Avir At Luling
Inspection history, citations, penalties and survey trends for this long-term care facility in Luling, Texas.
- Location
- 501 W Austin St, Luling, Texas 78648
- CMS Provider Number
- 676292
- Inspections on file
- 33
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Avir At Luling during CMS and state inspections, most recent first.
Surveyors found that the facility failed to follow professional food safety standards in the kitchen, including use and attempted service of multiple bread products past their best by dates, a stained and dirty handwashing sink, and a broken step-on trash can that required hand contact with a soiled lid. The AC unit in the kitchen was covered with dust, the cart used to distribute residents’ food was stained with brown substances, and a blue crate used to hold dishes was also visibly soiled. The Dietary Manager and Dietary Aide acknowledged that dietary staff were responsible for checking expiration dates and cleaning, and the Administrator confirmed that food should be discarded if not used by the best by date and that sanitation guidelines and facility policies on food storage and sanitation were not being followed.
The facility failed to maintain functioning toilets and sinks in several resident rooms, resulting in prolonged periods without reliable flushing toilets or running water at the sink. A resident with paraplegia reported having no working toilet or sink for weeks and having to manually flush the toilet by lifting the tank lid and pouring in water. Another resident with dementia and PTSD stated that his toilet often would not flush, his sink frequently had no water, and he had to go to another hall to bathe and wash his hands. Additional residents reported non-flushing toilets, lack of hot water, foul odors from toilets full of urine and feces, and the need to use shower rooms for basic hygiene. Observations confirmed non-functioning toilets and sinks and persistent foul odors. Staff and administration acknowledged ongoing plumbing problems, reliance on water jugs to flush toilets, and inconsistent water pressure, while some agency staff reported they were not trained or informed about flushing protocols or rounding to ensure toilets were flushed. Policy and in-service records did not show training on rounding for toilet flushing or providing hygiene alternatives, contributing to the deficiency in providing a safe, clean, and homelike environment.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Three residents experienced deficiencies in supervision and accident prevention, including one who eloped from the facility and was returned by a community member, another who was not identified or managed as a high elopement risk despite assessments, and a third who suffered a hip fracture after a fall when required fall prevention interventions such as a low bed and fall mat were not in place. Staff interviews and documentation revealed lapses in monitoring, communication, and care plan updates.
Two residents did not have all identified risks and physician-ordered interventions included in their care plans. One resident with severe cognitive impairment and high elopement risk lacked elopement interventions in the care plan, while another resident with a history of falls did not have fall prevention measures such as a low bed and fall mat documented in the care plan, despite these being ordered by the physician. Staff interviews confirmed expectations that such interventions should be included in care plans.
The facility did not ensure an RN was on duty for at least 8 consecutive hours each day, as required, with no RN present on multiple days due to ongoing staffing challenges and lack of a formal protocol for RN coverage. Staff interviews confirmed the absence of weekend RN coverage and reliance on ad hoc arrangements when RN services were needed.
A resident with moderate cognitive impairment and multiple mobility issues was admitted without their elopement risk being included in the baseline care plan, despite assessment findings indicating such a risk. The care plan failed to list necessary interventions, and staff interviews confirmed that this information should have been present to guide care. The omission was identified after the resident eloped from the facility and was returned by a community member.
A facility failed to report an incident of misappropriation of property within the required timeframe. A resident with moderately impaired cognition and various medical conditions was observed giving money to a CNA, who was an employee of the facility. The incident was reported to the facility's administrator by a hospital CEO, but it was not reported to the state agency as required. The facility's policies did not address the reporting of such incidents, and the CNA was suspended and later terminated.
A resident with cognitive impairment and a history of falls left the facility unsupervised and was found on railroad tracks after falling. The facility failed to ensure the resident's environment was free from hazards and did not provide adequate supervision. Staff were unaware of the resident's departure, and the facility's sign-out procedures were not effectively enforced, leading to an immediate jeopardy situation.
A resident with moderate cognitive impairment and a high fall risk eloped from the facility and was found on railroad tracks after falling. The facility did not report the incident to the State Agency within the required 24-hour timeframe, as the administrator believed the resident was not in harm's way and was unaware of the fall.
The facility failed to meet food service safety standards, with issues including improper storage of clean cups, a dirty can opener, unsealed pancake mix, a dirty refrigerator, and a dishwasher not reaching required temperatures. These deficiencies could risk foodborne illness.
The facility failed to have an RN on duty for 8 consecutive hours daily and lacked a full-time DON for 74 out of 184 days reviewed. This deficiency was confirmed by the Administrator and Regional Nurse, who acknowledged the absence of RN coverage on specific dates and the lack of a full-time DON since July. The facility's job description for the DON highlights the importance of this role in ensuring compliance and quality care.
