provided before the survey exit.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple lapses in protocol during the care of a resident. The resident, a female with a history of dermatitis, type II diabetes, obesity, cellulitis, and muscle wasting, was on enhanced barrier precautions due to a non-pressure wound on her right posterior thigh. During an observation, a CNA did not wear an isolation gown while performing incontinent care for the resident, and used soiled gloves to touch various surfaces, including the light switch and privacy curtains, without changing gloves or performing hand hygiene. The CNA also placed soiled wipes in an unlined trash can and failed to perform hand hygiene after removing gloves. An LVN, who was new to the facility, also failed to adhere to infection control protocols. The LVN did not set up a clean field for wound care supplies, placed soiled dressings in an unlined trash can, and did not change gloves or perform hand hygiene between tasks. The LVN applied wound care products with soiled gloves and contaminated the gloves further by reaching into her pocket. Additionally, the LVN did not perform hand hygiene after glove changes, citing the absence of a sanitizer machine in the room as the reason. Interviews with the CNA and LVN revealed a lack of adherence to the facility's infection control policies, including the use of personal protective equipment and hand hygiene practices. The Director of Nursing confirmed that the facility's policies require gloves and gowns to be worn during wound care for residents on enhanced barrier precautions, and that hand hygiene should be performed after glove removal or when gloves are soiled. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, leading to potential infection control issues.
Inadequate Perineal Care by CNA
Penalty
Summary
The facility failed to ensure that a certified nurse assistant (CNA) had the appropriate competencies and skill sets to provide proper nursing care, specifically in performing perineal care during a disposable underwear change. This deficiency was identified for one of the four CNAs reviewed for competent nursing care. The incident involved a resident who was cognitively intact and required assistance for activities of daily living due to incontinence of bowel and bladder. The CNA did not follow the facility's policy for perineal care, which requires washing the perineal area from front to back, and only wiped the resident when soiled with fecal matter. The deficiency was brought to the attention of the facility's administration by the resident's responsible representative, who reviewed camera footage showing the CNA's failure to perform proper perineal care. The Director of Nursing (DON) was informed, and an investigation was initiated. The resident was assessed by the Assistant Director of Nursing (ADON) and the Social Worker (SW), with no injuries or distress noted. The CNA admitted to not following the procedure and was subsequently counseled and removed from resident care for re-education.
Deficiency in Resident's ADL Care
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident, leading to deficiencies in personal hygiene, grooming, and oral care. The resident, a female with a history of cerebral infarction, depression, and spastic hemiplegia, required extensive assistance with personal hygiene and was dependent on staff for bathing. Despite being scheduled for showers three times a week, the resident reported receiving only five showers and one bed bath over a 60-day period. Observations confirmed that the resident had not been changed into fresh clothing for three days and had dirty dentures and fingernails. The facility's documentation and monitoring systems were inadequate, as evidenced by discrepancies in the Point of Care (POC) logs and shower sheets. The logs inaccurately reflected daily showers for a week, which the Director of Nursing (DON) found unlikely, indicating a lack of proper use of the POC system by aides. The DON, who had been employed for only a short time, acknowledged the need for a procedure to monitor compliance with ADLs and recognized the potential negative outcomes of failing to provide necessary care, such as infections and skin breakdown. Interviews with staff revealed a lack of consistent procedures and understanding of the facility's policies regarding ADL care. The DON and Administrator (ADM) both highlighted the importance of adhering to care plans and accommodating resident preferences, yet the ADM could not locate a specific policy on ADL care provision. Despite in-service training on nail care and personal hygiene, the facility's practices did not align with its policies, resulting in the resident's unmet needs and potential risks to her health and dignity.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure that a resident was safe from sexual abuse. The resident, a 73-year-old female with severe cognitive impairment and multiple medical conditions, alleged that she was sexually assaulted by two men. Despite the facility's initial assessment and the hospital's initial report indicating no signs of sexual assault, a subsequent sexual assault exam revealed the presence of semen in the resident's brief and on and in her vagina. The incident was reported to the facility staff, who then contacted law enforcement and transferred the resident to the hospital for further evaluation. However, the facility's investigation did not identify any alleged perpetrators or witnesses, and the initial findings were deemed unfounded. The facility's records indicated that only female staff worked with the resident on the day of the incident, and the cameras in the area did not record footage, as they were set to stream live feed only. The facility's staff and the resident's family were interviewed, but no conclusive evidence was found to identify the perpetrators. The facility's failure to protect the resident from sexual abuse and the lack of effective monitoring and investigation procedures led to the deficiency.
