Avir At Mineola
Inspection history, citations, penalties and survey trends for this long-term care facility in Mineola, Texas.
- Location
- 320 Greenville Highway, Mineola, Texas 75773
- CMS Provider Number
- 675668
- Inspections on file
- 35
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Avir At Mineola during CMS and state inspections, most recent first.
A CNA and an LVN were found in a secured unit living room with a blanket covering the overhead light, which was done because the light could not be turned off and shined into a resident's room. The CNA kept the resident's door open due to a history of wandering. The Maintenance Director confirmed the light switch had been intentionally disconnected, and both he and the Administrator acknowledged that covering lights with cloth is a fire hazard. The facility lacked a policy on this issue.
Three medication carts were found unlocked and unattended in hallways, with staff and residents passing by or sitting near the carts. LVNs admitted to leaving the carts unlocked while working, despite facility policy requiring secure storage accessible only to authorized personnel. The Administrator and ADON confirmed that carts should only be unlocked when staff are actively retrieving medications or standing directly in front of them.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that restrained their ability to function, resulting in a deficiency related to medication management.
A nurse aide worked for several months with an expired certification, providing direct care to residents. The facility lacked a policy for monitoring certification renewals, and administrative staff were unaware of the lapse until notified by another employee. The aide believed the facility would handle her renewal, and the monitoring system in place failed to identify the expired status.
Staff did not immediately inform a resident, the resident's doctor, and a family member about incidents such as injury, decline, or room changes that affected the resident, as required by policy.
A resident with a history of edema, hypertension, and CHF developed a weeping blister and swelling on her leg. Nursing staff applied dressings and wraps without notifying the physician or obtaining orders, and the DON was unaware of the treatment. The physician was not informed of the change in condition, and facility policy requiring prompt notification was not followed.
Two residents with chronic pain had their prescribed hydrocodone-acetaminophen tablets replaced with extra strength Tylenol after being admitted with pill bottles from outside sources. The misappropriation was discovered by a nurse during medication administration, and an internal investigation could not determine when the switch occurred or who was responsible. Both residents reported effective pain management and no complaints at the time of assessment.
A resident's medical record was not accurately maintained when the DON edited a wound care progress note originally written by an LVN, removing information about the previous dressing date without having performed the care herself. The LVN had documented the date found on the dressing, and the DON later acknowledged that the note should not have been changed. Facility policy requires accurate and complete documentation.
A shower room was found with black grime on the walls, a pink stain on the floor, and missing tiles that had not been repaired for over a month. Staff interviews revealed confusion over cleaning responsibilities and a lack of maintenance work orders, despite awareness of the issues by housekeeping and maintenance staff. Facility policy required daily cleaning and prompt repairs, but these were not consistently carried out.
Multiple residents with cognitive and behavioral impairments were not protected from physical abuse, including incidents where one resident slapped another after being startled, a CNA slapped a resident during a transfer, and a family member struck a resident during a dispute over discharge. These events involved both resident-to-resident and staff- or family-initiated abuse, with injuries and emotional distress documented.
The facility did not maintain an effective pest control program, as multiple residents and staff reported ongoing sightings of roaches and water bugs in resident rooms, the dining area, and other areas. Although staff were instructed to document pest sightings in designated binders, they relied on verbal reports, resulting in no written records. The pest control technician confirmed ongoing pest issues despite regular treatments, and the facility's policy requiring an effective pest control program was not followed.
A resident with multiple mental health diagnoses, who was cognitively intact, received Seroquel for bipolar disorder without a signed written consent form as required. Although the resident was aware of the medication, the facility did not obtain the necessary written consent acknowledging the risks and benefits, as confirmed by staff interviews and policy review.
Two residents with intact cognition reported missing personal clothing items—one after a laundry fire and another after her pants went missing. Both informed staff, but no formal grievance was filed, and the items were not replaced. Staff interviews revealed a lack of communication and understanding of the grievance process, and review of records confirmed no grievances were documented as required by facility policy.
