Avir At Magnolia
Inspection history, citations, penalties and survey trends for this long-term care facility in Luling, Texas.
- Location
- 1105 N Magnolia, Luling, Texas 78648
- CMS Provider Number
- 676044
- Inspections on file
- 34
- Latest survey
- November 5, 2025
- Citations (last 12 mo.)
- 23 (4 serious)
Citation history
Health deficiencies cited at Avir At Magnolia during CMS and state inspections, most recent first.
Two residents with cognitive and physical impairments were subjected to physical abuse and neglect by a CNA, including being exposed to soap in the eyes and being physically restrained and verbally abused during care. Witnesses failed to report the incidents immediately due to fear of retaliation, despite having received training on abuse reporting. These failures placed vulnerable residents at risk.
Two staff members failed to immediately report alleged abuse incidents involving a CNA, including placing soap in a resident's eyes and physically restraining another resident, despite being trained to do so. The delay in reporting was due to fear of retaliation and concerns about social media threats, resulting in a late notification to the abuse coordinator and delayed investigation.
Two residents with significant cognitive and physical impairments were involved in separate alleged abuse incidents that were not thoroughly investigated or promptly reported by the facility. Staff delayed reporting the incidents due to fear of retaliation, and the facility failed to identify when the incidents occurred or notify law enforcement in a timely manner. Investigation documentation was incomplete, and the abuse coordinator was not informed immediately, resulting in a deficiency in the facility's response to allegations of abuse.
A deficiency was cited for not ensuring a resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report does not provide further details about the specific circumstances or individuals involved.
Surveyors found that kitchen staff failed to label and date refrigerated food items and did not follow proper hand hygiene or sanitation protocols during meal preparation. Staff handled food and utensils without washing hands or wearing gloves, and equipment was not adequately sanitized between uses, despite having received training on these procedures.
Surveyors found that the facility did not have an infection prevention and control program in place, resulting in a deficiency related to infection control practices.
A resident with multiple mental health diagnoses was admitted without the required PASARR Level I screening being completed prior to admission. Staff interviews revealed confusion about the PASARR process and submission timelines, and documentation review confirmed the absence of the necessary screening report, resulting in a deficiency.
A resident with end stage renal disease who received dialysis three times weekly did not have this treatment addressed in their care plan, despite it being identified in their assessment. Nursing staff prepared the resident for dialysis based on experience rather than a documented plan, and the omission was acknowledged by the MDS nurse as an oversight.
A deficiency was found due to the facility's failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, as well as inadequate catheter care and insufficient measures to prevent UTIs.
The facility did not ensure an RN was on duty for at least 8 hours daily and failed to assign a full-time RN as DON, as evidenced by staffing records and facility documentation.
A medication cart was found unlocked and unattended in a hallway while an LVN was assisting a resident in a nearby room. The LVN, DON, and ADM all confirmed that facility policy requires medication carts to be locked when unattended, and that staff had been trained on this policy. Monitoring is conducted through compliance and walking rounds to ensure medication security.
A resident with dementia and a known history of elopement risk exited the secured memory care unit undetected by breaking a window and climbing over a fence. The resident was not discovered missing until a routine check, and was later found a mile away. The care plan identified elopement risk, but supervision and environmental safeguards were insufficient to prevent the incident.
A resident with a history of dementia, diabetes, and recurrent UTIs experienced a significant delay in receiving prescribed antibiotics after a positive urine culture for Escherichia coli. The resident reported increased pain and dysuria during the delay, and the medication administration record showed a gap in antibiotic administration with no documented explanation. Staff interviews revealed lapses in communication and adherence to policy regarding timely notification of the nurse practitioner and medication administration.
A resident with a history of UTIs experienced a significant delay in receiving prescribed antibiotics after a positive urine culture for Escherichia coli. Nursing staff did not promptly notify the practitioner of the abnormal lab results, resulting in the resident receiving her antibiotic seven days after the results were available. The resident reported increased pain and dysuria during this period, and documentation did not explain the delay or missed doses, contrary to facility policy requiring timely medication administration.
A resident with a history of heart issues experienced shortness of breath and chest pain, but the facility failed to notify the MD due to normal vital signs. The resident was later found unresponsive. The facility's policy requires immediate MD notification for any condition changes.
A resident with a mechanically altered diet due to dysphagia was given a peanut butter sandwich by a staff member, contrary to dietary orders specifying no bread. The resident, who required close supervision during meals, experienced distress and expired. The staff member admitted to not knowing the specific diet, revealing a gap in dietary management and staff training.
