Avir At Overton
Inspection history, citations, penalties and survey trends for this long-term care facility in Overton, Texas.
- Location
- 1110 Hwy 135 S, Overton, Texas 75684
- CMS Provider Number
- 675408
- Inspections on file
- 38
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 8 (2 serious)
Citation history
Health deficiencies cited at Avir At Overton during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a known fall risk experienced two falls, one resulting in a nasal laceration. For both events, the incident reports completed by an LVN documented that the physician and resident representative were not notified, and nursing notes lacked any record of notification attempts. The resident’s representative later reported learning of the injury only upon visiting and seeing the wound. Interviews with staff confirmed that facility practice and written policy required notifying the MD and resident representative after accidents with injury, and that such notifications should be documented on incident reports and in progress notes.
A resident with severe cognitive impairment, a diagnosis of senile brain degeneration, and a history of falls was admitted without a baseline care plan being completed within 48 hours, as required by facility policy. Record review showed no baseline care plan in the EMR and a later comprehensive care plan that only addressed falls and behavioral symptoms, omitting ADLs, transfers, social needs, and key orders. Interviews with the MDS nurse, DON, and administrator confirmed that baseline care plans were expected within 24–48 hours and that comprehensive plans used in place of baseline plans should include all essential care instructions, but this did not occur for this resident.
Two residents involved in a transport van motor vehicle accident were not assessed for injury by facility nursing staff upon return, despite one having a history of traumatic brain injury and spinal fusion and the other having severe cognitive impairment and prior stroke. EMS documentation indicated no visible injuries at the scene, and an LPN documented that EMS had evaluated and cleared both residents, but no immediate nursing or skin assessments were completed at the facility. One resident later reported neck, back, and hip pain and had to crawl over a seat to exit the van due to a malfunctioning wheelchair ramp, while the other reported being sore for several days and stated that no one checked him at the scene or on return. Staff interviews confirmed that the LPN did not assess the residents because she believed EMS had cleared them, and that the transporter and a CNA had to manually assist one resident out of the van through a side door, contrary to facility policies requiring nursing observation and documentation when there is a change in condition.
A resident with a history of behavioral symptoms stomped on another resident's foot in the dining room, resulting in a bruise. Staff observed the incident and intervened to separate the residents, and the injured resident was assessed and found to have no pain. Both residents had cognitive and behavioral diagnoses, and interventions for monitoring and redirection were in place, but the physical altercation still occurred.
Staff failed to immediately report an incident in which one resident stomped or kicked another resident's foot, resulting in a bruise. Although the incident was witnessed and reported to a nurse, it was not reported to the administrator as required, leading to a delay in notifying proper authorities. Both residents involved had significant cognitive and behavioral health diagnoses, and staff training records indicated that required abuse reporting training had been completed.
A CNA failed to provide privacy for a resident with severe cognitive impairment during incontinent care, leaving the individual exposed and visible from the hallway when the CNA left the room to get supplies. Staff interviews and facility policy confirmed that privacy measures, such as closing curtains and covering the resident, were required but not followed in this instance.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. The report identifies a lapse in ensuring resident safety and well-being.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
The facility failed to maintain RN coverage for at least eight consecutive hours daily, seven days a week, during July and August 2024. There was no RN coverage on specific days, as confirmed by the RN punch detail hour report and CMS PBJ report. Staffing issues and turnover contributed to the deficiency, with the ADON responsible for scheduling and the DON's hours not counting towards the required RN hours. The facility's policy requires RN presence to ensure resident safety.
The facility failed to maintain sanitary conditions in the kitchen, with issues in dish machine sanitation and improper thawing of raw foods. The dish machine's sanitizer was not registering due to unattached tubing, and frozen foods were thawed inappropriately in the sink. These deficiencies could risk foodborne illnesses among residents.
The facility failed to maintain a safe and sanitary environment, with issues in the Women's and Men's locked units, and the main dining room. A resident's room had a stained mattress and smeared walls, while hallways had damaged doors and floors. The dining room had a sagging ceiling and dirty vents. Staff interviews revealed a lack of maintenance action, with the administrator citing funding delays for repairs.
A facility failed to remove a worn and damaged mechanical lift sling from service, posing a risk to a resident with significant medical conditions. The resident, dependent on staff for transfers, was observed using a faded sling over two days. Staff interviews revealed a lack of awareness and adherence to inspection and maintenance policies, with the DON and Administrator unaware of the sling's condition and washing procedures.
The facility failed to post daily nurse staffing information in a prominent location, as required. Observations on two consecutive days revealed that the postings were partially blocked by medication carts and not clearly visible. Interviews with the ADON, DON, and Administrator highlighted a lack of awareness regarding the visibility of the postings, which were later moved to a more accessible location.
A resident with a full code status was found unresponsive, but the RN did not initiate CPR or call 911 immediately, assuming the resident was already deceased. Emergency services were called 29 minutes later, but the resident was pronounced deceased after CPR was initiated by emergency personnel. The facility's policy required CPR for full code residents unless there were signs of irreversible death.