A resident with a history of cerebral infarction and diabetes experienced repeated tooth infections and was referred to an oral surgeon for extraction. Despite scheduled appointments, the resident did not attend, and the facility failed to provide necessary assistance as per their dental services policy. This inaction could lead to increased pain and infection.
The facility failed to provide food in the correct consistency for residents on a pureed diet. The dietary manager did not follow the recipe for pureed peach cobbler, resulting in a thin, runny consistency instead of the required pudding or mashed potato texture. This oversight was confirmed by CNAs and could affect residents' safety and nutritional intake.
The facility failed to maintain proper infection control practices, as observed in wound care and incontinent care for two residents, and in the cleanliness of a shared shower and toilet area. An LVN did not sanitize hands or change gloves during a dressing change, and a CNA failed to sanitize hands between glove changes, touched a wipes dispenser with dirty gloves, and stored clean gloves with a cell phone. Additionally, the shared area was found unsanitary, with feces, urine, and improperly disposed of razors, highlighting a lapse in adherence to infection control protocols.
The facility failed to maintain a safe and sanitary environment, with issues such as mold in light covers, rust on pipes, dirty chair cushions, and unsecured lights. The Maintenance Director was unaware of these issues, which were identified during an observation. Both the Maintenance Director and Administrator acknowledged the need for repairs to promote safety and a homelike environment.
The facility failed to maintain a pest-free environment, with live roaches observed in resident rooms and the kitchen. A CNA and two residents confirmed sightings of roaches, and the Dietary Manager noted periodic roach presence despite monthly pest control services.
A facility failed to obtain signed consent forms for the administration of psychotropic and antidepressant medications to a resident with multiple mental health diagnoses. The resident's EHR contained unsigned consent forms for Ziprasidone, and no consent forms for Trazodone or Zoloft, contrary to facility policy. This oversight risked the resident receiving medications without informed consent.
The facility failed to include critical medications in the care plans for two residents, leading to potential missed or inaccurate care. One resident with severe cognitive impairment was prescribed Xarelto, an anti-coagulant, which was not reflected in their care plan. Another resident with moderate cognitive impairment and behavioral issues was prescribed Sertraline, an anti-depressant, also missing from their care plan. The Regional MDS Nurse confirmed these omissions.
A resident with moderate cognitive impairment did not receive a scheduled shower or change of clothes, as staff were unavailable to assist. The resident, who requires assistance for daily living activities, was observed wearing the same stained T-shirt over several days. Facility policy requires documentation and supervisor notification for missed care, but this was not followed.
A resident's room contained a small refrigerator placed on a dresser near the bed, creating a potential accident hazard. The resident, with a history of diabetes, schizophrenia, and major depressive disorder, expressed concern about the refrigerator falling. The facility's maintenance policy requires a hazard-free environment, which was not maintained in this case.
The facility did not ensure that pharmacist recommendations for medication regimen reviews were reviewed and documented by attending physicians for two residents. One resident was not monitored for Xarelto side effects, and another continued on Sertraline without physician response to dose reduction recommendations. The absence of a DON contributed to the lack of documentation.
A resident was prescribed Sertraline for depression without a documented diagnosis in their clinical record. The care plan did not address the use of an antidepressant, and the MRR recommended clarifying the diagnosis, but there was no documented physician response. The absence of a DON led to a lack of documentation showing that pharmacy recommendations were sent to or reviewed by physicians.
Unsanitary Kitchen Conditions and Use of Expired Bread in Food Service
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the kitchen. Surveyor observations showed that the handwashing sink in the kitchen had a brown stain around the drain and faucet, and the step-on trash can next to the sink was covered with a brown sticky substance on the lid and was non-functional, requiring staff to touch the lid to open it. The Dietary Manager and Dietary Aide both stated that all dietary staff were responsible for cleaning the sink and trash, and the Administrator stated the step-on trash was intended to prevent staff from touching the trash after handwashing. Additional observations revealed multiple bread products on the kitchen bread rack that were past their best by dates, including several packs of sliced bread and hotdog buns. During lunch service, the Dietary Manager was about to serve a slice of bread from a package with a best by date that had already passed and then removed it from the serving line after checking the date. The Dietary Manager stated that all staff, especially the cook, were responsible for checking expiration dates, that the bread had been expired for almost a week, and that residents were at risk for illness when they ate bread past the best by date. The Administrator stated that if food was not used by the best by date, it should be discarded and that serving food a week after the best by date could have a negative impact on a resident, depending on the product. Further observations in the kitchen showed that the AC unit was covered with dust, the silver cart used to distribute residents’ food down the hall was stained with brownish substances on both sides, and the blue crate used to store dishes was also stained with a brownish substance. The Dietary Manager acknowledged that the AC had dust that could cause cross contamination to food, that the silver cart needed to be power washed and the kitchen deep cleaned, and that the blue crate was not cleaned as it should be and was used to store dirty dishes. The Dietary Aide confirmed that the AC unit looked dusty, the silver cart had a lot of dirt and did not look good, and the blue crate used for dishes did not look clean. Facility policies on Food Receiving and Storage and Sanitation required safe food handling practices, proper dating and rotation of foods, and that kitchen areas, equipment, and waste containers be kept clean, in good repair, and sanitary.