The facility failed to meet the nutritional needs of residents due to inadequate food supplies and improper menu substitutions. Observations revealed that the facility did not have sufficient food from 07/31/2024 to 08/06/2024, leading to menu changes without consulting the RD. The DS had to purchase food daily using the Administrator's personal credit card, and the facility lacked emergency food supplies. This deficiency placed residents at risk for inadequate nutrition.
The facility failed to label and date prepped food items in the kitchen, as observed during a survey. Milk, juices, cheese, and other items were not properly labeled or sealed, posing a risk of contamination. Interviews with dietary staff and the administrator highlighted the importance of labeling to track food freshness and prevent bacterial growth, as per the facility's policy.
A facility failed to conduct an updated PASRR evaluation for a resident with mental illness, despite new diagnoses of major depressive disorder and mood disorder unspecified. The resident's care plan included interventions for psychotropic drug use, but the only PASRR evaluation on record was from 2018, indicating a negative result for mental illness. Interviews with staff revealed a lack of clarity regarding the need for updated PASRR assessments, with the administrator acknowledging that a new evaluation should have been conducted.
A newly admitted resident with complex medical needs did not have a baseline care plan implemented upon admission, as required by facility policy. The resident's care plan was left blank initially and was only completed several days later, despite the facility's policy to complete it on the day of admission. Interviews with staff, including an LVN and the DON, confirmed the delay, which could risk improper care and decreased quality of life for the resident.
Two residents in a facility did not receive necessary assistance with personal hygiene, including bathing and nail care, over a period of several days. One resident, with hemiplegia and other conditions, was not bathed for five days, resulting in strong body odor and dirty fingernails. Another resident reported embarrassment due to facial hair and untrimmed nails, which were not addressed despite requests. Staff interviews confirmed that these care responsibilities were not fulfilled, leading to potential health risks and a decline in residents' quality of life.
The facility failed to develop an activity program based on the preferences of two residents, leading to boredom and increased risk of depression. A resident with severe cognitive impairment and limited vision reported dissatisfaction with repetitive activities and lack of suitable reading materials. Another resident with moderate cognitive impairment expressed boredom and a lack of engaging activities, leading to fabricating stories for entertainment. The activity calendar showed scheduled activities that were not conducted, and the environment was not conducive to group engagement.
A resident with asthma and on oxygen therapy was found with an aerosol air freshener in their room, which is against facility policy. Staff were unaware of its presence, and the facility lacked a clear policy on allowed materials in rooms.
The facility failed to adhere to its oxygen therapy protocols, as observed in two residents requiring oxygen. A resident's tubing was not changed weekly as per policy, with outdated tubing and an empty humidifier reservoir noted. Despite the facility's policy, the tubing was not replaced until later, potentially risking respiratory infections. Interviews with staff revealed discrepancies in documentation and execution of the oxygen administration policy.
A resident was given anti-acid medications without a physician's order, and the facility failed to ensure the resident swallowed the medication before leaving the room. The resident, with a history of dyspepsia, was found with four tablets of anti-acid medicine at his bedside, which were not listed on his MAR. The med aide admitted to providing the medications upon request without verifying a physician's order or ensuring immediate consumption, violating the facility's medication administration policy.
A dietary aide began working in the kitchen without receiving necessary orientation and training, lacking a food handler's certificate. The Dietary Manager admitted to the oversight, and the Human Resource Manager confirmed that all staff should be trained before starting work. The aide assisted with food service and preparation tasks unsupervised, contrary to facility protocol.
Failure to Protect Residents from Physical Abuse and Neglect
Penalty
Summary
The facility failed to protect two residents from physical abuse and neglect by a certified nursing assistant (CNA). In the first incident, a female resident with moderate cognitive impairment, blindness in one eye, and other significant medical conditions was subjected to physical abuse in the shower room. Two nursing assistants (NAs) witnessed the CNA put soap directly on the resident's face, causing soap to run into her eyes and resulting in the resident expressing discomfort and irritation. The incident was not reported immediately by the witnesses due to fear of retaliation from the CNA. In the second incident, a male resident with severe cognitive impairment, hemiplegia, and a history of aggressive behaviors was physically restrained by the same CNA during peri-care. Witnesses described the CNA using her knee and hands to pin the resident's arms and chest, and placing a hand around his throat while verbally abusing him. The resident was observed to become distressed, repeatedly asking for the CNA to stop. Again, the incident was not reported immediately by the staff present, citing fear of the CNA and her connections outside of work. Both incidents were eventually reported to the facility's abuse coordinator after a delay. Interviews and witness statements confirmed that staff were trained to report abuse immediately but failed to do so in these cases. The residents involved had significant cognitive and physical impairments, making them particularly vulnerable. The facility's failure to ensure timely reporting and protection from abuse constituted noncompliance and placed residents at risk of harm.
