Avir At Lindale

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency in the facility’s food and nutrition services related to improper storage, labeling, dating, and documentation of food items in the kitchen. During observations in the kitchen refrigerator, surveyors found eight covered cups containing a pudding-like substance that were not labeled or dated, one container of pureed liquids that was not covered, dated, or labeled, four covered bowls of salad that were not labeled or dated, six cups of orange liquid that were not dated or labeled, three covered containers of a milk-like substance that were not dated or labeled, and four covered cups of red liquid that were not dated or labeled. Additionally, two one-gallon pitchers, one containing a brown tea-like liquid and one containing a red liquid, were not dated or labeled. A large metal pan covered with tinfoil containing several smaller items wrapped in tinfoil, identified by the Dietary Manager as sweet potatoes, was also not dated or labeled. In the dry food storage area, surveyors observed bowls being used as scoops inside the flour and cornmeal bulk bins, and a box of dry pinto beans dated 4/7/2026 that had been opened but not resealed. These conditions were noted during the same kitchen observation period and reflected failures to follow sanitary food storage practices and to protect food from contamination as required by the Texas Food Establishment Rules and the facility’s own policies. The report does not identify specific residents by number or medical condition, but the cited deficiency applies to all residents who receive food prepared and stored in the facility kitchen. Surveyors also determined that the facility failed to maintain and produce temperature logs for the hot food line. At the time of the investigation, no temperature logs were available for review. A dietary aide reported that staff typically check food temperatures prior to service, such as checking grease temperature while cooking chicken strips, but acknowledged that temperatures are not consistently documented. The Dietary Manager confirmed that food temperature logs were not consistently maintained and that existing logs and records had been discarded or removed by a previous dietary manager. Although the Dietary Manager stated she currently checked temperatures of each dish on the menu, she was unable to provide documentation for review, resulting in a deficiency related to failure to document and verify compliance with required hot and cold holding temperatures as outlined in the FDA Food Code and facility policies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. During observations on 02/08/2026, the handwash sink by the pantry door had no hand soap in the dispenser, and the kitchen employee restroom also had no soap in the dispenser. There were no foot-operated trash cans at the handwash sinks, and employees were observed using 55-gallon trash cans and removing the lids with clean hands. In the pantry, the bulk sugar bin had a plastic bowl being used as a scoop left inside the product. Multiple food-contact and nonfood-contact surfaces were observed soiled. The microwave by the kitchen door was heavily soiled with food debris, splatters, and spills on the rotating platter, walls, and door. Several reach-in stainless steel coolers and freezers had dried spills, splatters, food debris, and fingerprints on shelves, door sills, vents, gaskets, hinge areas, and handles. The drip pan under the stove burners was caked with thick black substances, burned food debris, liquids, and a paper clip. The deep fryer contained dark oil with fried bits floating on the surface, fries on the drain ledge, and heavy built-up oil on the back area. Food storage and labeling practices were also deficient. Thickened liquid products in the cooler and beverage containers placed in the ice bin had no open dates, despite packaging instructions that they could be kept only a limited number of days after opening. An opened box of frozen chickenless tenders was not reclosed and sealed. Hamburger meat was thawing on top of a cardboard container instead of in a container or on a tray to catch juices. A prepared pan of fruit gelatin had no label or date. During tray line service, pureed foods were placed in individual bowls on the steam table, but pureed bread was not served to residents receiving pureed diets.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the menu was followed for 1 of 1 meals reviewed for menus and nutritional adequacy. The planned noon menu for 02/09/2026 included beef chili, boiled squash, scalloped potatoes, cornbread, and cake with frosting, and the diet spreadsheet indicated residents on pureed diets were to receive pureed bread, 2 ounce (#16 dip). During an observation and interview in the dietary department at 11:45 AM, the DM retrieved a zipped plastic bag labeled as pureed bread from the cooler, placed it on the serving line, and placed a #16 dipper on top of the bag. She stated the bread was not cornbread but regular bread. During tray line service from 12:10 PM to 12:55 PM, dietary trays containing pureed food items did not have pureed bread placed on the plates or in a dish on the trays. The DM was not present at the serving line during the entire meal service. During an interview at 1:05 PM, the DM said it was the cook's responsibility to place the pureed bread on the dietary trays and said she expected bread to be served to all residents if it was part of the menu. A facility Diet Roster dated 02/10/2026 showed 4 residents receiving pureed food from the kitchen. The facility policy titled Menu Checklist: Nutritional and Regulatory Requirements stated grains include breads and that minimum daily grain equivalents include bread.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure MDS data was electronically transmitted to the CMS system within 14 days after completion of the assessment for 1 of 1 resident reviewed for assessments, Resident #77. Record review showed Resident #77 was a re-admission dated 9/20/2025, and the most recent MDS assessment was dated 09/21/2025. During an interview on 02/10/2026 at 10:30 AM, the MDS Coordinator stated that Resident #77 was admitted on [DATE] and that the submission was missed due to oversight. She said the MDS should have been transmitted on 10/4/2025 and that the facility uses CMS's RAI Assessment Transmission policy because it does not have its own policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to post a list of names, addresses, and telephone numbers for all pertinent State agencies and advocacy groups in a form and manner accessible and understandable to residents and resident representatives for 1 of 1 facility bulletin boards. During observation on 02/09/2026 at 3:15 PM, the required posting board did not display the contact information for the Medicaid Fraud Control Unit. During interviews later that day, the SW stated he was unsure where the required posting was located or whether it was posted, the DON stated she was unsure where it was located or whether it was posted, and the ADM stated that he did not have the required posting available to residents. On 02/10/2026 at 10:50 AM, the ADM stated there was no specific facility policy on required postings and that the facility follows HHS and CMS guidelines.