Failure to Maintain Functioning Toilets and Sinks in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment by not maintaining functioning toilets and sinks in multiple resident rooms. Four residents were identified as being affected by non-functioning or inconsistently functioning bathroom fixtures. Surveyors’ observations confirmed that toilets did not flush and sinks produced no water or only low-pressure water in these residents’ rooms. Residents reported that these problems had been ongoing for weeks to months, and that they frequently had to rely on alternative locations, such as shower rooms or communal bathrooms, to perform basic hygiene tasks like handwashing, showering, and toothbrushing. One resident with paraplegia, depression, and generalized anxiety disorder, and with a BIMS score indicating no cognitive impairment, reported having no water in his sink or a working toilet for six weeks. He stated that he had to remove the toilet tank lid and pour a gallon of water into the tank to flush, despite his paraplegia, and expressed unhappiness about the lack of working bathroom fixtures in his room. Observation confirmed that his toilet did not flush and no water came from his sink. Another resident with a history of atherosclerotic heart disease, difficulty walking, anxiety, major depressive disorder, dementia, and PTSD reported that his water sometimes worked and sometimes did not, and that this had been occurring for a few months. He stated that the toilet took a long time to fill and could not always be flushed, that he considered the situation unsanitary and a health hazard, and that he had to go to another hall to shower, wash his hands, and could not brush his teeth in his own bathroom. Observation confirmed his toilet did not flush and his sink produced no water. A third resident with cerebral infarction, need for assistance with personal care, unsteadiness on feet, and generalized anxiety disorder, and with a BIMS score indicating no cognitive impairment, stated that his only issue at the facility was his bathroom. He reported that his toilet did not flush, his sink produced no water or only non-hot water, and that he had to use the shower room to brush his teeth, wash his hands, or use the bathroom. He stated that his bathroom often smelled foul because urine or feces remained in the unflushed toilet, and that staff only flushed the toilet once a day, with gallons of water kept in the room for flushing by pouring into the tank. Observation confirmed that his sink did not work and his toilet did not flush. A fourth resident with Alzheimer’s disease, Parkinson’s disease, muscle weakness, difficulty walking, and major depressive disorder, and with a BIMS score indicating moderate cognitive impairment, reported having no hot water in the sink and a full toilet. Observation revealed a toilet full of fecal matter and urine with a foul odor, and a later observation the same day showed the toilet still unflushed and the odor persisting. Interviews with staff and administration showed inconsistent awareness, training, and practices regarding the plumbing issues and interim measures. The maintenance director stated that the facility needed replumbing, that only certain rooms were affected, and that water bottles were being used to flush toilets by pouring water into the tank when residents requested assistance or when staff rounded. Some CNAs and nurses reported that they were told to use water jugs to flush toilets and to check toilets during rounds, and that the problem had been ongoing from about a week to up to two months, depending on the staff member’s account. However, an agency CNA and an agency LVN reported they had not been trained or specifically informed about flushing toilets with water bottles or performing toilet-flushing rounds. The administrator acknowledged that water pressure on the affected hall was inconsistent, that water bottles were placed in rooms for flushing, and that staff were told to check toilets during rounds, but also stated he was unsure whether in-services had been completed on offering alternatives for toothbrushing and handwashing. Record review showed no in-services on rounding to ensure toilets were flushed or on offering alternatives for hygiene, and no grievances related to bathroom concerns, despite multiple resident reports of ongoing problems. Facility policies on environmental services and resident rights indicated expectations for maintaining a standard of excellence in housekeeping and for treating residents with dignity and respect, including a dignified existence. Nonetheless, the documented observations and interviews demonstrated that several residents lived with non-functioning toilets and sinks for extended periods, relied on staff or themselves to manually flush toilets with water jugs, and experienced foul odors and lack of in-room access to running water for basic hygiene. These conditions and the inconsistent staff training and response led to the cited deficiency for failing to maintain sanitary, orderly, and comfortable interior conditions and to honor residents’ rights to a safe, clean, comfortable, and homelike environment.