Failure to Timely Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse were reported immediately, but not later than two hours after the allegations were made, to the abuse coordinator for two residents. Staff members witnessed or were aware of incidents involving a certified nursing assistant (CNA) allegedly placing soap in a resident's eyes during a shower and physically restraining another resident by pinning him with her knee and hand during care. Despite being trained to report abuse immediately, the staff members involved did not report these incidents to the abuse coordinator as required. The residents involved had significant cognitive and physical impairments. One resident was a female with moderate cognitive impairment, depression, dementia, epilepsy, blindness in one eye, and required substantial assistance with activities of daily living. The other resident was a male with severe cognitive impairment, hemiplegia, dementia with mood disturbance, seizures, and was dependent on staff for toileting hygiene. Interviews and record reviews indicated that the residents did not report feeling unsafe, and family members did not express concerns about their care. However, staff interviews revealed that the incidents were not reported promptly due to fear of retaliation from the CNA involved and concerns related to social media threats. Multiple staff members, including nursing assistants and nurses, confirmed they were trained to report abuse immediately to the abuse coordinator, whose contact information was made available to all staff. Despite this, the delay in reporting was attributed to fear of the CNA and lack of comfort in approaching supervisory staff. The abuse coordinator was eventually notified several days after the incidents, which delayed the initiation of an investigation into the alleged abuse. The facility's policy required immediate reporting of suspected abuse, neglect, or exploitation, which was not followed in these cases.
Failure to Thoroughly Investigate and Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to thoroughly investigate and report two separate allegations of abuse involving two residents. In both cases, the facility did not identify the specific timeframe when the alleged abuse occurred and did not notify local law enforcement in a timely manner. The investigation documentation was incomplete, lacking essential details such as the date and time of the incidents, and there was no immediate notification to the abuse coordinator by the staff who witnessed or were aware of the alleged abuse. The facility's self-reporting template and investigation report reflected missing or delayed information, and the police were not promptly notified, with no case number or documentation initially provided. The first resident involved was an elderly female with diagnoses including depression, dementia, epilepsy, blindness in one eye, and cognitive communication deficit. She required substantial assistance with activities of daily living. The second resident was an elderly male with severe dementia, hemiplegia, seizures, diabetes, and a history of agitation and combative behavior, requiring total staff assistance for toileting and hygiene. Both residents were the subjects of allegations that a staff member had either put soap in the female resident's eyes or physically restrained and verbally abused the male resident during care. Multiple staff members witnessed or were aware of these incidents but delayed reporting them due to fear of retaliation from the accused staff member. Interviews with staff revealed that the incidents were not reported immediately as required by facility policy and regulatory expectations. Staff cited fear of the accused staff member, who was known for making threats, as the reason for the delay. The facility's abuse coordinator and administrator were not informed until days after the incidents, and the subsequent investigation was hampered by the lack of timely reporting and incomplete information. The facility's failure to promptly and thoroughly investigate and report the allegations, as well as to notify law enforcement, constituted a deficiency in responding appropriately to alleged violations of abuse and neglect.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No further information about the residents involved or their conditions at the time of the deficiency is included in the report.
Failure to Follow Food Safety and Hand Hygiene Protocols in Kitchen
Penalty
Summary
Surveyors observed multiple failures in food storage, preparation, and distribution within the facility's kitchen. Four chocolate flavored creme pies were found in a spare refrigerator without any labeling or dating, contrary to facility policy requiring all refrigerated foods to be labeled and dated. Additionally, a staff member was observed preparing pureed meals without washing her hands at the start of the process or wearing gloves. She handled various utensils and retrieved ingredients from the refrigerator without performing hand hygiene or donning new gloves between tasks. The same staff member was also seen licking her finger to remove excess food and failed to properly wash and sanitize equipment, only rinsing the blender cup instead of using the dishwasher as required. Interviews with the kitchen manager and the staff member confirmed that both had been trained on hand hygiene and food labeling protocols. The kitchen manager acknowledged that improper hand hygiene and failure to label and date food could result in residents becoming ill. Review of facility policies confirmed the requirements for hand hygiene and proper food labeling and dating, as well as the expectation that all staff adhere to these standards to prevent the spread of infection and ensure food safety.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, as the facility did not have an established or operational program to prevent and control infections among residents and staff. The absence of such a program was directly observed and documented by surveyors.