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents had reasonable access to receive their mail in a timely manner for 1 of 9 confidential residents reviewed. During a confidential group interview, one resident stated they had been expecting a package on a Saturday but did not receive it until the following Monday. An interview with Receptionist A indicated that mail was delivered to a Post Office Box in town, picked up throughout the week, and then distributed directly to residents, but she was unsure whether mail was obtained on Saturdays. An interview with the ADM, Human Resources manager, and Business Office manager confirmed there was no process for obtaining and distributing mail from the Post Office Box to residents on Saturdays, and the ADM stated the key to the Post Office Box had not been made available to the weekend receptionist. Record review of the February 2021 Resident Rights policy stated residents have rights to communication with and access to people and services, access to a telephone, mail, and email, and to communicate in person and by mail, email, and telephone with privacy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to display information on how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by those benefits on its required postings bulletin board. During an observation on 02/09/2026 at 3:15 PM, the required posting for Medicare and Medicaid benefits was not displayed in the bulletin board area that was observed. During interviews on 02/09/2026, the SW stated he was unsure where the required posting was located or whether it was posted, the DON stated she was unsure where it was located or whether it was posted, and the ADM stated it might be in the admissions office but was not made available to residents. The Admissions Director stated there was nothing posted in the facility regarding how to apply for and use Medicare and Medicaid benefits, although she was available to help residents if needed. On 02/10/2026, the ADM stated there was no specific facility policy on required postings and that the facility follows HHS and CMS guidelines.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to submit a required 5‑day follow‑up investigation report to the State Survey Agency after an allegation related to potential neglect/abuse was reported. A male resident with dementia and myelopathy, who had a quarterly MDS showing a BIMS score of 08 indicating moderate cognitive impairment, experienced a fall. During a subsequent care plan meeting, the resident’s family raised concerns to staff about the inaccuracy of the timing of documentation of the fall. The facility initiated an investigation, and the allegation was reported to the State Survey Agency through TULIP as an intake. The facility’s internal provider investigation report documented that the family’s concerns were addressed and that the investigation outcome was inconclusive. Record review of the TULIP website showed that, for the specific intake number associated with this allegation, no 5‑day report or provider investigation report had been submitted. The Administrator stated in interview that, to his knowledge, he did not send in the 5‑day investigation report for this incident and was unsure what had happened, speculating there may have been an internet outage but providing no confirmation. He acknowledged that the interventions were implemented but the report itself was not turned in to the State Survey Agency. This failure occurred despite a facility policy on Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, which requires the Administrator to provide a follow‑up investigation report within five business days of the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect two residents from abuse and neglect. In the first incident, a female resident with a history of stroke, severe cognitive impairment, and significant physical limitations required moderate to maximal assistance with activities of daily living. On the morning of the incident, a CNA, identified as agency staff, assisted the resident with morning care. During the process, the CNA grabbed the resident by the arm, resulting in a skin tear on the resident's left forearm. The resident reported that the aide was being too rough and that she had told the aide to stop. A roommate corroborated that the resident was vocalizing distress and that the aide continued to dress her despite her protests. The facility did not have a personnel file for the agency CNA involved in the incident. In the second incident, another female resident with moderately impaired cognition, limited mobility, and a need for extensive assistance with bathing was left unattended in the shower by a CNA. The CNA left the resident alone to retrieve a towel, during which time the resident remained unsupervised. The CNA later reported that the resident refused care and became physically aggressive, after which the CNA left the facility before the end of her shift. The resident was later assisted out of the shower by another staff member. Facility policy explicitly states that residents requiring shower assistance are never to be left alone during bathing. Both incidents were confirmed through interviews, record reviews, and facility documentation. The facility's own policies require staff to use safe lifting and movement techniques and to remain with residents during bathing. The actions and inactions of the CNAs involved directly resulted in the residents not being protected from abuse and neglect, as required by facility policy and regulatory standards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents who were unable to perform activities of daily living (ADLs) received necessary services to maintain good personal hygiene, specifically regarding appropriate incontinent care. Three residents were identified as not receiving proper care: one resident was observed wearing two saturated briefs at the same time, a practice known as double briefing, which is not permitted by facility policy. Two other residents reported having been double briefed in the past, although they could not recall specific dates or staff involved. Observations and interviews confirmed that double briefing had occurred, and one resident was found with redness to the buttocks during care. Medical records indicated that the affected residents had significant physical and cognitive impairments, including chronic respiratory failure, heart failure, diabetes, quadriplegia, dementia, and incontinence. Care plans for these residents included interventions such as regular checks for incontinence and prompt changing of disposable briefs. Despite these interventions, staff interviews revealed that double briefing had been practiced, sometimes at the direction of other staff members, and that staff were aware this was not acceptable due to the risk of skin breakdown and infection. Staff interviews further confirmed knowledge of the facility's expectations regarding incontinent care, with several CNAs and an LVN stating that double briefing was not allowed and could lead to skin integrity issues. Documentation showed that at least one CNA had received training indicating not to double brief residents. Facility policies reviewed emphasized the importance of cleanliness, comfort, and prevention of infection and skin irritation, but the observed and reported practices did not align with these standards.