A resident with multiple medical conditions and intact cognition did not receive scheduled showers as outlined in his care plan, despite not refusing care. Documentation and staff interviews revealed missed and irregularly timed showers, with staff citing time constraints and workload as reasons for the lapse. Facility policy required assistance with ADLs, but the resident did not consistently receive necessary hygiene care.
The facility failed to ensure a clean, comfortable, and homelike environment due to a shortage of clean bed and bath linens. Observations revealed inadequately stocked linen closets and carts, with staff confirming the shortage and attributing it to staffing limitations and linen being hidden or destroyed. The Housekeeping/Laundry Supervisor noted insufficient staffing and the Administrator acknowledged the risk to residents.
The facility failed to resolve grievances related to missing clothing for four residents, including those with Alzheimer's and dementia. Despite reports from family members, grievances were either not documented or inadequately resolved, leading to ongoing issues with missing personal items. Family members expressed frustration and resorted to handling laundry themselves or purchasing new clothing.
The facility failed to properly label, date, and dispose of food items, leading to potential risks of food contamination. Observations revealed expired and unlabeled items in the kitchen's refrigerator and freezer. Despite regular walk-throughs by the Dietary Manager, these issues were not addressed, and the Administrator was unaware of the deficiencies.
The facility failed to coordinate hospice care effectively for residents, resulting in missing or outdated hospice documentation. This deficiency involved three residents whose hospice binders lacked essential documents like care plans and medication profiles. Interviews revealed that the hospice companies were responsible for providing these updates, but lapses in communication and coordination led to potential risks in resident care.
The facility failed to maintain proper infection control practices, including staff not wearing PPE during care for a resident on enhanced barrier precautions, improper hygiene during incontinent care for a resident with cerebral palsy, and inadequate storage of clean and dirty linens. Additionally, a resident's catheter bag was found on the floor, and a linen cart was left uncovered, all of which pose infection risks.
A resident in an LTC facility was administered Klonopin without documented informed consent from the resident or their responsible party. The LVN assumed consent was unnecessary due to the resident's prior use of the medication. The ADON and DON confirmed the oversight, highlighting the importance of consent for psychotropic medications. The facility's policy requires informed consent and education on medication risks and benefits, which was not followed.
A resident with Alzheimer's disease and a history of falls did not have their care plan updated after three falls, despite interventions being in place. The facility's staff, including the ADON and DON, acknowledged the oversight, which was contrary to the facility's policy requiring care plan revisions after assessments.
A resident requiring moderate assistance with personal hygiene was observed with unaddressed chin hair, despite expressing discomfort. Facility staff, including a CNA and LVN, failed to provide necessary grooming, impacting the resident's dignity and self-esteem. The facility's ADL policy was not followed, leading to a deficiency in care.
A resident with multiple diagnoses, including Alzheimer's, did not have a required Depakote level test conducted as ordered, due to inconsistent nurse staffing and oversight. The ADON acknowledged responsibility, and the DON and Administrator recognized the risk of potential toxicity from the missed lab test.
A resident's bathroom was found to be consistently dirty and unsanitary, with brown stains, sticky floors, and a strong urine odor. The resident, who required assistance with toileting, reported dissatisfaction with the cleanliness. Housekeeping staff admitted to cleaning the bathroom only once a day, and the Housekeeping Supervisor cited staffing shortages as a challenge. The facility's policy emphasized maintaining a clean environment, which was not met in this case.
A facility failed to maintain an effective pest control program, resulting in roaches in a resident's bathroom. Despite multiple pest sightings documented in logs, the Pest Control Technician was unaware of the issue in resident areas, as he only treated the exterior and kitchen. Interviews revealed that the Maintenance Supervisor and Administrator were also unaware of the complaints, highlighting a breakdown in communication and oversight.