Failure to Complete PASARR Screening Prior to Admission
Penalty
Summary
A resident with a history of schizoaffective disorder, insomnia, depression, and generalized anxiety disorder was admitted to the facility without the completion of the required PASARR Level I screening prior to admission. Record review showed that the resident's care plan addressed depression related to schizoaffective disorder, and a psychiatric evaluation documented ongoing mental health concerns, including increased depression and anxiety. However, there was no evidence in the resident's electronic health record of a completed PASARR Level I Am screening report, as required by facility policy and federal regulations. Interviews with facility staff, including the MDS Coordinator, DON, and ADM, revealed a lack of clarity regarding the PASARR submission process and timelines. The MDS Coordinator acknowledged the requirement to submit the PASARR after the IDT meeting within 14 days, while the DON and ADM were uncertain about the specific timeframe for submission. The facility's PASRR policy mandates that the Level I screening be completed before admission, but this was not done for the resident in question, resulting in a deficiency related to the PASARR screening process.
Failure to Care Plan Dialysis for Resident with End Stage Renal Disease
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with end stage renal disease who was receiving dialysis three times a week at an external dialysis center. Despite the resident's medical history, which included diagnoses such as end stage renal disease, depression, dementia, muscle wasting, vitamin D deficiency, type 2 diabetes, and hypertension, the care plan did not address the dialysis treatment as required. The resident's annual MDS assessment indicated the need for dialysis, but this was not reflected in the care plan dated after the assessment. Interviews with nursing staff revealed that while routine preparations and checks were performed before the resident was transported for dialysis, these actions were based on the nurse's experience rather than guidance from a documented care plan. The MDS nurse acknowledged that the dialysis treatment should have been included in the care plan and attributed the omission to unintentional negligence. The facility's policy requires that all active problems identified in the comprehensive assessment be incorporated into the care plan, but this was not followed in the case of the resident's dialysis treatment.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder. It also notes failures in providing appropriate catheter care and in implementing measures to prevent urinary tract infections. The deficiency is based on observations or findings that the facility did not consistently ensure proper care practices for these residents, as required by regulatory standards.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to have a registered nurse (RN) on duty for at least 8 hours each day and did not designate a registered nurse to serve as the director of nursing (DON) on a full-time basis. This deficiency was identified through review of staffing schedules and facility records, which showed noncompliance with the required RN coverage and DON assignment.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart on the 100 hall was observed to be unlocked and unattended by a resident's room. The nurse responsible for the cart, an LVN, was in a resident's room with the door closed and out of sight of the cart at the time. The LVN confirmed during an interview that she was responsible for the cart and had been trained on the facility's policy, which requires medication carts to be locked whenever unattended. She stated that she forgot to lock the cart because she was rushing to assist a resident. Interviews with the DON and ADM confirmed that all nursing staff had been trained on medication storage policies, which require medication carts to be locked when not in use. Both the DON and ADM stated that monitoring is conducted through compliance rounds and walking rounds to ensure adherence to this policy. Review of the facility's Medication Labeling and Storage Policy further confirmed the requirement for all medications and biologicals to be stored in locked compartments, with access limited to authorized personnel.
Failure to Prevent Elopement of High-Risk Resident from Secured Unit
Penalty
Summary
A resident with a history of dementia, unsteadiness, and high elopement risk was admitted to the facility and placed in the memory care unit due to previous attempts to leave unattended and poor safety awareness. The resident's care plan identified elopement risk and included interventions such as placement in a secured unit and providing diversions. Despite these measures, the resident was able to exit the facility undetected. On the morning of the incident, the resident was last seen asleep in his room by staff. Later, staff discovered the resident missing and initiated a search. It was determined that the resident had escaped through a window in the dining area of the memory care unit, which was found broken with the screen pushed out. The resident's walker was left by a table, and he was later located approximately a mile away from the facility. Interviews with staff confirmed that the resident was not observed leaving, and the escape was not detected until a routine check revealed his absence. The resident later explained that he had loosened screws on the window to facilitate his escape and used a chair in the backyard to climb over the fence. The resident reported being bored and wanting to socialize, and also mentioned seeking cigarettes as a motivation for leaving. Staff interviews indicated that the resident had previously shown stress when out of cigarettes, and that the facility was aware of his high risk for elopement. The deficiency occurred due to the failure to provide adequate supervision and maintain an environment free from accident hazards, allowing the resident to exit the secured unit undetected.