Penalty

Inspection fine: $12,425

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide adequate supervision and a timely response to a call light for a resident with multiple risk factors for falls. The resident, who had diagnoses including Parkinson's disease, ataxia, osteoporosis, and moderate cognitive impairment, was care planned as a fall risk and required moderate assistance with transfers. On the morning of the incident, the resident activated her call light and called for help while sitting on the side of her bed. After waiting without receiving assistance, she attempted to get up on her own and subsequently fell, resulting in a sprained left ankle. The fall was unwitnessed and occurred during a shift change, a period when staffing was affected by a CNA no-show. Multiple staff interviews confirmed that the call light was on when the resident was found on the floor, but staff were unable to determine how long it had been activated. Video footage reviewed by facility leadership and the resident's responsible party showed the resident calling for help and falling after not receiving timely assistance. The facility's incident and accident reports indicated a pattern of unwitnessed falls during the night shift in the weeks surrounding the incident. At the time of the fall, the resident was found on the floor by incoming CNAs, who notified the nurse on duty. The nurse assessed the resident, who initially denied injury, but later complained of ankle pain and was sent to the hospital, where a sprain was diagnosed. The failure to respond promptly to the call light and provide adequate supervision during a known high-risk period directly contributed to the resident's avoidable fall and injury.

Penalty

Inspection fine: $12,425

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed multiple failures in the facility's kitchen regarding food storage, preparation, and sanitation practices. Staff were not wearing required beard nets, and several large baking sheets and steam table pans were found with carbon build-up, moisture, water, and food particles inside. The three-compartment sink was filled with dirty pots and pans, and the steam table had food splatter on the glass. Dried blood was found on the floor near a handwashing sink, which lacked soap and paper towels, and the hand sanitizer at the kitchen entrance was empty or broken. Trash and debris were present in multiple areas, and an open package of meat in the refrigerator was unlabeled and not sealed. The refrigerator door was left open with frost buildup, and expired food was found on the counter. Temperature logs for refrigerators and freezers had not been maintained since a specified date, and there was no evidence of dishwasher sanitization testing or cleaning logs for October. The ice machine seal was dirty and not listed on the cleaning log. Interviews revealed that staff had not been in-serviced on kitchen sanitation, serving sizes, or food temperatures, and the dietary manager was absent and had recently quit. Some staff were unsure if all dietary staff had food handler certifications, and one dishwasher reported not being trained on dishwashing or sanitization procedures. The administrator and ADON were unaware of the kitchen's condition, and there was no documentation of staff training on kitchen sanitation. These findings indicate a failure to comply with professional standards for food service safety, potentially placing residents at risk.

Penalty

Inspection fine: $12,425

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide residents and their representatives with adequate information regarding their rights to file grievances, including the grievance procedure, access to grievance forms, information about the grievance officer, and the process for filing anonymous grievances. During record review, it was found that 9 out of 13 grievances had not been followed up by the grievance officer or administrator. Interviews revealed that the Resident Council President and other staff were aware of grievances that had not received responses, and there was no system in place for submitting grievances anonymously. Grievance forms were only available outside the social worker's office, and the process for handling grievances was not consistently followed. The administrator and social worker (grievance officer) acknowledged that several grievances had not been addressed and that there was a lack of follow-up. The assistant director, who helped residents file grievances, stated she was not informed of the outcomes. The facility's grievance policy required prompt notification and written responses within five working days, but this was not consistently implemented. The lack of proper grievance handling and communication placed residents at risk of having their concerns unresolved.

Penalty

Inspection fine: $12,425

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide palatable, appetizing, and appropriately tempered food for residents during the noon meal on 10/28/2025. Multiple residents and a family member reported dissatisfaction with the food, describing it as cold, unappetizing, overly salty, or lacking in flavor. Observations during meal service confirmed that food items such as spaghetti and garlic bread were served cold or hard, salads were only cool, and drinks were missing from trays. Test trays prepared for surveyors also reflected these issues, with the Registered Dietitian (RD) present and agreeing that the food was not hot, bread was hard, and drinks and desserts were missing from some trays. Interviews with residents revealed consistent complaints about the quality and temperature of the food, with several stating that meals were not enjoyable and sometimes inedible. The Administrator acknowledged the absence of a dietary manager, who had recently resigned, and stated that the facility's policy requires food to be nourishing, palatable, and served at safe temperatures. The facility's own policy on food preparation and service, revised in November 2022, mandates compliance with safe food handling practices, which was not met during the observed meal service.