Fire Hazard Created by Covering Overhead Light with Blanket in Secured Unit
Penalty
Summary
Staff failed to ensure the resident environment in the secured unit living room was free from accident hazards when a blanket was observed covering the overhead light. On the date of observation, an LVN and a CNA were present in the living room with the blanket covering the light, and the LVN removed the blanket upon the surveyor's entry. The LVN acknowledged that covering the light was unsafe and stated that the CNA typically covered the light in the dining room as well. The CNA explained that the blanket was used because the overhead light could not be turned off and shined directly into a resident's room, and that the resident's door was kept open due to a history of wandering. The CNA was unsure if covering the light with a blanket was safe. The Maintenance Director confirmed that the light switch in the living room had been intentionally disconnected prior to his employment to prevent staff from turning off the light and sleeping during shifts. He stated that staff should not hang blankets over lights, as it is a fire hazard. The Administrator was unaware of the disconnected switch and agreed that covering lights with cloth is a fire hazard. The facility did not have a policy regarding covering lights with cloth or other items.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that three medication carts (Medication Cart #1, #2, and #3) were left unlocked and unattended in various hallways of the facility. On multiple occasions, the carts were found unsupervised with residents and staff passing by, and in some cases, residents were sitting near the unlocked carts. Interviews with LVNs revealed that the carts were left unlocked because staff were actively using them or had recently accessed them, but the carts were not secured immediately after use. Staff acknowledged the importance of keeping medication carts locked to prevent unauthorized access but admitted to leaving them unlocked during their shifts. The facility's policy requires that medications and biologicals be stored securely and only accessible to authorized personnel. Despite this, the medication carts containing medications, including PRN medications, were accessible to unauthorized individuals when left unlocked and unattended. Both the Administrator and ADON confirmed that medication carts should only be unlocked when staff are actively retrieving medications or standing directly in front of the cart, which was not consistently followed during the survey observations.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Ensure Nurse Aide Maintained Current Certification
Penalty
Summary
The facility failed to ensure that a nurse aide, CNA E, had a current and valid nurse aide certification while employed and actively providing care to residents. Record review showed that CNA E's nurse aide certification had expired, and she continued to work her normal full-time shifts, except for four days of paid time off, during the period her certification was not valid. The Business Office Manager (BOM) and Administrator were unaware of the expired certification until it was brought to their attention by another staff member. The facility did not have a policy in place regarding nurse aide certification renewal, expirations, or registry verification, and relied on an annual employee checklist that was supposed to be completed for all employees. Interviews revealed that CNA E was unaware her certification had expired, believing the facility would handle the renewal as her previous employer had done. She also indicated that her work schedule prevented her from seeking assistance with the renewal process. The Administrator confirmed that the facility and corporate office monitor for expiring certifications, but CNA E did not appear on their lists, and there was no explanation for why her certification was not renewed on time. The lack of a clear policy and monitoring process contributed to CNA E working for several months with an expired certification.
Failure to Promptly Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The report specifically notes that the required notifications were not made promptly when events impacting the resident occurred, as mandated by regulations.
Failure to Notify Physician and Obtain Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, staff did not notify the physician of the resident's weeping edema, redness, and blister on her right leg, nor did they obtain physician orders for wound care or the application of dressings prior to applying them. The resident, who had a history of edema, hypertension, and congestive heart failure, was observed with a nonstick dressing and gauze wrap on her right leg, which was swollen and red. The resident reported that nurses had applied these dressings due to a weeping blister and to prevent her sheets from getting wet. Interviews revealed that the physician was not aware of the resident's condition or the need for a dressing, and the Director of Nursing (DON) was also unaware that a dressing had been applied. The DON confirmed that staff had not notified the physician or obtained orders for the ace wrap or for the treatment of the swelling and weeping. Nursing staff admitted to applying dressings and wraps without physician notification or orders, despite facility policy requiring prompt notification of changes in a resident's condition, including skin conditions and swelling.