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Prevent Accidents Due to Inadequate Supervision and Implementation of Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement necessary interventions to prevent accidents for three residents. One resident, with moderate cognitive impairment and mobility issues, was able to leave the facility unsupervised and was returned by a community member after being found at a gas station over a mile away. Staff interviews revealed that the resident was last seen during a smoke break, and there was a lack of awareness among staff regarding the resident's whereabouts until he was brought back. Documentation showed that the resident was assessed as high risk for elopement, but interventions were limited to routine monitoring, and staff did not consistently monitor or supervise the resident as required. Another resident, with severe cognitive impairment and a history of stroke, was identified as high risk for elopement based on assessments and physician notes. However, the care plan did not include information or interventions related to this risk, and multiple staff members were unaware of any residents being high elopement risks. This lack of communication and failure to update care plans and inform staff resulted in inadequate supervision and increased the risk of elopement for this resident. A third resident, with a history of falls and moderate cognitive impairment, was not provided with required fall prevention interventions. Despite physician orders for a low bed and fall mat, the resident's bed was not in the lowest position and the fall mat was not in place at the time of a fall that resulted in a left hip fracture. Staff interviews confirmed that the interventions were not implemented, and the care plan did not specify these requirements. The incident report and staff statements indicated a lack of consistent implementation and monitoring of fall prevention measures for this resident.
Removal Plan
- Resident was discharged to a secured facility.
- All entrances to the facility have been key-pad locked and residents are not allowed out of the facility without an assigned staff member being with them.
- One resident who is high risk for elopement was placed on 1:1 monitoring until secure placement is located.
- All resident elopement assessments were completed, and high risk residents were identified.
- High risk resident's care plan was formulated and any resident care plans requiring updates were done.
- Administrator in-serviced department heads and facility staff on interventions for the identified high risk resident, including 1:1 monitoring, updated care plan, and Kardex update.
- Staff not available in person were contacted by phone and verbally in-serviced.
- Staff are informed that the administrator/designee will notify staff through the above measures and through an in-service if any other resident is deemed high risk for elopement.
- PRN, agency staff, and new hires will be educated on this process as they are assigned to work.
- Administrator will interview staff on their understanding and retention of education given to them on elopement and where to find information on residents at high risk for elopement.
- Regional Nurse will monitor new admission elopement assessments for high risk residents to validate that interventions are in place and communication is in the EMR system.
- Administrator will document this on an audit form.
- Regional nurse in-serviced the administrator and the director of nursing on reviewing any new admission elopement assessments to identify a resident scoring ten or more.
- Ensuring that any new staff are educated to the interventions of a resident deemed high-risk for elopement.
- Initial comprehension of education with the administrator and the DON was completed by questioning on understanding of the training by the regional nurse consultant.
- Regional nurse will document compliance using an audit form.
- Ad.Hoc QAPI meeting was completed with the IDT and the medical director to discuss this plan of removal.
- Resident's fall care plan interventions and Point of Care Kardex were reviewed and updated to reflect the resident's current condition.
- Regional Nurse Consultant/ADON reviewed the facility fall assessment report to identify residents at risk of falls and to validate that current interventions are in place on the resident care plan and Point of Care Kardex.
- RNC and the ADON reviewed all facility residents to validate that their fall interventions were care planned and that the Point of Care Kardex was updated to list the fall interventions.
- Audit was documented utilizing the PCC Fall Assessment score report.
- Additional residents were identified as at risk for falls. Each had a care plan developed with interventions added to their POC Kardex.
- RNC/administrator educated facility staff regarding where to find the information for fall interventions.
- Staff not receiving the initial education will receive it before starting their next assigned shift.
- Nurses were instructed to review the care plan, and CNAs were instructed to review the Point of Care Kardex.
- Interdisciplinary team were given a list of resident fall interventions by the RNC, to refer to while making rounds on their regularly assigned residents before the morning stand-up meeting and reporting any concerns during that meeting.
- IDT manager on duty will make rounds on the weekend to identify and immediately resolve concerns with fall interventions.
- Administrator verified the initial comprehension of staff training by questioning staff and documenting it on an audit form.
- Administrator and the RNC will document these tasks on a facility created audit form for record keeping purposes.
- RNC will review falls to ensure that the care plan is updated with a new intervention and that those interventions, if applicable, are carried over to the Point of Care Kardex.
- Any concerns will be corrected immediately and re-education given to the management team.
- Education understanding will be completed by the administrator by questioning the facility staff about where they can find the fall intervention information.