Penalty

Inspection fine: $168,062

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate respiratory care for two residents requiring tracheostomy care, leading to significant deficiencies. One resident, a female with a history of cardiac arrest, cerebral infarction, pneumonia, and pulmonary edema, experienced respiratory distress due to an obstructed tracheostomy inner cannula. Despite attempts to suction, the obstruction was not cleared, resulting in the resident's hospitalization and subsequent death. The medical director indicated that standard practice would involve removing the inner cannula to check for obstructions, which was not done in this case. Another resident, a male with acute and chronic respiratory failure and pneumonitis, also did not receive proper tracheostomy care. The facility lacked full-time qualified staff to perform necessary tracheostomy care, relying instead on a respiratory therapist who was only available on a PRN basis. The Director of Nursing stated that nurses were not permitted to remove or change cannulas, which contradicted the expectations set by the Regional Nurse, who indicated that nursing staff should be able to perform such tasks for certain types of tracheostomies. These failures resulted in the identification of an Immediate Jeopardy situation, as the facility did not ensure that residents received care consistent with professional standards. The lack of proper tracheostomy care placed residents at risk for serious harm, impairment, or death, highlighting significant deficiencies in the facility's ability to provide necessary respiratory care and services.

Removal Plan

• Nursing staff will be in-serviced to respond to medical emergencies for residents, when their tracheostomy becomes clogged, a mucus plug is identified, or resident is having difficulty breathing.
• Resident #2 will be provided for appropriately, with having all nurses trained in decannulation/re-cannulation of tracheostomy, in the case of a mucus plug/blockage, by the facility respiratory therapist, or by the Director of Nursing, who will be trained by the facility respiratory therapist.
• The Director of Nursing, Clinical Support Specialist, and VP of Clinical Operations will deliver all following in-service education to nurses one on one. All nursing staff will be in-serviced prior to them arriving to the facility for their next shift. Competency with return demonstration will be completed.
• The DON will review new hire orientation packet to ensure these above in-services are completed prior to the first shift on the floor, including tracheostomy competencies including decannulation/re-cannulation emergency procedures.
• Facility policy was updated to reflect decannulation and re-cannulation of tracheostomy is necessary in an emergency situation where the airway is compromised by a mucus plug, and the suction catheter meets resistance.
• Physician orders added to each resident with a tracheostomy, to include, may decannulate and re-cannulate tracheostomy if unable to establish patent airway or mucus plug present, per LVN/RN.
• Resident orders updated to include a tracheostomy one size smaller to be included in emergency supply box at bedside.
• The 24-hour report in the EMR which runs all progress notes in real time, will be monitored daily in the clinical meeting for changes in condition by the clinical team, DON/ADON/MDS.
• The DON or designee will perform random in person audits with nursing staff to ensure they understand the tracheostomy decannulation/re-cannulation procedure.
• DON/ADON's will make rounds daily, the weekend RN supervisor will round on all residents on the weekend, on all residents in facility to ensure no changes in condition are in progress regarding trach status.
• The Director of Nursing and VP of Clinical Operations viewed each resident with a tracheostomy to ensure all emergency supplies were present at bedside.
• An interim QAPI committee meeting was completed.
• IDT will review for compliance monthly in QAPI.

Penalty

Inspection fine: $168,062

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and glove use among staff members. During incontinent care for a resident, CNAs failed to change gloves and perform hand hygiene, and one CNA reused disposable wipes multiple times without folding them, which could lead to cross-contamination. The CNAs admitted to being nervous during the observation, which contributed to their mistakes. In another instance, the Treatment Nurse did not change gloves or perform hand hygiene while performing wound care on two residents. The nurse also failed to wear appropriate personal protective equipment (PPE) during the procedure. Additionally, the facility did not have enhanced barrier precautions (EBP) in place for a resident with a stage 3 pressure ulcer, and the necessary signage was missing from the resident's door. The Treatment Nurse acknowledged the importance of EBP and admitted to oversight in implementing it. The facility also failed to manage a resident's suction canister properly, leaving it unemptied for four days after the resident was discharged to the hospital. This oversight could lead to bacteria build-up and potential infection risks. The Regional Nurse confirmed that suction canisters should be emptied after each use to prevent bacterial growth. These deficiencies highlight significant lapses in infection control practices, potentially putting residents and staff at risk for infection and cross-contamination.