Misappropriation of Controlled Medication from Resident Supplies
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their prescribed hydrocodone-acetaminophen 5-325 mg tablets. Both residents had a history of chronic pain and were admitted with pill bottles containing this controlled medication, which had been brought from home or another facility. Upon review, it was discovered that a significant number of these tablets had been replaced with extra strength Tylenol, as identified by a nurse during medication administration. The nurse used a pill identifier to confirm that the pills in the bottles were not hydrocodone-acetaminophen but Tylenol, and this was found to be the case for both residents. The facility's investigation revealed that six nurses had access to the locked medication cart from which the pills were taken. Drug testing was conducted on the nurses who had access during the relevant period, and one nurse tested positive for the medication but provided evidence of a personal prescription. However, further testing to determine if the medication in her system was within prescribed limits was inconclusive due to a lab error. The facility was unable to determine exactly when the pill swap occurred or to substantiate which staff member was responsible for the misappropriation. The police were notified, and a report was filed, but the investigation could not confirm whether the hydrocodone was present in the bottles at the time of admission. Both residents involved were assessed and reported that their pain had been well managed, with no complaints or evidence of unrelieved pain at the time of interviews and observations. The facility's policies on abuse, neglect, exploitation, and controlled substances required verification of controlled medications upon receipt, but did not specifically address the verification of medications brought in pill bottles from outside sources or the use of pharmacy blister packs for such medications. This gap in procedure contributed to the failure to prevent the misappropriation of resident property.
Inaccurate Medical Record Documentation Due to Unauthorized Note Editing
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented in accordance with accepted professional standards. Specifically, the Director of Nursing (DON) edited a progress note originally written by an LVN regarding wound care provided to a resident. The LVN's original note indicated that the previous dressing was dated three days prior to the wound care, suggesting a possible lapse in daily wound care. Five days after the original entry, the DON altered the note to remove the reference to the previous dressing date, despite not having performed the wound care herself. Interviews revealed that the LVN documented the date found on the dressing during the wound care and was unaware of why the DON changed her note. The DON admitted to editing the note because she perceived it as a red flag and suspected the LVN of falsifying documentation, but acknowledged that she should not have changed the note and should have addressed her concerns differently. Facility policy requires documentation to be concise, accurate, and complete, and the administrator confirmed the expectation for accurate records.
Failure to Maintain Clean and Safe Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment in one of its shower rooms, specifically the B hall shower room. Observations revealed thick black grime on the walls, a pink stain on the floor, and missing tiles on the shower floor. Staff interviews indicated that the shower had not been cleaned recently, and the missing tiles had been present for approximately 40-45 days. Housekeeping staff were unclear about their responsibilities for cleaning the shower, and the Maintenance Director acknowledged awareness of the missing tiles for several months, but no work order had been submitted for repairs. The Administrator was only made aware of the condition on the morning of the survey. Record reviews confirmed that no maintenance work orders had been logged for the shower room in question for several months. Facility policy requires daily cleaning of showers by housekeeping and weekly deep cleaning by the Housekeeping/Laundry Supervisor, but these procedures were not consistently followed. Staff interviews highlighted the importance of cleanliness for infection control and resident safety, but also revealed lapses in communication and follow-through regarding cleaning and maintenance responsibilities.
Failure to Protect Residents from Abuse by Peers, Staff, and Family
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse, including physical abuse by other residents, staff, and a family member. Several incidents were documented where residents with cognitive impairments, such as Alzheimer's disease, dementia, and schizophrenia, were involved in altercations resulting in physical harm. For example, one resident was slapped by another after being startled awake, and another was struck in the face by a peer who believed his foot was at risk. In another case, a resident was hit on the cheek by a fellow resident during a dining room altercation. These incidents occurred despite care plans and staff awareness of the residents' behavioral risks and cognitive limitations. Staff also failed to prevent abuse by facility personnel. In one incident, a CNA slapped a resident on the back of the hand during a transfer when the resident became combative. The event was witnessed by another CNA, and the action was acknowledged as abuse by the facility's administrator. The resident involved was dependent on staff for most activities of daily living and had a history of combative behavior, which was documented in her care plan. The staff member involved was suspended and subsequently terminated, but the incident itself demonstrated a lapse in protecting the resident from staff-initiated abuse. Additionally, the facility did not prevent abuse by a family member. In one case, a resident with severe cognitive impairment was slapped in the face by a family member during a dispute over discharge against medical advice. The incident resulted in visible injury and required intervention by staff and law enforcement. The resident expressed a desire to remain in the facility and not leave with the family member, but the abuse occurred before the situation was de-escalated. These failures to prevent abuse placed residents at risk of physical harm, mental anguish, or emotional distress, as documented in the report.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches and water bugs in resident rooms, the dining area, and other parts of the building. Multiple residents, all with intact or moderately impaired cognition, reported seeing roaches and water bugs in their rooms and common areas, particularly around the dining room coffee area and in bathrooms. These sightings were reported to various staff members, including housekeepers, CNAs, and nurses, who acknowledged the complaints and stated they would report the issues. Staff interviews confirmed the ongoing presence of pests, with CNAs and housekeepers observing roaches in shower rooms and on the unit, and reporting these verbally to the Maintenance Director. However, the required documentation in the pest control binders was not completed by staff, as confirmed by both the Maintenance Director and a review of the binders, which showed no staff entries regarding pest sightings. The Maintenance Director stated that staff were instructed to document pest sightings, but instead relied on verbal reports, leading to a lack of written records. The pest control technician confirmed that the facility was being treated twice a month and identified American roaches and water bugs coming from plumbing areas, as well as German roaches in the kitchen, which were nearly resolved. Despite these treatments, residents and staff continued to observe pests. The facility's policy required an effective pest control program, but the lack of consistent documentation and ongoing pest sightings indicated the program was not effectively implemented.