- RNC will complete education understanding with the management IDT by questioning them regarding IDT rounds and identifying problems with fall interventions specifically.
- Ad.Hoc QAPI meeting was held with the medical director and the IDT to discuss this plan of removal.
Failure to Include Elopement and Fall Interventions in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required. For one resident with a history of cerebral infarction, severe cognitive impairment, and high risk for elopement, the care plan did not include any information or interventions addressing the elopement risk, despite assessments and physician notes identifying this risk. Multiple staff interviews revealed a lack of awareness regarding residents at high risk for elopement, even though facility leadership confirmed that this resident was considered high risk. For another resident with a history of falls, moderate cognitive impairment, and significant dependence for activities of daily living, the care plan did not include specific fall prevention interventions such as keeping the bed in a low position or ensuring a fall mat was at the bedside. These interventions were present in the physician's orders but were not reflected in the care plan. Staff interviews indicated an expectation that such interventions would be documented in the care plan, and facility policy required individualized fall prevention plans based on resident risk factors. The deficiencies were identified through record reviews, staff interviews, and policy reviews, which showed that the care plans did not reflect all identified risks and physician-ordered interventions for the residents. This lack of comprehensive care planning could result in staff not being aware of or implementing necessary interventions to address the residents' medical, nursing, and psychosocial needs.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required registered nurse (RN) coverage for at least 8 consecutive hours a day, 7 days a week, as evidenced by a review of daily sign-in schedules showing no RN charge nurse present on eight specific days within the review period. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator (ADM), confirmed that there was no RN coverage on weekends during this time frame. The ADON and DON both stated that if RN services were needed, they would reach out to the regional nurse or DON, but there was no established protocol for when an RN was unavailable. The facility had ongoing difficulties hiring an RN, particularly for weekend shifts, and had an open job posting for this position. The absence of an RN on duty was not due to a lack of need for RN-level care, but rather due to staffing challenges and the facility's belief that their resident population did not require high-acuity nursing services. The DON reported being present during weekdays, and the facility occasionally used agency RNs, but consistent weekend coverage was not maintained. There was no specific policy in place regarding RN coverage, and the facility relied on state guidelines and ad hoc arrangements when RN-level care was required.
Failure to Include Elopement Risk in Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan that included necessary instructions for effective and person-centered care for a resident within 48 hours of admission. Specifically, the baseline care plan did not address the resident's identified risk for elopement, despite an admission elopement risk assessment indicating the resident was at risk and required routine monitoring. The baseline care plan incorrectly stated that the resident did not have a history of wandering or elopement and omitted interventions related to elopement risk, even though the assessment and provider investigation report confirmed the risk and subsequent elopement event. Interviews with nursing staff, the ADON, DON, and administrator revealed that care plans are expected to include critical information such as fall and elopement risks, along with appropriate interventions. Staff relied on care plans and 24-hour reports for guidance on resident care, and it was confirmed that the ADON was responsible for updating care plans with new interventions. The facility's policy required comprehensive, person-centered care plans reflecting current assessments and interventions, but this was not followed in the case of the resident who later eloped from the facility.
Failure to Report Misappropriation of Property
Penalty
Summary
The facility failed to report an alleged violation involving misappropriation of property within the required 24-hour timeframe to the State Survey Agency. This incident involved a resident who was observed giving money to a CNA, who was an employee of the facility at the time. The resident, who had a history of moderately impaired cognition and various medical conditions, including hypertension, diabetes, and borderline personality disorder, was not in the facility when the incident occurred but had planned to return. The CNA was reported to have requested and accepted money from the resident, which was observed by a staff member from a hospital where the resident was receiving care. The facility's administrator was informed of the incident by the hospital's CEO but did not report it to the state agency, as the resident was not physically present in the facility at the time. The facility's policies on preventing resident abuse and resident rights did not specifically address the reporting of abuse, neglect, or exploitation. Interviews with the facility's administrator and regional director of operations revealed that the CNA was suspended and later terminated following the investigation. However, there was uncertainty about whether the incident was reported to the state, as the resident was not at the facility when it occurred. The resident expressed a desire for privacy regarding the money and mentioned feeling bad about the CNA losing her job. The facility's failure to report the incident in a timely manner could place residents at risk for further misappropriation.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment for its residents, resulting in a significant incident involving a resident who left the facility unsupervised. The resident, a male with a history of type II diabetes, Parkinson's disease, and moderate cognitive impairment, was found approximately 0.9 miles away from the facility on railroad tracks after falling. The resident's quarterly care plan indicated a risk for falls due to poor safety awareness and mobility issues, and his most recent fall risk assessment showed a high risk for falls. Despite these indicators, the resident was able to leave the facility without signing out or notifying staff, leading to an immediate jeopardy situation. Interviews with facility staff revealed a lack of awareness and supervision regarding the resident's departure. The resident's cognitive abilities were inconsistent, with staff noting that he was sometimes alert and oriented but often confused and unable to remember the facility's sign-out procedures. On the day of the incident, the facility was understaffed, with only one nurse on duty who was unfamiliar with the resident's cognitive status. This lack of supervision and understanding of the resident's needs contributed to the resident's ability to leave the facility unsupervised. The facility's policies required residents to sign out and notify staff when leaving, but these procedures were not effectively communicated or enforced. Interviews with staff indicated that there was confusion about which residents could leave the facility independently and a lack of consistent monitoring to ensure all residents were accounted for. The facility's failure to adhere to its own policies and provide adequate supervision placed the resident at risk of harm, leading to the identification of an immediate jeopardy situation.