Sanitation Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. Observations revealed expired food products in the dry storage area, including 19 cans of evaporated milk and 6 containers of prune juice. Additionally, an open container of prune juice past its use-by date was found in the double door refrigerator. The walk-in freezer had two stacks of food product boxes on the floor, which is against the facility's policy. Interviews with the Dietary Manager, Dietitian, and Cook confirmed that expired food products should have been discarded and that food should not be stored on the floor, as these practices could lead to contamination and foodborne illness. The facility's Dietary Services Policy and Procedure Manual mandates that food should be stored off the floor and regularly checked for expiration dates, but these guidelines were not followed. The Dietary Manager admitted that the expired prune juice and evaporated milk should have been discarded and that dietary staff should regularly check dates and discard expired food products. The Dietitian and Cook also confirmed that expired food products should be removed and that failure to do so could result in food poisoning. The facility's policy does not specifically address the storage of food products or boxes on refrigerator/freezer floors, but it does require that all foods be covered, labeled, and dated. The facility's in-service record emphasizes the importance of checking for expired items and ensuring that all food is properly labeled and dated, but these procedures were not adequately followed, leading to the observed deficiencies.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life. There was no documentation of the facility's effort to resolve grievances collected at Resident Council meetings on 11/07/2023, 12/12/2023, and 01/09/2024. This failure placed residents at risk of indignity and diminished quality of life. The Resident Council meetings documented various grievances, including issues with brief sizes, call lights not being answered, staff gossiping, and food quality, among others. However, there was no follow-up or resolution documented for these grievances. During a confidential group interview on 02/21/2024, residents expressed that they had been complaining about staff behavior, call lights not being answered, and food quality for the past 3 to 4 months without any resolution or feedback from the administration. The Activity Director confirmed that she attended all Resident Council meetings and documented the grievances but did not follow up or report back to the residents. The Administrator stated that the Activity Director was expected to give grievances to the appropriate Department Head and report the results back to the Resident Council, which was not done. The facility's policies on filing grievances and Resident Council support were not adhered to, leading to the deficiency.
Verbal Abuse by Social Worker
Penalty
Summary
The facility failed to ensure residents had the right to be free from abuse and neglect, specifically for one resident (Resident #68). The incident involved a social worker who verbally abused Resident #68 by calling him 'stupid' in a moment of agitation. This incident was witnessed by the ADON, who reported it immediately. The social worker was called back to the facility by administration to complete a medical records task and appeared agitated, which led to the verbal abuse. The resident was assessed and reassured by staff members following the incident, and the social worker was suspended during the investigation. The resident expressed that he felt safe in the facility and was not worried about the social worker. Resident #68 had a diagnosis of Vascular Dementia, Anxiety, Acute Congestive Heart Failure, Major Depressive Disorder, Irritable Bowel Syndrome, Acute Kidney Failure, and Chronic Atrial Fibrillation. His MDS assessment indicated normal cognitive abilities, and he was independent in performing all ADLs. The incident occurred near the front entrance and was observed by other residents and staff. The ADON stated that the social worker's behavior was unprofessional and that staff were aware that residents could have behaviors but were not to react negatively. Attempts to reach the social worker for an interview were unsuccessful.
Failure to Maintain Grooming and Personal Care
Penalty
Summary
The facility failed to provide necessary services to maintain grooming and personal care for six residents. Resident #4 had long fingernails with brown debris, a curled toenail emitting a foul odor, and an unkempt beard and hair. Despite being observed on multiple occasions, his grooming issues were not addressed, leading to discomfort and potential infection risks. Resident #69 had long fingernails with debris, an unkempt beard, and soiled clothes. He was unaware of his grooming issues and agreed to have his nails trimmed when informed. The staff acknowledged the infection control and dignity concerns but failed to address them promptly. Resident #81 had a scruffy beard and long, dirty fingernails, which were not addressed in his care plan. Resident #74 had dry, flaky skin, dirty feet, and long toenails causing pain. Despite his complaints, his grooming needs were neglected, leading to potential infection risks. Resident #12 had long, jagged nails that caused self-inflicted scratches. She had repeatedly asked for nail trimming over two weeks, but her requests were ignored. Resident #240 had nails with blackish substance underneath, which was not cleaned despite her request. Interviews with staff revealed inconsistencies in responsibilities and lack of training regarding nail care. CNAs were responsible for trimming nails unless the resident had diabetes, in which case nurses were to arrange for nail care. However, there was no clear protocol or backup plan in place, especially in the absence of a social worker. The facility's policy emphasized maintaining residents' dignity and well-being, but the observed deficiencies indicated a failure to adhere to these standards.