Delay in Antibiotic Administration Following Positive UTI Result
Penalty
Summary
A female resident with a history of dementia, diabetes, muscle wasting, and recurrent urinary tract infections (UTIs) was not administered her prescribed antibiotic, Bactrim, in a timely manner following a positive urine culture indicating a UTI. The resident reported dysuria to the medical doctor, who ordered a urinalysis. The urine specimen was collected and results indicated a high microbial load of Escherichia coli. Despite this, there was a delay of seven days before the resident received her prescribed antibiotic treatment. The medication administration record (MAR) showed that the resident received only one dose of Bactrim initially, with no further doses administered until several days later, and there was no documentation explaining the gap in administration. Interviews with nursing staff revealed uncertainty and lack of recall regarding the delay, with staff acknowledging that the standard process would be to notify the nurse practitioner and obtain orders promptly upon receiving lab results. The facility's policy required medications to be administered safely, timely, and as prescribed, but this was not followed in this instance. The resident reported experiencing increased pain and dysuria during the period she did not receive her antibiotics, expressing concern about potential kidney damage. Staff interviews confirmed that the delay in starting antibiotics was not in line with expectations and that the nurse practitioner should have been notified within 24 hours of positive lab results. The facility administration acknowledged that the situation did not meet their standards and could not explain how the error occurred.
Delay in Practitioner Notification and Antibiotic Administration Following Positive UTI Lab Result
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of laboratory results that were outside clinical reference ranges, specifically in the case of a female resident with a history of dementia, diabetes, muscle wasting, and recurrent urinary tract infections (UTIs). After the resident reported dysuria, a urine sample was collected and later confirmed to be positive for a UTI with a high microbial load of Escherichia coli. Despite the positive lab results, there was a delay in notifying the practitioner and obtaining an order for antibiotics. The resident did not receive her prescribed antibiotic, Bactrim, until seven days after the positive UTI results were received. Documentation showed that only one dose was administered initially, with a gap of several days before the full course of antibiotics was started. There was no documentation explaining the delay or the missed doses during this period. Interviews with nursing staff and administration confirmed that the expected protocol was not followed, and the nurse responsible for receiving lab results did not promptly notify the practitioner or obtain timely orders. The resident reported experiencing increased pain and dysuria during the period she was not receiving antibiotics. Staff interviews indicated that the delay was not in line with facility policy, which requires medications to be administered in a safe and timely manner as prescribed. The failure to promptly communicate lab results and administer prescribed medication resulted in the resident not receiving the intended therapeutic benefit in a timely manner.
Failure to Notify MD of Resident's Condition Change
Penalty
Summary
The facility failed to immediately inform a resident's physician when there was a significant change in the resident's condition. A male resident, who was moderately cognitively impaired and had a history of heart failure, hypertension, and other health issues, experienced shortness of breath and chest pain. Despite these symptoms, the Assistant Director of Nursing (ADON) did not notify the facility's Medical Doctor (MD) because the resident's vital signs appeared normal, and he seemed comfortable. The resident was later found unresponsive and without a pulse or respirations. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) on duty was on break during the incident and was not informed of the resident's symptoms. The resident's MD stated that he expected to be notified of any significant changes, such as shortness of breath or chest pain, and would have ordered a STAT chest x-ray if informed. The Director of Nursing (DON) confirmed that the facility's policy required immediate notification of the MD for any changes in a resident's condition. The facility's failure to follow this policy could place residents at risk of illness, injury, and decreased quality of life.
Failure to Adhere to Resident's Dietary Needs Leads to Fatal Incident
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet the individual needs of a resident, leading to a serious incident. The resident, who had a mechanically altered diet due to dysphagia and other medical conditions, was given a peanut butter sandwich by a staff member, contrary to the dietary orders that specified no bread. This incident occurred during snack time when the staff member, unaware of the resident's specific dietary restrictions, provided the sandwich, which was not suitable for the resident's mechanical soft diet. The resident had a history of severe cognitive impairment, dysphagia, and other health issues that required a mechanically altered diet with close supervision. The resident's care plan and dietary orders clearly indicated the need for a mechanically soft diet with no bread, to prevent choking and aspiration risks. Despite these orders, the staff member provided a peanut butter sandwich, which was a dense and dry food item, unsuitable for the resident's dietary needs. The incident resulted in the resident experiencing distress and ultimately expiring. Interviews with staff revealed a lack of awareness and adherence to the resident's dietary orders, as well as inconsistencies in the communication and understanding of the resident's dietary needs. The staff member involved admitted to not knowing the specific diet the resident was on at the time of the incident, highlighting a critical gap in the facility's dietary management and staff training processes.