Failure to Report Resident Elopement and Fall
Penalty
Summary
The facility failed to report an incident involving a resident who eloped from the facility without staff knowledge and was found approximately an hour later after falling on railroad tracks about a mile from the facility. The resident, a male with a history of type II diabetes, Parkinson's disease, and moderate cognitive impairment, was admitted to the facility with a high risk for falls and a low initial risk for elopement. However, after the incident, his elopement risk assessment score increased significantly. The facility did not report this incident to the State Agency within the required 24-hour timeframe, as the administrator believed the resident was his own responsible party, was not injured, and had not missed medication doses. The facility's Preventing Resident Abuse Policy did not specify when abuse or neglect should be reported to the Health and Human Services Commission (HHSC). The administrator and the charge registered nurse (CRN) believed that elopement involved residents who were in harm's way due to cognitive issues or dementia. The administrator assumed the resident had signed out and was unaware of the fall on the railroad tracks, which would have prompted a report. The Long-Term Care Regulation Provider Letter required reporting of incidents involving neglect or a missing resident within 24 hours, which the facility failed to do.
Food Service Safety Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several areas, as observed during a survey. Clean plastic cups were improperly stored on wet trays without air-drying nets, which could prevent proper air circulation and promote microorganism growth. Additionally, the tabletop can opener was found to be covered in sticky grime, including the blade and base, which could lead to food contamination. An opened bag of pancake mix was not stored in a sealed container, risking contamination and deterioration of food quality. The reach-in refrigerator was observed to have dirty racks and a buildup of stains from spilled liquids, indicating a lack of cleanliness and maintenance. This could potentially lead to contamination of stored food. Furthermore, the low-temperature dishwasher failed to reach the required 120 degrees Fahrenheit during the wash cycle, with temperatures recorded as low as 92 degrees Fahrenheit. This failure could result in dishes not being properly sanitized, increasing the risk of foodborne illness. The facility's policies on sanitization and food storage were not followed, as evidenced by the observations. The sanitization policy requires that all equipment and utensils be kept clean and sanitized, and the dishwasher operated according to manufacturer's instructions. The food storage policy mandates that dry foods be stored in a manner that maintains packaging integrity. These deficiencies in food storage, preparation, and sanitation could place residents at risk for foodborne illnesses.
Failure to Maintain RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to comply with the requirement of having a registered nurse (RN) on duty for at least 8 consecutive hours a day, 7 days a week, and did not employ a full-time Director of Nursing (DON) for 74 out of 184 days reviewed. Specifically, the facility did not have an RN scheduled on numerous dates from March through August 2024. Additionally, the facility has been without a full-time DON since July 31, 2024. This lack of RN coverage and absence of a full-time DON could potentially compromise the supervision of nursing services provided to residents. During an interview on September 5, 2024, the Administrator and Regional Nurse confirmed the absence of an RN on the specified dates and acknowledged the lack of a full-time DON since the end of July. They admitted that they were unable to schedule an RN for the selected dates, which would have ensured better clinical oversight of the nursing services. The facility's job description for the DON emphasizes the role's responsibility in planning, organizing, and directing the Nursing Services Department to maintain compliance with regulations and ensure high-quality care.