Failure to Obtain Written Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided written consent prior to the administration of an antipsychotic medication, Seroquel. Record review showed that the resident, who had diagnoses including personality disorder, bipolar disorder, major depression, and anxiety, was cognitively intact and able to understand and communicate. The resident's care plan and physician orders documented the use of Seroquel for bipolar disorder, and medication administration records confirmed that the medication was being given as prescribed. However, the required Consent for Antipsychotic or Neuroleptic Medication Treatment (Form 3713) was not signed by the resident, despite her being her own responsible party and aware of the medication. Interviews with the resident, ADON, and Administrator confirmed that the consent should have been obtained and signed at the time the medication was ordered, in accordance with facility policy. The absence of a signed consent form indicated that the resident had not formally acknowledged the risks and benefits of the medication as required.
Failure to Promptly Address and Document Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for two residents regarding missing personal clothing items. One male resident with intact cognition and a history of dementia and chronic obstructive pulmonary disease reported that all his underwear had been destroyed in a facility laundry fire. He stated he had informed several CNAs, nurses, and laundry staff about the loss, but no one provided information or resolution regarding his missing underwear. Interviews with laundry staff and the Housekeeping/Laundry Supervisor confirmed awareness of the loss, but no formal grievance was filed, and the items were not replaced. A female resident with intact cognition and diagnoses including personality disorder, bipolar disorder, major depression, and anxiety reported missing a pair of pants valued at $40. She stated she had informed the Administrator, but no action was taken, and her pants were neither found nor replaced. The Housekeeping/Laundry Supervisor acknowledged being aware of the missing pants and that extensive searches had been conducted without success, but again, no grievance was filed. Interviews with facility staff, including the Administrator and Social Worker, revealed a lack of communication and understanding regarding the grievance process. Staff members were either unaware of the need to file a grievance or did not convey the information to the appropriate personnel. Review of the facility's grievance log confirmed that no grievances were recorded for either resident during the relevant period, despite the facility's policy requiring all grievances to be documented and resolved within three working days.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
A deficiency was identified when a resident who required assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, did not receive showers as scheduled according to his care plan. The resident, an adult male with diagnoses including myocardial infarction, hypertension, muscle weakness, and chronic obstructive pulmonary disease, was cognitively intact and did not refuse care. His care plan specified that he preferred showers on Tuesday, Thursday, and Saturday, and required assistance from staff to complete these tasks. Record reviews showed inconsistencies in the documentation of showers provided, with some days showing no shower and others indicating showers at irregular times, including multiple entries on the same day. During interviews, the resident reported not receiving a shower in over a week and expressed feeling bad about not receiving regular showers. Staff interviews confirmed that the resident did not refuse showers and that it was the responsibility of CNAs and nurses to ensure showers were provided as scheduled. One CNA admitted to not providing a shower due to time constraints and being busy with other resident needs. The facility's policies required that residents unable to perform ADLs independently receive necessary services to maintain hygiene and grooming. Despite these policies, the resident did not consistently receive scheduled showers, and staff acknowledged the importance of providing this care to prevent skin issues and maintain resident comfort. The deficiency was further supported by the facility's own documentation and staff statements regarding the failure to provide showers as planned.