Removal Plan
- The regional nurse consultant, regional reimbursement consultant, the director of nursing, and the MDS audited all Matrix EHR orders to validate that they matched the RD Dining Meal ticket system and that they were on the Resident Profile so that the CNAs and other facility workers can identify the diet that the resident is on and any precautions that are in place. Any concerns or discrepancies were corrected immediately upon discovery. Snacks ordered for weight loss interventions were audited and all were correct.
- The director of nursing/designee in-serviced facility staff on where to find the diet information for a resident. Facility staff will receive the information before starting their next assigned shift. Agency staff will receive the information before starting their assigned shift.
- The CNA who fed the resident bread was individually re-educated by the administrator and the director of nursing regarding following the resident diet and where to find diet information.
- The regional nurse consultant in-serviced the administrator and the director of nursing on new admissions to the facility and the process of entering the diet into the Matrix EHR and completion on the Resident Profile. New admission orders will be reviewed in the Interdisciplinary Team Meeting (IDT) and corrections made when needed. The RD Dining Meal Ticket system will also be checked at that time to validate that everything matches. The MDS will then develop a care plan for any dietary needs identified per the regulation.
- The RD recommendations will be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders entered per the above processes. The Resident Profile and care plan will be updated at that time. Any concerns will be discussed in the weekly Quality of Care meeting.
- Speech therapy recommendations will be reviewed upon receiving by the director of nursing/designee for any diet changes and new orders will be entered per the above processes. The Resident Profile and care plan will be updated at that time. Any concerns will be discussed in the weekly Quality of Care meeting.
- An Ad Hoc QAPI meeting was held with the facility medical director to discuss the deficiency and actions put in place by the facility.
- The administrator will monitor the new orders for diets from the RD or the Speech Therapist, weekly for one month and randomly thereafter by reviewing the facility activity report, actual food on meal trays, and documenting findings on a log created by the facility. Any concerns or trends will be brought to the monthly QAPI meeting for tracking and trending and new IDT recommendations.
Facility Fails to Meet Nutritional Needs Due to Inadequate Food Supplies
Penalty
Summary
The facility failed to ensure that menus and nutritional adequacy met the nutritional needs of residents in accordance with established national guidelines. This deficiency was observed during two meals where the facility did not have the necessary food supplies to prepare and serve the planned or alternate menu. The facility was found to have insufficient food supplies from 07/31/2024 through 08/06/2024, with only enough food available for lunch, dinner, and the next day's lunch on 08/06/2024. This lack of food supply could place residents at increased risk for inadequate nutrition. During observations and interviews, it was revealed that the facility's menus rarely matched what was served, and residents often did not eat from the facility's kitchen due to dissatisfaction with the food. The Dietary Supervisor (DS) admitted to substituting menus due to unavailable food and residents' dislikes without consulting the Registered Dietitian (RD). The DS also stated that the facility was supposed to have a seven-day supply of food, but the order for 07/31/2024 was not approved by Corporate due to budget constraints. As a result, the DS had to purchase food daily using the Administrator's personal credit card. The Administrator confirmed awareness of the situation and stated that Corporate was not informed about the lack of food until the State Surveyors inquired. The facility did not have emergency food supplies for sheltering in place or evacuations. The RD was not contacted regarding menu changes until after the surveyors' visit, and the facility's menu substitution forms were not signed off by the RD. The facility's failure to maintain adequate food supplies and follow established guidelines for menu preparation and nutritional adequacy led to this deficiency.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in their kitchen, as observed during a survey. Specifically, the facility did not label or date food items that were prepped, which is a critical step in ensuring food safety. Observations revealed that milk, orange juice, and cranberry juice were not dated or labeled with the date they were prepped. Additionally, a pitcher of juice in the refrigerator was covered but not labeled, and a personal drink in a Styrofoam cup was found in the kitchen. Other items, such as a package of cheddar cheese, a large container of Blue Bunny Sherbet, and an opened box of taco shells, were not properly sealed, labeled, or dated. Interviews with dietary staff and the administrator confirmed the importance of labeling and dating food to track how long it has been opened and to prevent contamination. The Dietary Manager emphasized that all food in the refrigerator, freezer, and pantry should be dated and labeled to maintain freshness and prevent bacterial growth. The facility's Food Receiving and Storage Policy also mandates that all food stored in the refrigerator or freezer be covered, labeled, and dated. The failure to comply with these standards placed residents at risk of foodborne illness.