Penalty

Inspection fine: $168,062

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the dignity and respect of a resident by not ensuring that her urinary catheter drainage bag was covered with a privacy bag as required. This deficiency was observed on multiple occasions, specifically on three separate days, where the resident's catheter drainage bag was left uncovered and facing the door. The resident, who was cognitively intact and able to communicate effectively, expressed that the lack of privacy cover bothered her. The facility's policy and the resident's care plan both indicated the necessity of a privacy cover for the urinary catheter drainage bag to maintain the resident's dignity. Interviews with facility staff, including a CNA, an LVN, and the Regional Nurse, confirmed that it was the responsibility of the nursing staff to ensure privacy covers were used on urinary catheter drainage bags. The staff acknowledged the importance of these covers for maintaining resident dignity. Despite this, the resident's catheter bag remained uncovered, indicating a lapse in adherence to the facility's policies and procedures regarding resident dignity and privacy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain sanitary conditions in its kitchen, which could potentially place residents at risk of foodborne illness. Observations revealed that the dry pantry was unclean, with dried spills, scattered beans, and pieces of paper and cardboard on the floor. Containers on the open wire rack were found to be sticky and greasy, with flour-like, cornmeal-like, and dirt-like substances on their lids and bodies. Additionally, food items in the cooler were not labeled or dated, and some trays contained unknown food products without labels or dates. The facility's freezers and coolers were also found to be in unsanitary conditions. The handles and fronts of the freezers were soiled with food debris and unknown substances, and vents were covered with food and dried liquid splash. In one cooler, a 10 lb. chub of hamburger meat was thawing improperly, with blood seeping out and pooling on the shelf. The deep fryer was noted to have a buildup of grease and floating food detritus, and stainless steel serving pans were stacked wet and greasy, indicating they were not air-dried before storage. Interviews with the dietary manager and administrator revealed that the facility was experiencing staffing issues, with the previous dietary manager having left abruptly and new employees still being trained. The dietary manager from a sister facility was temporarily managing the kitchen and acknowledged the unsanitary conditions, noting that corrective actions were being taken. Facility policies on sanitation and food safety were reviewed, highlighting the need for clean and sanitary food service areas and proper date marking of food items.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with End Stage Renal Disease on hemodialysis. The baseline care plan did not include instructions for managing the resident's fluid restrictions, which were part of the admission physician orders. The resident's medical records, including the Medication Administration Record (MAR) and meal ticket, lacked any indication or instructions for fluid restrictions, leading to a lack of awareness among staff members about the resident's needs. Interviews with the resident and various staff members, including a medication aide, a charge nurse, and dietary staff, revealed that none were aware of the resident's fluid restrictions. The resident himself was unaware that sodas counted towards his fluid intake. The facility's policy on baseline care plans required that such plans include initial goals based on admission orders and dietary instructions, but this was not adhered to in the case of the resident, resulting in a deficiency in providing person-centered care that meets professional standards.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain acceptable parameters of nutritional status for Resident #286, who was on fluid restrictions due to End Stage Renal Disease and undergoing hemodialysis. The physician's order for fluid restrictions was not initiated or communicated to the nursing and dietary departments for eight days. The order specified a fluid restriction of 1200cc per day but did not include instructions on how to distribute this amount throughout the day. This lack of communication and clarity in the physician's order led to the resident not receiving the appropriate care to maintain his well-being. Resident #286, a male with moderately impaired cognition, was unaware of his fluid restrictions and continued to consume fluids without limitation. The facility's records, including the Medication Administration Record (MAR) and meal tickets, did not reflect the fluid restrictions, and staff members, including the Medication Aide and Charge Nurse, were not informed of the restrictions. The dietary staff also did not receive any communication regarding the fluid restrictions, resulting in the resident receiving more fluids than prescribed. Interviews with facility staff, including the Vice President of Clinical Operations (VPCO) and Director of Nursing (DON), revealed that the discrepancy between the hospital discharge order and the facility's order was not noticed, and the fluid restrictions were not implemented since the resident's admission. The facility's policy on fluid restrictions was not followed, as the physician's order was not verified, and the distribution of fluids was not communicated to the relevant departments. This oversight placed the resident at risk for fluid overload, which could lead to serious health complications.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure pharmaceutical services were provided to meet the needs of a resident, specifically by not ensuring that medications were administered as ordered. A medication aide, identified as MA C, left a resident's medications unattended at the bedside. The resident, who had multiple diagnoses including End Stage Renal Disease, Diabetes Mellitus, atrial fibrillation, coronary artery disease, chronic obstructive pulmonary disease, and a cerebrovascular accident, was found with a cup of clear liquid and a small plastic container with 12 pills on an over-the-bed table. The resident, who had a BIMS score indicating moderately impaired cognition, was unaware of who left the medications. During an interview, MA C admitted to leaving the medications at the bedside after watching the resident start taking them, without ensuring all medications were consumed. The Director of Nursing (DON) confirmed that the expectation was for medication aides and nurses to stay with residents until all medications were taken, to prevent the risk of residents not receiving their medications as ordered. The facility's policy on medication administration required medications to be administered as ordered, which was not adhered to in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain grooming and personal hygiene for a resident who was dependent on staff for activities of daily living. The resident, who had multiple diagnoses including weakness, muscle wasting, and cognitive deficits, reported that she was not receiving regular showers on her scheduled days. She expressed that the aide responsible for her care often did not return to provide the necessary assistance, leaving her feeling unclean. The resident also mentioned that the aide would sometimes attempt to provide care at inappropriate times, such as early in the morning, which she found disruptive. Interviews with facility staff revealed that the aide in question had been restricted from entering the resident's room and was eventually terminated for poor performance, including not changing residents at night. The facility's records showed that the resident received only 14 out of the 18 scheduled showers over a six-week period. The facility had a policy in place to ensure residents received showers as per their request or scheduled protocols, but this was not adhered to in the case of this resident.