Deficiency in Providing Clean Linens
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by the lack of clean bed and bath linens. Observations on multiple occasions throughout the day revealed that the clean linen closets and carts across various halls were inadequately stocked, with some containing only a few pillowcases, gowns, or sheets, and others completely devoid of towels and wash rags. This deficiency was confirmed by interviews with staff, including a CNA who reported having to wait for clean linens and a Housekeeping/Laundry Supervisor who acknowledged the shortage and attributed it to staffing limitations and linen being hidden or destroyed. The Housekeeping/Laundry Supervisor noted that the laundry staff had clocked out early, leaving no one to complete the laundry for the rest of the day. The supervisor also mentioned that the facility's laundry PPD only allowed for 1.4 employees per day, which was insufficient for the facility's census of 78 residents. The Administrator confirmed the expectation for clean towels and wash rags to be available and recognized the risk posed to residents by the lack of these items. The facility's policy on supplies and equipment emphasized the need for housekeeping and laundry supplies to be readily available, which was not adhered to in this instance.
Failure to Resolve Grievances on Missing Clothing
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances related to missing clothing for four residents. Resident #46, who had diagnoses including anxiety, depression, and Alzheimer's disease, had lost four wardrobes of clothes since admission. Despite the family member reporting the issue to the facility, no grievance was documented, and the family member resorted to purchasing new clothes due to the facility's inaction. Resident #73, diagnosed with dementia and other mental health disorders, also experienced issues with missing clothing. A grievance was filed, but the resolution did not confirm whether the missing clothes were found and returned. The family member expressed frustration over the repeated need to purchase new clothing and eventually decided to handle the laundry themselves to prevent further losses. Resident #182, who had Alzheimer's disease and other health conditions, had a grievance filed regarding missing clothing and personal items. The grievance report did not indicate if the items were recovered, and the family member confirmed that the clothes were still missing at the time of the resident's passing. Similarly, Resident #10, who was cognitively intact, reported missing clothes, but no grievance was documented. The family member confirmed the loss of a significant number of clothing items, and the facility's staff had been using the roommate's clothes for the resident.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen's handling of food items. During a survey, it was found that the facility did not label and date all food items, and dietary staff did not dispose of expired food items. Additionally, frozen food items were not effectively resealed, labeled, or dated. These lapses were observed in various storage areas, including the kitchen refrigerator, walk-in refrigerator, and walk-in freezer. Specific observations included expired items such as a bottle of white vinegar and a pitcher of tomato juice, as well as unlabeled and improperly sealed items like shredded carrots, thawed bacon, and various frozen goods including chicken, breadsticks, French fries, and pepperoni. The dietary staff, including a cook with five years of experience, acknowledged the responsibility for labeling, dating, and disposing of expired foods but were unaware of the deficiencies until pointed out by the surveyor. The Dietary Manager, who has been in the role for eight years, also conducted regular walk-throughs but was unaware of the issues. The Administrator, who oversees the Dietary Manager, admitted to infrequent walk-throughs in the kitchen and was unaware of the expired and improperly stored food items until the survey. The facility's dietary policy and FDA Food Code guidelines emphasize the importance of labeling, dating, and discarding expired food to prevent foodborne illnesses, but these were not followed, leading to the identified deficiencies.