Failure to Conduct Updated PASRR Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment. Specifically, the facility did not have an accurate PASRR Level 1 assessment for a resident who had a diagnosis of major depressive disorder and mood disorder unspecified. This resident was admitted with several diagnoses, including Type 2 Diabetes, Dysphasia with Cerebrovascular disease, and Major Depressive disorder. Despite these diagnoses, the only PASRR evaluation on record was from 2018, which indicated a negative result for mental illness. The resident's care plan included interventions for psychotropic drug use, yet no updated PASRR assessment was conducted following the addition of new mental health diagnoses. Interviews with facility staff revealed a lack of clarity and understanding regarding the need for updated PASRR evaluations. The MDS coordinator acknowledged that the resident's diagnoses should have triggered a new PASRR assessment, but stated that only certain diagnoses automatically prompted such evaluations. The Director of Nursing deferred to the MDS coordinator on PASRR evaluation questions, and the Assistant Director of Nursing, who was the charge nurse for the resident, was unaware of the need for psychoactive medications. The facility administrator admitted that a new PASRR evaluation should have been conducted with each new diagnosis, indicating a failure to adhere to state guidelines for PASRR assessments.
Failure to Implement Timely Baseline Care Plan for New Resident
Penalty
Summary
The facility failed to implement a baseline care plan for a newly admitted resident, identified as Resident #128, which is necessary to provide effective and person-centered care. Upon admission, Resident #128 had several medical conditions, including dysphagia following a cerebral infarction, persistent atrial fibrillation, prostate cancer, flaccid hemiplegia of the right side, and dysarthria. Despite these complex medical needs, the baseline care plan, which should have been completed on the day of admission, was left blank by the MDS Coordinator. This oversight was noted during a review of the care plan dated several days after admission, which eventually included interventions for the resident's swallowing problems, incontinence, prostate cancer, atrial fibrillation, and right-sided hemiparesis. Interviews with facility staff revealed a lack of adherence to the facility's policy regarding the timely completion of baseline care plans. The LVN stated that baseline care plans should be completed before the end of the shift on the day of admission, while the DON confirmed that the care plan for Resident #128 was not completed until several days later. The administrator also acknowledged that baseline care plans are expected to be completed on the day of admission. This delay in creating a baseline care plan could potentially place residents at risk for decreased quality of life, improper care, and injury, as it did not meet the professional standards of quality care required for newly admitted residents.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene. This deficiency was observed in two residents, who did not receive adequate assistance with bathing and nail care. Resident #21, a male with hemiplegia, hemiparesis, and other conditions requiring assistance with personal care, did not receive a shower or bath for a period of five days, despite not refusing such care. Observations noted a strong body odor, oily hair, and blackish substance under his fingernails, which he attributed to bowel matter. He expressed frustration over repeated requests for bathing that were unmet due to staff being too busy. Resident #40, a female resident, also experienced neglect in personal hygiene care. She reported embarrassment due to facial hair and untrimmed nails, which she had requested to be addressed by staff but was told they were too busy. She could not recall the last time she had a shower, estimating it had been over a week. Interviews with staff, including CNAs and the DON, confirmed that nail care and bathing were responsibilities of the nursing staff, with a schedule in place for showers. However, documentation did not indicate any refusals of care by the residents, suggesting a lapse in the facility's adherence to its care policies. The facility's policy on nail care, revised in 2010, emphasizes the importance of regular cleaning and trimming to prevent infections and maintain hygiene. Despite this, the facility failed to ensure that these basic care needs were met for the residents, leading to potential health risks and a decline in their quality of life. The staff interviews highlighted a lack of awareness or action regarding the residents' unmet care needs, contributing to the deficiency observed by the surveyors.
Failure to Provide Resident-Centered Activity Program
Penalty
Summary
The facility failed to develop an activity program based on the preferences of two residents, leading to a lack of engagement and increased risk of depression and boredom. Resident #48, a female with severe cognitive impairment, limited vision, and multiple health conditions, expressed dissatisfaction with the activities provided. She reported that the activities were repetitive and not tailored to her needs, such as the lack of reading materials suitable for her vision and the absence of diabetic-friendly food options during events. Observations confirmed that she often sat in her room without engaging in any activities, contributing to her feelings of depression and boredom. Resident #50, a male with moderate cognitive impairment and depression, also reported boredom and dissatisfaction with the activities offered. He noted that the activities were repetitive and did not align with his interests, such as his preference for live music over the music played during meals. He expressed that the lack of engaging activities led him to fabricate stories about staff for entertainment. Observations and interviews confirmed that he spent much of his time alone and did not participate in activities that matched his interests. The facility's activity calendar showed scheduled activities that were not conducted on specific dates, and the activities that did occur were often not conducive to group engagement due to environmental factors like noise. The Activity Director acknowledged these issues, including the lack of variety in the activity calendar and the failure to consider individual resident preferences. The facility's policies on group programs and activities were not adequately followed, contributing to the deficiency.