Penalty

Inspection fine: $196,740

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from neglect, specifically in ensuring the availability of necessary emergency medical supplies and adequately trained staff. Two residents, one with acute respiratory failure and morbid obesity, and another with severe cognitive impairment and tracheostomy status, were directly affected by these deficiencies. The facility did not have essential supplies such as AED pads, Ambu bags, and emergency tracheostomy equipment readily available, which are critical for residents with respiratory needs. In one incident, a resident experienced a cardiorespiratory arrest and was without oxygen to the brain for approximately 10 minutes until EMS arrived. The staff was unable to perform adequate emergency care due to the absence of necessary equipment, such as an Ambu bag and AED pads, on the crash cart. Additionally, the staff was not familiar with the resident's care needs, and there was a lack of emergency tracheostomy supplies at the bedside, which contributed to the delay in providing life-saving interventions. The facility also failed to ensure that staff were adequately trained in noninvasive respiratory care and the use of respiratory equipment. Interviews with staff revealed that there was no formal training or competency check-offs for the use of the Trilogy system, which is a noninvasive respiratory support system. This lack of training and preparedness left staff unable to effectively respond to respiratory emergencies, further endangering the residents' health and safety.

Removal Plan

• All nurses will be educated on respiratory therapy for nurses, including but not limited to tracheostomy care, Trilogy care, Tracheostomy suctioning, by the respiratory therapist.
• The VP of Clinical Operations, Clinical Support Specialist, respiratory therapist and ADON will deliver in service education to nurses one on one.
• If emergency items are on back order from the supplier, the facility is able to obtain said supplies from many of our sister facilities. The Director of Nursing, Administrator, ADON, and Treatment Nurse were educated by the VP of Clinical Operations, to notify the VPCO immediately if emergency supplies are back order and are needed by the facility immediately. The VPCO will ensure supplies are obtained from a sister facility.
• Ambu bags, AED, AED Pads, and extra emergency tracheostomy cannulas are available in the facility and on the crash cart, verified by the VP of Clinical Operations.
• Resident #2 has emergency Ambu bag, emergency tracheostomy cannula in a designated red and black tool box, labeled Ambu bag and extra trach, at the bedside, placed by the VP of Clinical Operations.
• Each resident in house with a tracheostomy has the emergency box with supplies at the bedside, placed by the VP of Clinical Operations.
• There are extra emergency Ambu bag toolboxes in the medication room for future residents with tracheostomy's, to be utilized on admission to facility. Nurses were in serviced by the VP of Clinical Operations regarding the new emergency toolboxes. All nurses will be in serviced on this new system before they are able to return to facility for their shift. All new nurses will be trained on this practice prior to starting their shift on the floor. This training will be placed in the clinical orientation packet with HR by the VP of Clinical Operations.
• All nurses were in-serviced by the VP of Clinical Operations regarding checking the crash cart every night to ensure all items are present on the crash cart according to the emergency crash cart checklist, and any items missing from the crash cart, to notify the DON immediately, so the items can be replaced on the crash cart. The 100-hall nurse is designated to check the crash cart every night, this is included on the in-service given to nursing staff by the VP of Clinical Operations. Also included on the in-service was for the nurses to leave any items that are missing from the crash cart, unchecked on the crash cart log. All nurses will be in-serviced on this system prior to returning to their shift. All new nurses will be trained on this practice prior to beginning their shift. This information is added to the clinical orientation with HR by the VP of Clinical Operations.
• All nurses will be educated on the Crash Cart policy and policy for ensuring emergency equipment for tracheostomy residents including Ambu bag and emergency trach are at the bedside of tracheostomy residents.

Penalty

Inspection fine: $196,740

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide basic life support, including CPR, to a resident who required emergency care prior to the arrival of emergency medical personnel. The resident, who was a full code status, experienced a medical emergency where she turned blue and had no pulse or heart rate. When the facility staff requested the crash cart, it was found that essential emergency supplies, such as AED pads and an ambu bag, were missing. This deficiency in emergency preparedness led to a delay in providing the necessary life-saving interventions. The resident, who had a tracheostomy and was at risk for respiratory complications, did not have the required emergency equipment at her bedside as ordered by the physician. The facility nurses were only able to perform chest compressions without the aid of an ambu bag or AED pads. The resident was without oxygen to her brain for approximately 10 minutes before EMS arrived, resulting in severe brain damage and her subsequent placement on hospice care. Interviews with facility staff revealed that there was a lack of familiarity with the resident's care needs and a failure to ensure that emergency supplies were available and accessible. The crash cart had not been properly checked and stocked, as evidenced by missing check-offs on the crash cart checklist. Staff members reported that they were informed by the former DON that the necessary supplies were on back order, which contributed to the unavailability of critical emergency equipment during the incident.