Deficiency in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was observed in three residents who were reviewed for hospice services. The facility did not maintain the hospice binders for these residents, which should have contained essential documents such as the most recent plan of care, hospice election form, physician recertification, and hospice medication profile. This lack of documentation and coordination could place residents at risk of receiving inadequate end-of-life care. For Resident #27, the facility did not have the necessary hospice documentation in the resident's binder. Interviews revealed that the hospice company was responsible for maintaining these documents, but the binder only contained a sign-out sheet. The hospice RN acknowledged the oversight and planned to deliver the binder. Similarly, Resident #35's binder was outdated, lacking recent IDT meeting notes and medication lists, which could lead to missed orders or treatments. The hospice company was expected to provide updated documents, but this was not consistently done. Resident #15's hospice binder was also missing critical documents, including the most recent plan of care and medication profile. The hospice DON admitted that the documents were not updated due to a lapse in coordination. The facility's policy required obtaining updated hospice documents, but this was not adhered to, resulting in a lack of communication and coordination of care. Interviews with facility staff and the administrator highlighted the expectation for hospice companies to provide updated documents, which was not consistently met, leading to potential medication errors and inadequate care.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) while providing care to a resident on enhanced barrier precautions. This resident had pressure wounds and required specific wound care, yet the staff neglected to wear gowns, which are essential to prevent the spread of infections. The ADON admitted to forgetting to wear the PPE despite knowing its importance. Another deficiency was noted in the care provided to a resident with cerebral palsy, where a CNA failed to follow proper hygiene protocols during incontinent care. The CNA used the same wipe multiple times and did not perform hand hygiene when changing gloves, which is crucial to prevent cross-contamination. The Director of Nursing (DON) and ADON acknowledged the importance of proper PPE use and hand hygiene to protect residents and staff from infections. Additional issues were identified in the facility's laundry room, where clean clothes were found touching the floor, and dirty linens were improperly stored. This improper storage poses a risk of infection. Furthermore, a resident's catheter bag was observed lying on the floor, which could lead to cross-contamination. The facility's linen cart was also found uncovered, exposing supplies to potential contamination. These practices indicate a lack of adherence to infection control policies, putting residents at risk of infection.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident or their responsible party was informed and participated in treatment decisions, specifically regarding the administration of psychoactive medications. The deficiency involved a resident who was cognitively impaired and required antianxiety medication. The resident was administered Klonopin (Clonazepam) without documented informed consent from either the resident or their responsible party. This oversight occurred despite the facility's policy requiring informed consent for psychotropic medications. The Licensed Vocational Nurse (LVN) involved did not obtain the necessary consent before administering the medication, as she assumed it was unnecessary due to the resident already being on the medication, albeit at an increased dosage. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the consent process was not followed, emphasizing the importance of obtaining consent for psychotropic medications due to their potential to alter mental states and cause other risks. The facility's policy mandates that residents or their representatives be educated on the risks and benefits of such medications, which was not adhered to in this case. Interviews with facility staff, including the LVN, ADON, DON, and Administrator, revealed a lack of adherence to the facility's policy on psychoactive medications. The staff acknowledged the failure to obtain informed consent and the potential implications of this oversight. The facility's policy clearly outlines the necessity for informed consent and the role of the attending physician and psychiatric provider in medication management, which was not executed in this instance.
Failure to Update Resident Care Plan After Falls
Penalty
Summary
The facility failed to ensure that Resident #46's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for one of the 21 residents reviewed for care plans. Specifically, the care plan was not updated following Resident #46's falls on three separate occasions: 07/09/2024, 07/12/2024, and 08/25/2024. The care plan interventions, which were initially set on 06/14/2024, did not reflect any new measures implemented after these incidents. Resident #46, an elderly male with a history of anxiety, unspecified psychosis, depression, and Alzheimer's disease, was admitted to the facility with significant cognitive impairments. His quarterly MDS assessment indicated he had short-term and long-term memory problems and required substantial assistance with daily activities. Despite having a history of falls, the care plan did not include updated interventions after his falls, which included a laceration on 07/09/2024 and a witnessed fall on 08/25/2024. Interviews with facility staff, including an LVN, the ADON, the DON, and the Administrator, revealed that interventions such as a low bed, fall mat, and regular monitoring were in place. However, these were not documented in the care plan. The ADON and DON acknowledged their responsibility for updating care plans and recognized that the failure to do so could lead to continued falls, as staff would not have the latest information on interventions. The facility's policy required the comprehensive care plan to be reviewed and revised after each assessment, which was not adhered to in this case.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a female resident who required moderate assistance with personal hygiene. The resident, who had a mildly impaired cognitive status with a BIMS score of 13, was observed on multiple occasions with chin hair approximately 3-4 cm in length. Despite the resident expressing that the chin hair made her feel bad and wanting it removed, the facility staff did not address this grooming need. Interviews with facility staff, including a CNA, LVN, ADON, DON, and the Administrator, revealed a lack of awareness and action regarding the resident's grooming needs. The CNA admitted not noticing the chin hair, while the LVN acknowledged its presence but did not take action. The ADON and DON emphasized the importance of grooming for the resident's dignity and self-esteem, yet the task was not completed. The facility's policy on ADLs, which includes grooming, was not adhered to, resulting in a deficiency in providing appropriate care and services.