Aerosol Air Freshener Found in Resident's Room
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards, as evidenced by the presence of a 12-ounce aerosol air freshener bottle at the bedside of a resident with a diagnosis of asthma and who was receiving oxygen therapy. The use of aerosols is contraindicated for individuals with these conditions. The resident, who had mild cognitive impairment and required substantial assistance for transfers, dressing, and bathing, was not aware of how the aerosol came to be in her room. Interviews with facility staff, including an LVN and the DON, revealed that they were unaware of the presence of the aerosol in the resident's room and acknowledged that it was against facility policy to have such items in resident rooms. The facility's admission packet did not contain information on allowed materials in rooms, and the facility was unable to provide a policy on air fresheners when requested. This oversight could potentially place residents at risk of avoidable accidents and injury.
Failure to Adhere to Oxygen Therapy Protocols
Penalty
Summary
The facility failed to provide appropriate respiratory care for residents requiring oxygen therapy, specifically for two residents reviewed for oxygen use. The deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not adhere to its policy of changing, dating, and initialing oxygen humidifiers, tubing, and cannulas weekly. Resident #53's oxygen tubing was observed to be dated 7/01/24, and the humidifier reservoir was found empty, indicating a lapse in the facility's protocol. Despite the facility's policy requiring weekly changes, the tubing was not replaced until 7/14/24, as confirmed by the resident and staff interviews. Resident #53, who was admitted with multiple diagnoses including joint replacement surgery, pneumonitis, and diabetes, was found to have oxygen tubing that was not changed according to the facility's policy. The resident's care plan included interventions for oxygen therapy, yet the tubing was not replaced in a timely manner, potentially placing the resident at risk for respiratory infections. Interviews with the LVN and DON revealed discrepancies in the documentation and execution of the facility's oxygen administration policy, with the DON unable to explain the presence of outdated tubing. The facility's administrator acknowledged the policy breach, confirming that the tubing should have been replaced weekly.
Failure to Administer Medications Safely and as Prescribed
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for a resident, identified as Resident #58, by administering anti-acid medications without a physician's order and not ensuring the resident swallowed the medication before leaving the room. Resident #58, a male with a history of dyspepsia, hypertension, long-term use of antithrombotic/antiplatelets, and anemia, was observed with four tablets of anti-acid medicine at his bedside, which were not listed on his Medication Administration Record (MAR). The resident reported receiving anti-acid medications from the med aide without a physician's order and sometimes taking multiple tablets at once. Interviews with the med aide and the Director of Nurses (DON) revealed that the facility's protocol required a physician's order for all medications, including over-the-counter ones like anti-acids. The med aide admitted to providing the resident with anti-acid medications upon request, without verifying a physician's order or ensuring the resident took the medication immediately. The DON confirmed that it was against best practices to administer medications without reviewing the MAR and to leave medications at the resident's bedside. The facility's policy on administering medications, revised in December 2012, mandates that medications be administered safely, timely, and as prescribed, with proper documentation on the MAR. The med aide's actions of providing anti-acid medications without a physician's order and not observing the resident taking the medication violated this policy, potentially putting the resident at risk of consuming unprescribed medications and experiencing adverse effects.
Inadequate Training for Dietary Aide
Penalty
Summary
The facility failed to provide sufficient support personnel with the appropriate competencies and skills to carry out the functions of the food and nutrition service. This deficiency was identified when a dietary aide, referred to as Dietary Aide H, was found to have started working in the kitchen without receiving the necessary orientation and training. The personnel file for Dietary Aide H lacked a certificate of food handlers' course and any records of orientation or training. On the day of the incident, the Dietary Manager admitted to calling Dietary Aide H to work without prior training or orientation, acknowledging the mistake and stating that he was not qualified to perform any tasks in the kitchen. Further interviews revealed that the Human Resource Manager was unaware of Dietary Aide H working that day and confirmed that all staff were required to undergo training and orientation before starting work. The Dietary Manager later stated that Dietary Aide H was supposed to undergo three days of training and orientation before working alone in the kitchen, which did not occur. Despite being unqualified, Dietary Aide H assisted with food service and some food preparation tasks without supervision. The facility's protocol for dietary staff orientation and training was not provided at the time of the survey exit.
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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