Removal Plan

• All nurses will be educated on the crash cart policy and where to find emergency medical equipment to perform CPR.
• All equipment required, including but not limited to, Ambu bag, AED, AED pads, and emergency tracheostomy cannulas, will be available for use in the facility, and at the bedside of tracheostomy residents, and on the crash cart.
• The VP of Clinical Operations, Clinical Support Specialist, and ADON will deliver in-service education to nurses one on one.
• Ambu bags, AED, AED Pads, and extra emergency tracheostomy cannulas are available in the facility and on the crash cart, verified by the VP of Clinical Operations.
• Resident #2 has emergency Ambu bag, emergency tracheostomy cannula in a designated red and black tool box, labeled Ambu bag and extra trach, at the bedside, placed by the VP of Clinical Operations.
• Each resident in house with a tracheostomy has the emergency box with supplies at the bedside, placed by the VP of Clinical Operations.
• There are extra emergency Ambu bag toolboxes in the medication room for future residents with tracheostomy's, to be utilized on admission to facility.
• Nurses were in-serviced by the VP of Clinical Operations regarding the new emergency toolboxes.
• All nurses will be in-serviced on this new system before they are able to return to facility for their shift.
• All nurses were in-serviced by the VP of Clinical Operations regarding checking the crash cart every night to ensure all items are present on the crash cart according to the emergency crash cart checklist, and any items missing from the crash cart, to notify the DON immediately, so the items can be replaced on the crash cart.
• Nurses to leave any items that are missing from the crash cart, unchecked on the crash cart log.
• All nurses will be educated on the Crash Cart policy and policy for ensuring emergency equipment for tracheostomy residents including Ambu bag and emergency trach care at the bedside of tracheostomy residents.
• The facility respiratory therapist educated all nurses on the use of the Ambu bag in case of respiratory distress during the on-site training.
• All nurses will be in-serviced on this policy before they return to facility for their next shift by the facility respiratory therapist or RN trained by the facility respiratory therapist before beginning their next shift.
• All nurses on staff at this time besides one that is in the hospital, have been in-serviced by the VP of Clinical Operations.
• All new nurses will be educated on the policy for crash cart and emergency tracheostomy supply boxes prior to starting their shift.
• This information will be included in the orientation packet.
• Will review for compliance in QAPI.
• The DON/designee will monitor daily to ensure all items are present on crash cart and the nurse who checked the crash cart initials are on the crash cart log.
• Nurses call the DON with any missing items.

Penalty

Inspection fine: $115,764

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary treatment and services to prevent the development and deterioration of pressure injuries for a resident. The resident, who was readmitted with chronic conditions such as chronic kidney disease, diabetes, hypertension, and congestive heart failure, was at risk for developing pressure ulcers. Upon admission, the resident had one stage 3 pressure ulcer and two unstageable pressure ulcers. Despite having orders for wound care to be performed twice daily, the resident did not receive 6 out of 10 scheduled treatments for MASD on the bilateral buttocks, leading to the deterioration of the condition into a necrotic unstageable pressure ulcer. The facility also failed to follow its policy by not assessing the resident's deteriorating wound. The care plan required monitoring and documenting the location, size, and treatment of skin injuries, and reporting any abnormalities to the physician. However, the facility did not have a system in place to ensure that treatments and assessments were performed as ordered and per policy. The wound care doctor noted that several factors, including incontinent care not being performed timely, lack of turning and repositioning, and decreased nutrition, could have contributed to the deterioration of the resident's wound. The facility's documentation of wound treatments policy required accurate documentation of wound assessments and treatments, including response to treatment and changes in condition. However, the facility did not adhere to this policy, as evidenced by the lack of documentation for the resident's wound care on specific dates. This failure resulted in the identification of an Immediate Jeopardy situation, indicating a serious threat to the health and safety of the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, which is necessary to provide effective and person-centered care. Resident #1, a male with diagnoses including heart failure, muscle weakness, diabetes, hypertension, and difficulty walking, did not have a completed baseline care plan. The sections for activities of daily living, fall/safety/restraints/alarms, nutrition, pain, skin, sensory needs, elimination, infection, anticoagulant therapy, treatment(s)/procedures, and physician orders were not filled out, and the care plan was neither locked nor signed. Resident #2, a female with diagnoses including dementia, weakness, atrial fibrillation, chronic obstructive pulmonary disease, and hypertension, also did not have a baseline or comprehensive care plan. The Director of Nursing (DON) confirmed the absence of the care plan and acknowledged that the facility had an action plan to address this issue. The MDS Coordinator, who was responsible for initiating the baseline care plans, had been on vacation, contributing to the delay. The facility's policy mandates that a baseline care plan be developed within 48 hours of admission, including essential healthcare information such as initial goals, physician orders, dietary orders, therapy services, and PASARR recommendations if applicable.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for two residents. For Resident #1, the care plan indicated a full code status, while the physician orders and an Out-Of-Hospital Do-Not-Resuscitate Order indicated a DNR status. This discrepancy could lead to confusion among staff regarding the resident's wishes in the event of an emergency. Interviews with LVN A, MDS Coordinator B, and the DON confirmed that the code status in the care plan should match the physician orders to ensure proper care during critical situations. For Resident #2, the facility did not complete a care plan at all. The resident, who had diagnoses including dementia, weakness, atrial fibrillation, chronic obstructive pulmonary disease, and hypertension, was admitted to the facility, but no care plan was developed from the time of admission until the time of the survey. This lack of a care plan could result in the resident's needs not being met. Interviews with facility staff confirmed that comprehensive care plans should be completed within 7-14 days of admission to ensure that all resident needs are identified and addressed.