Failure to Provide Scheduled One-on-One Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and supported the physical, mental, and psychosocial well-being of residents, as required by comprehensive assessments and care plans. Specifically, the facility did not ensure that one-on-one activities were provided according to the schedule for three residents. This deficiency was identified through observation, interviews, and record reviews, which revealed that the residents did not receive the necessary in-room activities for the months of January and February 2024. Resident #6, a legally blind female with severe cognitive impairment and depression, did not receive any one-on-one activities or attend group activities during the specified period. Her care plan indicated a preference for in-room activities and a risk for mood instability. The Activity Director confirmed that Resident #6 did not receive the required visits and acknowledged the potential negative impact on her mental and social well-being. Similarly, Resident #36, who had severe cognitive impairment and multiple physical disabilities, did not receive any in-room or group activities. Her care plan also highlighted a preference for in-room activities and a risk for social isolation. The Activity Director admitted that Resident #36 did not receive the necessary activities and recognized the potential for increased depression and anxiety. Resident #37, with severe cognitive impairment and physical disabilities, also did not receive the required one-on-one activities or attend group activities. The Activity Director noted that Resident #37 would benefit from music and other in-room activities but did not receive them, potentially leading to boredom and cognitive decline.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice. For Resident #18, the facility did not date, bag, or replace the nebulizer tubing and mouthpiece every seven days. Observations revealed that the nebulizer mouthpiece was found on the floor and the oxygen tubing was undated and unbagged. Resident #18's care plan did not include any problem area for oxygen or nebulizer treatment, and there were no physician orders regarding the care of the nebulizer equipment. Staff interviews confirmed that the equipment was not properly maintained, which could lead to respiratory infections. For Resident #19, the facility failed to date and replace the oxygen tubing and mask every seven days, and the air filter for the air concentrator was not cleaned and was covered in debris. Observations showed that the oxygen tubing and humidifier bottle were undated, and the nebulizer mask was not bagged and displayed an outdated date. Resident #19 confirmed that she was continuously on oxygen and used the nebulizer, and staff interviews indicated that the equipment was not properly maintained. The hospice RN and other staff members acknowledged that the failure to change and date the equipment could result in respiratory infections. The facility's Respiratory Therapy - Prevention of Infection Policy outlined specific procedures for maintaining respiratory equipment, including changing oxygen tubing and nebulizer setups every seven days and cleaning air filters weekly. However, the facility did not adhere to these protocols, as evidenced by the undated and unbagged equipment for both residents. Staff interviews and record reviews further confirmed the lack of proper documentation and maintenance, highlighting a significant deficiency in the facility's respiratory care practices.
Failure to Ensure Call Lights Were Within Reach
Penalty
Summary
The facility failed to ensure that residents received services with reasonable accommodation of their needs, specifically regarding the accessibility of call lights. Observations revealed that five residents had their call lights out of reach, which could prevent them from calling for assistance when needed. For instance, Resident #54, who was totally dependent on staff for movement, had her call light on the floor and out of reach. Similarly, Resident #24, who required substantial assistance for transfers, also had his call light on the floor and out of reach while he was in bed with a wound vac attached to his left foot wound. Resident #52, who was legally blind and at risk for falls, was found in her bed with her call light on the floor, and she was unaware of its location. Resident #81, who was dependent on a manual wheelchair for indoor mobility, had his call light under his bed and out of reach. Lastly, Resident #69, who required substantial assistance for transfers and had a history of falls, was observed in his wheelchair with his call light on the floor. A CNA present in the room acknowledged that having call lights on the floor could create fall risks. Interviews with staff, including the ADON, Nurse Consultant, and Administrator, confirmed that the expectation was for call lights to be within reach of residents to prevent potential dangers such as falls or unmet needs. The facility's policy on answering call lights also emphasized the importance of ensuring call lights are within easy reach of residents when they are in bed or confined to a chair.
Failure to Complete Timely Admission Assessment
Penalty
Summary
The facility failed to conduct an accurate comprehensive assessment of a resident's functional capacity. Specifically, the facility did not complete the admission assessment for a resident within the required 14-day period. The resident, a [AGE] year-old female, was admitted with multiple diagnoses including muscle wasting, lack of coordination, difficulty in walking, chronic kidney disease, pneumonia, fluid overload, metabolic encephalopathy, and essential hypertension. Despite these complex medical conditions, the admission MDS assessment was still in progress and had not been signed by an RN as of the survey date, which was beyond the required completion date. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of Medicaid MDS assessments. The Nurse Consultant and MDS Coordinator both indicated that someone from the corporate office was responsible for these assessments, but neither knew the person's name. The Administrator confirmed that the MDS assessment should have been completed within 14 days of admission and acknowledged that the resident might not receive appropriate care without a completed assessment. The facility's policy also mandates that the interdisciplinary assessment team conduct timely resident assessments within 14 days of admission to describe the resident's capability to perform daily life functions and identify significant impairments in functional capacity.