Failure to Assist Resident with Dental Services
Penalty
Summary
The facility failed to assist a resident in obtaining necessary dental services following a referral to an oral surgeon for a tooth extraction. The resident, who had a history of cerebral infarction, Type 2 diabetes mellitus with kidney complications, and a periapical abscess, was initially treated with antibiotics for a tooth infection in February. Despite being referred to an oral surgeon for extraction after a dental visit in March, the resident did not attend the appointment. The facility's records did not provide documentation of the dental visit or reasons for the missed oral surgeon appointment. In July, the resident experienced another tooth infection and was again referred to an oral surgeon. An appointment was scheduled for early August, but the resident did not attend. Interviews with the Regional RN confirmed the resident's treatment history and the missed appointments, but no explanation was provided for the failure to follow through with the oral surgeon visits. The facility's policy on dental services, which includes assistance with appointments and transportation, was not adhered to, potentially leading to increased pain and infection for the resident.
Inappropriate Food Consistency for Residents on Pureed Diet
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of residents on a pureed diet. Specifically, the dietary manager (DM) did not puree the peach cobbler to the required pudding or mashed potato consistency for four residents who were ordered a pureed diet. During observations, the pureed peach cobbler was found to have the consistency of a nectar-thick liquid, which was inappropriate for residents requiring a pureed diet. Interviews with certified nursing assistants (CNAs) confirmed that the dessert was thin and runny, and not suitable for the residents' dietary needs. The DM admitted to not following the recipe, which led to the incorrect texture of the peach cobbler. The recipe required the cobbler to be blended until smooth, with the consistency of moist mashed potatoes or pudding, but the DM only pureed the peaches with some liquid. This oversight could contribute to choking, poor intake, and weight loss among residents who received pureed meals. The facility's records and guidelines for a Dysphagia Puree (Level 1) Diet emphasized the importance of achieving the correct consistency to accommodate residents with severe chewing and swallowing problems.
Infection Control Deficiencies in Wound Care and Shared Facilities
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observed deficiencies. During a wound dressing change for a resident with a venous wound and peripheral vascular disease, an LVN did not sanitize hands or change gloves between the removal of the old dressing and the application of the new dressing. The LVN admitted to not being aware of the need for such precautions, indicating a lack of proper training or adherence to infection control protocols. In another instance, a CNA providing incontinent care to a resident with moderate cognitive impairment and total dependence on others for toileting did not sanitize her hands between glove changes. The CNA also touched a wipes dispenser with dirty gloves and stored clean gloves in her scrub pocket alongside her cell phone. The CNA acknowledged these lapses, citing a lack of available hand sanitizers and being in a hurry as reasons for her actions. The Regional RN confirmed that these practices were against the facility's infection control procedures, which require hand hygiene and proper glove use to prevent cross-contamination. Additionally, the shared shower and toilet area on the South Hall was found to be in an unsanitary condition, with feces and urine on the floor, used gloves, and razors improperly disposed of. Housekeeping staff and supervisors acknowledged the state of the area, attributing it to staffing shortages and turnover. The facility's policy requires that environmental surfaces be cleaned appropriately, but the observed conditions indicated a failure to adhere to these standards, potentially leading to the spread of infection.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During an observation conducted with the Maintenance Director, several environmental concerns were identified. These included mold inside the overhead light cover in a resident's room, rust on a ceiling pipe above a bed, a dirty chair cushion, a stripped window sill, and mold on the hallway ceiling. Additionally, there was dust and dirt in two hallway air conditioning vents, unsecured overhead lights, missing ceiling tiles, and mold on a wall area above a door entrance. A broken ceiling tile was also noted in the hallway, along with a wall penetration and a broken cabinet hinge in the ice machine room. Interviews with the Maintenance Director and the Administrator revealed that the Maintenance Director was not previously aware of these issues, and both acknowledged that addressing these concerns would promote resident safety and a more homelike environment. The facility's policy on Maintenance Service, dated December 2009, states that the Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times, ensuring the building is in good repair and free of hazards.
Pest Control Deficiency
Penalty
Summary
The facility failed to maintain a resident environment free of pests and rodents, as evidenced by the presence of live roaches in resident rooms and the kitchen. During an observation on September 3, 2024, a live roach was seen on the wall of a resident room, and a CNA confirmed the sighting. Two residents reported seeing live roaches on their bedroom floor approximately two weeks prior. Additionally, on September 5, 2024, several live roaches were observed on the kitchen floor in front of the stove. The Dietary Manager acknowledged periodic sightings of roaches in the kitchen, despite the facility's monthly pest control service. The facility's policy, dated May 2008, states that an ongoing pest control program is maintained to keep the building free of insects and rodents.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was fully informed and understood their health status, care, and treatments, specifically regarding the administration of psychotropic and antidepressant medications. The resident, who had multiple diagnoses including Alzheimer's disease, Parkinsonism, bipolar disorder, anxiety disorder, schizoaffective disorder, and major depressive disorder, was not provided with the necessary information to make informed decisions about their treatment. The facility did not obtain signed consent forms for the administration of antipsychotic medication Ziprasidone and antidepressant medications Zoloft and Trazodone prior to their administration. The resident's electronic health record contained three unsigned consent forms for Ziprasidone, and there were no consent forms for Trazodone or Zoloft. The facility's policy required that consents be obtained for any psychotropic medication, but this was not adhered to. The Regional Nurse confirmed the absence of signed consent forms and could not explain why they were missing. This oversight placed the resident at risk of receiving medications without their knowledge or consent, potentially affecting their ability to make informed decisions about their care.