Failure to Obtain Ordered Lab Test for Resident
Penalty
Summary
The facility failed to ensure that laboratory services were obtained to meet the needs of a resident who required monitoring of Depakote levels. The resident, an elderly male with diagnoses including anxiety, unspecified psychosis, depression, and Alzheimer's disease, had a lab order for a Depakote level to be drawn on a specific date. However, the lab result for that date was not found in the resident's electronic medical record, indicating that the test was not conducted as ordered. This oversight was acknowledged by the Assistant Director of Nursing (ADON), who admitted responsibility for ensuring the lab was obtained. Interviews with the ADON, Director of Nursing (DON), and the Administrator revealed that the failure to obtain the lab was attributed to inconsistent nurse staffing, as the facility had been using agency staff to fill nursing positions. The DON and Administrator both expressed that they expected labs to be obtained as ordered and recognized the risk of not obtaining the lab, which could lead to potential toxicity. The facility's policy required staff to process test requisitions and arrange for tests, but this was not followed in this instance.
Failure to Maintain Clean and Sanitary Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in one of the bathrooms used by a resident. The resident, who was cognitively intact and required assistance with toileting, reported that his bathroom was consistently dirty and unpleasant to use. Observations confirmed the presence of numerous brown stains on the bathroom door, sticky floors, and a strong urine odor. The toilet and surrounding areas were covered with brown substances resembling dried feces, and the toilet water was discolored. The resident expressed dissatisfaction with the cleanliness of his bathroom and preferred to use other toilets in the facility. Interviews with housekeeping staff revealed that the bathroom was supposed to be cleaned daily, but the housekeeper responsible for the area admitted to cleaning it only once a day. The housekeeper also noted that picking up dirty clothing was not her responsibility. The Housekeeping Supervisor acknowledged the unsanitary condition of the bathroom and attributed it to being short-staffed, which affected her ability to monitor cleaning activities effectively. Despite these challenges, the expectation was for all rooms and bathrooms to be cleaned daily to ensure a sanitary environment for residents. The facility's Administrator confirmed that the housekeeping staff was expected to clean each room and bathroom daily. The Administrator also stated that department heads were responsible for ensuring that cleaning was completed each day. The facility's Homelike Environment policy emphasized the importance of maintaining a clean, sanitary, and orderly environment, which was not upheld in this instance, leading to the deficiency.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in Resident #2's bathroom on C Hall. Observations and interviews revealed that the resident had noticed roaches in his room and bathroom since his admission. Despite notifying the facility staff, the issue persisted, and the resident expressed dissatisfaction with the cleanliness maintained by the new owners. During an observation, two small brown roaches were found in the resident's bathroom, confirming the resident's complaints. The pest control logs from May to July 2024 documented multiple instances of roach sightings throughout the facility, including in the kitchen, hallways, and resident rooms. Despite these records, the Pest Control Technician reported being unaware of roach activity in the hallways or resident rooms, as he only treated the exterior and kitchen areas during his visits. The technician also noted that he had not had access to the pest control logs for several months and was not informed of the roach sightings by the Maintenance Supervisor or Administrator. Interviews with the Maintenance Supervisor and Administrator revealed a lack of awareness regarding the roach complaints and sightings. The Maintenance Supervisor stated that he was unaware of any complaints and believed the pest control logs were regularly reviewed. The Administrator also expressed unawareness of the issue and emphasized the importance of maintaining pest control to ensure a bug-free environment for residents. The facility's pest control policy, revised in May 2008, indicated an ongoing program to keep the building free of insects and rodents, but the implementation appeared ineffective in this case.
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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