Failure to Develop Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop a comprehensive care plan within seven days after the comprehensive assessment was required to be completed for a resident. The resident, a [AGE] year-old female with multiple diagnoses including muscle wasting, lack of coordination, difficulty in walking, chronic kidney disease, pneumonia, fluid overload, metabolic encephalopathy, and essential hypertension, was admitted on [DATE]. The comprehensive care plan was not completed when reviewed on 02/24/2024, and the Admission MDS Assessment was still in progress as of 02/22/2024. Interviews with the Nurse Consultant, MDS Coordinator/LVN, and the Administrator revealed that the comprehensive care plan was expected to be completed within 21 days of admission, and the baseline care plan within 48 hours of admission. The Nurse Consultant acknowledged that without a completed MDS or comprehensive care plan, nursing staff might not know the appropriate care needed for the resident, potentially leading to improper care methods such as incorrect transfers. The facility's policy on care plans, revised in December 2016, stated that the comprehensive, person-centered care plan should be developed within seven days of the completion of the required comprehensive assessment (MDS).
Failure to Follow Protocol After Resident Fall
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice. Specifically, the facility did not assess Resident #29 prior to moving her after she fell from her bed to the floor. This failure was observed when the Director of Therapy moved Resident #29 from the floor to the bed without conducting necessary assessments, despite being instructed by LVN B to wait until pain assessments, vital signs, and other evaluations were completed. The Director of Therapy ignored these instructions and proceeded to move the resident and perform range of motion exercises, which was against the facility's protocol for handling falls. Resident #29, an elderly female with a history of repeated falls, dizziness, muscle weakness, and other significant medical conditions, was found on the floor by her bed. Her medical records indicated severe cognitive impairment and a need for assistance with activities of daily living. Despite these conditions, the Director of Therapy moved her without waiting for the required assessments, potentially putting her at risk for further injury. Interviews with the staff, including LVN B, the Director of Therapy, the Nurse Consultant, and the Administrator, confirmed that the facility's protocol was not followed. The Director of Therapy admitted to making a mistake and acknowledged that she should have waited for the nurse to complete the necessary assessments. The facility's policy on falls required that a nurse assess and document vital signs, neurological status, and pain before moving a resident who had fallen, which was not adhered to in this case.
Expired Medications Found in Storage and Treatment Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions and expiration dates. This deficiency was observed in the Pod 2 medication storage room, medication cart, and nurse treatment cart. Specifically, five bottles of medications in the Pod 2 medication storage room, two medications in the Medication Aide cart, and one bottle of aspirin in the nurse treatment cart were found to be past their expiration dates. The staff, including an agency nurse and a medication aide, were unaware of the facility's policies regarding the checking and removal of expired medications. During interviews, the agency nurse and medication aide both indicated a lack of formal training and clarity on who was responsible for auditing the carts and storage rooms for expired medications. The Assistant Director of Nursing (ADON) confirmed that the nurses were primarily responsible for checking the medications, followed by the ADON. The ADON acknowledged that expired medications could potentially be ineffective in treating residents' conditions, posing a risk to their health.
Failure to Provide Accessible Survey Results to Residents
Penalty
Summary
The facility failed to place the most recent survey results in a location that was easily accessible to residents, as required by regulations. Observations on multiple occasions revealed that the survey book was not located in common areas frequented by residents, and there was no clear signage indicating its location. A small, hard-to-read sign was found on the receptionist's desk, which was too high for residents in wheelchairs to see. Interviews with the receptionist and the Activity Director confirmed that they were unaware of the survey book's location, and the receptionist stated that the book was sometimes kept behind the desk, making it inaccessible to residents, visitors, and families. In a group interview, nine residents expressed that they did not know where or how to access the survey results and were unaware that such a manual existed. They indicated a preference for being able to reach the manual themselves without having to ask for it. The Activity Director and the Administrator both acknowledged that residents have the right to view past surveys and that the current placement of the survey book and signage did not facilitate this. The facility's policy on Resident Rights, revised in January 2011, reflected that residents had the right to examine survey results, but this was not being effectively communicated or facilitated in practice.
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What surveyors actually found near you
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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.
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Illustrative
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Nursing homes near Killeen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosewood Heights | 0.6 mi | ★★★★★ | 5 | 0 |
| Harker Heights Nursing & Rehabilitation | 5.1 mi | ★★★★★ | 6 | 0 |
| Hill Country Heights | 9.6 mi | ★★★★★ | 7 | 0 |
| Copperas Cove Nursing & Rehabilitation | 10.5 mi | ★★★★★ | 12 | 0 |
| Creekside Terrace Rehabilitation | 15.1 mi | ★★★★★ | 3 | 0 |
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