Failure to Include Medications in Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which resulted in deficiencies in addressing their medication needs. Resident #3, a [AGE] year-old with severe cognitive impairment and a history of traumatic brain injury, was prescribed Xarelto, an anti-coagulant, but this was not included in their care plan. The omission of this critical medication in the care plan could lead to missed or inaccurate care, as the care plan did not reflect the resident's current medical needs. Similarly, Resident #33, a [AGE] year-old with moderate cognitive impairment and a history of behavioral issues, was prescribed Sertraline, an anti-depressant, which was also not included in their care plan. The absence of this medication in the care plan indicates a failure to address the resident's mental health needs adequately. The Regional MDS Nurse confirmed these omissions and acknowledged that the care plans should have included these medications to ensure the residents' care needs were met.
Failure to Provide Scheduled Hygiene Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Specifically, the nursing staff did not provide a shower or change the stained shirt of a resident on his scheduled shower day. The resident, who has moderate cognitive impairment and requires assistance for showering and dressing, was observed wearing the same stained T-shirt over several days. The resident expressed dissatisfaction with the situation, stating that he had not showered in two weeks and that staff often attempted to assist him during his smoke break, leading to missed opportunities for care. Interviews with staff revealed that the resident's shower was not documented on the scheduled day due to a CNA being called away for another task, and no other staff were available to assist. The facility's policy requires documentation of showers and any refusals, along with notifying a supervisor if a resident refuses care. However, the documentation was incomplete, and the resident did not receive the necessary hygiene care, which could lead to issues such as body odor or skin problems.
Unsafe Placement of Refrigerator Poses Hazard
Penalty
Summary
The facility failed to ensure a safe environment for a resident by allowing a small refrigerator to be placed on top of a clothes dresser near the head of the resident's bed. This setup posed a potential accident hazard. The refrigerator measured approximately 19x32 inches and was placed on a dresser measuring 30x30 inches. This arrangement was observed during a survey, and the resident expressed concern about the refrigerator potentially falling over. The resident involved had a medical history that included type 2 diabetes, schizophrenia, and major depressive disorder, with a BIMS score indicating intact cognition. The resident's care plan noted concerns such as decreased vision, fall risk, and the need for assistance with activities of daily living (ADLs). The facility's maintenance policy requires the environment to be free of hazards, yet this policy was not adhered to in this instance, leading to the identified deficiency.
Failure to Review Pharmacist Recommendations
Penalty
Summary
The facility failed to ensure that the pharmacist's medication regimen review recommendations were reviewed by the attending physician and documented for two residents. For one resident, the pharmacist recommended monitoring for side effects of Xarelto, an anticoagulant prescribed for traumatic brain injury. However, there were no physician orders to monitor for these side effects, and the medication administration records did not show any documentation of monitoring. The resident's care plan also lacked a focus area addressing the use of the anticoagulant. For another resident, the pharmacist recommended clarifying the diagnosis for the use of Sertraline, an antidepressant, and considering a dose reduction. Despite these recommendations, there was no documented response from the physician, and the resident continued to be prescribed the same dosage. The facility's policy required that the pharmacist's recommendations be sent to the attending physicians within 24 hours, but due to the absence of a Director of Nursing, there was no documentation showing that the recommendations were reviewed by the physicians.
Failure to Document Diagnosis for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was not given a psychotropic drug unless necessary to treat a specific condition as diagnosed and documented in the clinical record. A resident was prescribed Sertraline, an antidepressant, for depression without a documented diagnosis of depression in their clinical record. The resident's care plan did not address the use of an antidepressant, and the medication regimen review (MRR) recommended clarifying the diagnosis for Sertraline. However, there was no documented response from the physician to this recommendation. The facility's process for handling MRR recommendations was compromised due to the absence of a Director of Nursing (DON). The Regional RN confirmed that the facility had been without a DON for periods of time, which resulted in a lack of documentation showing that the pharmacy recommendations had been sent to or reviewed by the physicians. This deficiency could lead to physicians not being aware of or acting upon pharmacist recommendations, potentially placing residents at risk of receiving unnecessary psychotropic medications.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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