Penalty

Inspection fine: $261,383

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to consult with the physician when Resident #1 experienced a change in condition, specifically when he refused all oral medications for four days leading up to his hospitalization due to urosepsis. Additionally, the facility did not notify the physician when Resident #1 refused to have ordered labs obtained, which could have identified an underlying urinary tract infection. There was also a failure to inform the physician when Resident #1 had decreased oral intake in the days preceding his hospitalization, potentially contributing to dehydration and subsequent health complications. These failures resulted in the identification of an Immediate Jeopardy situation, highlighting the risks posed to residents by delays in medical treatment and potential health decline. Resident #1, a [AGE] year old with multiple complex medical conditions including heart failure, diabetes, dementia, and chronic kidney disease, was admitted to the facility with a history of joint replacement surgery and other comorbidities. Despite his severe cognitive impairment and dependency on staff for various activities of daily living, the facility did not appropriately communicate his refusal of medications, labs, and decreased oral intake to the physician. This lack of communication and action could have potentially led to a delay in necessary medical interventions and contributed to his deteriorating health status. The facility's policies and procedures clearly outlined the importance of promptly informing the resident, consulting with the resident's physician, and altering treatment when necessary in cases of significant changes in a resident's condition. However, the staff members, including nurses and medical assistants, failed to adhere to these protocols by not notifying the physician of Resident #1's refusals and decreased intake. The lack of communication and documentation regarding these critical issues ultimately resulted in an Immediate Jeopardy situation being identified, highlighting the serious implications of the facility's failures in resident care and communication with medical providers.

Penalty

Inspection fine: $261,383

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure appropriate care for a resident (Resident #1) with a Foley catheter, leading to a deficiency in preventing urinary tract infections and pain. Upon returning from the hospital with a Foley catheter on 1/1/24, there was no order entered for catheter care, and documentation of catheter care was lacking from 1/1/24 to 1/17/24. Despite having the catheter in place, Resident #1 did not receive the necessary care during this period. The facility also did not clearly document the discontinuation of the Foley catheter or the circumstances surrounding it. The deficiencies in care were highlighted when Resident #1 was admitted to the hospital on 1/22/24 and diagnosed with urosepsis, ultimately leading to the resident's passing on the same day. The lack of appropriate catheter care and documentation not only put Resident #1 at risk of urinary tract infections and sepsis but also resulted in tragic consequences. The facility's failure to ensure catheter care for Resident #1, despite the presence of the Foley catheter, raised concerns about the overall quality of care provided to residents with indwelling catheters. The facility's policies and procedures regarding catheter care were not effectively implemented in Resident #1's case. The absence of documented catheter care, inadequate order entry for catheter care, and lack of clarity on catheter discontinuation all contributed to the deficiency identified during the survey. The failure to provide essential care for residents with indwelling catheters not only posed immediate risks to Resident #1 but also highlighted potential systemic issues within the facility's approach to urinary catheter management.

Penalty

Inspection fine: $261,383

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide care that would ensure acceptable parameters of nutritional status for a resident, resulting in a significant weight loss of 15% over 26 days. The resident, an 87-year-old male with multiple diagnoses including dementia, diabetes, and chronic kidney disease, was not appropriately monitored for weight during his stay. Despite having physician orders for daily weights and nutritional supplements, there were no documented weights for the resident from the time of admission until his hospitalization. Additionally, there was a lack of documentation regarding the resident's oral intake for most of his stay, with only sporadic notes indicating fair fluid intake and a significant decline in the days leading up to his hospitalization. The resident's care plan indicated he was at risk for dehydration and malnutrition, with interventions including a mechanical soft diet and vitamin supplements. However, the facility did not follow through with the prescribed daily weights or adequately monitor his nutritional intake. Interviews with staff revealed inconsistencies in the understanding and execution of weight monitoring protocols. The resident's significant other and family member also noted irregularities in the resident's care, including infrequent weighing and inconsistent assistance with meals. The resident's condition deteriorated significantly, leading to hospitalization where he was found to be cachectic and diagnosed with sepsis and encephalopathy. The facility's failure to monitor the resident's weight and nutritional intake as per the care plan and physician orders contributed to this decline. Interviews with various staff members, including the DON, CNAs, and LVNs, highlighted a lack of communication and adherence to protocols, ultimately resulting in the resident's severe weight loss and subsequent hospitalization.