A resident with a full code status was found unresponsive, but CPR was not initiated by the attending RN, who believed the resident was already deceased. The facility's policy required CPR unless a DNR order was present or there were signs of irreversible death. Emergency services initiated CPR upon arrival, highlighting a failure to follow protocol.
The facility failed to protect residents from abuse, resulting in incidents where a resident with severe cognitive impairment slapped another resident, and another resident pulled the first resident by her shirt collar. Despite interventions in place, such as serving meals first to prevent altercations, the measures were inadequate. Staff interviews highlighted insufficient supervision on the secured unit, contributing to the incidents.
A facility failed to report a resident's allegation of verbal abuse involving racial slurs by a CNA and an LVN. Despite conflicting accounts from staff and the resident's history of making false accusations, the administrator did not consider the incident as verbal abuse and did not report it to the state agency, leading to a racially discriminatory environment.
Failure to Notify Physician and Representative After Resident Falls With Injury
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s representative and attending physician of significant changes in condition following falls. An elderly male resident with senile degeneration of the brain, severely impaired cognition, and a history of falls prior to and during his admission was identified as being at risk for falls in his comprehensive care plan dated 6/22/25. A comprehensive MDS indicated he was unable to complete the BIMS interview and had severely impaired cognition. Despite this known fall risk and cognitive impairment, required notifications were not made after two separate fall incidents. Record review showed that on 6/22/25 at 5:16 a.m., the resident sustained a witnessed fall in which he ran into a door facing and fell to the floor, resulting in a 1x0.5 cm laceration to the bridge of his nose. The incident report for this fall, completed and signed by LVN A, documented that the resident representative was not notified. The corresponding nursing progress note, entered at 5:18 a.m. by LVN A, described the fall and treatment (area cleaned and topical antibiotic applied) but contained no documentation of notification or attempted notification of the responsible party. The resident’s responsible party later reported that she was not called about this fall and only discovered the injury when she visited the facility the next day and saw the laceration on his nose. A second incident report dated 6/27/25 at 1:51 a.m. documented an unwitnessed fall for the same resident. In the notifications section of this report, also signed by LVN A, it was recorded that the attending physician was not faxed, the physician was not notified, and the resident representative was not notified. The nursing progress note for this fall, entered at 1:52 a.m. by LVN A, likewise contained no documentation of physician or responsible party notification or attempted notification. Interviews with another LVN, the DON, and the administrator confirmed that facility practice and written policy required notification of the physician and resident representative after accidents or incidents involving injury, and that the incident reports would reflect whether such notifications were made. Facility policy and resident rights documents further stated that the nurse must notify the attending physician and the resident’s representative when the resident is involved in an accident or incident resulting in injury or requiring a physician visit.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a baseline care plan within 48 hours of admission for one resident. The resident was an elderly male admitted with a diagnosis of senile degeneration of the brain, a progressive neurodegenerative disorder associated with dementia. A comprehensive MDS showed a BIMS score of 99, indicating he was unable to complete the interview and had severely impaired cognition. He had a history of falls prior to admission and had experienced falls while in the facility. Record review of the electronic medical record on 3/11/26 showed there was no baseline care plan completed for this resident. Further record review showed that a comprehensive care plan initiated on 6/22/25 for this resident addressed only falls and behavioral symptoms, and did not include other required areas such as ADLs, transfers, social needs, and orders. Interviews with the MDS nurse, DON, and administrator confirmed that baseline care plans were expected to be initiated within 24–48 hours of admission and that, if a comprehensive care plan was used instead, it should include instructions for all key care areas. The facility’s written policy on baseline care plans required development of a baseline plan within 48 hours of admission, including initial goals, physician, dietary, and therapy orders, social services, and PASARR recommendations as applicable. Despite these expectations and policy requirements, the resident’s baseline care plan was not completed within the required timeframe.
Failure to Assess Two Residents After Transport Van Motor Vehicle Accident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that two residents involved in a motor vehicle accident (MVA) in the facility transport van were assessed for injury upon return to the facility, in accordance with professional standards of practice and facility policy. Resident #1, an older male with a history of focal traumatic brain injury with loss of consciousness, dementia with behavioral disturbance, and thoracic spine fusion, required substantial/maximal assistance with transfers and used a manual wheelchair for mobility. On the day of the accident, EMS documentation indicated no visible injuries, and the resident denied loss of consciousness, head strike, and use of blood thinners. A nursing progress note by LVN A documented that the van had been rear-ended, that police and EMS were called, that EMS evaluated and treated the resident, and that no injuries or pain were reported at that time. However, no nursing assessment or skin assessment was completed by facility staff upon the resident’s return after the accident. For Resident #1, the following day a nursing note by LVN B documented that the resident, described as alert and oriented x4, complained of back pain and bilateral hip pain following the MVA. Subsequent documentation noted continued complaints of stiffness and mild pain, and x‑rays of the cervical spine, bilateral hips, and lumbar spine were obtained, which showed no acute changes. Despite these later assessments, record review showed that a facility skin assessment was not completed after the accident. Interviews further clarified that Resident #1’s family member believed he should have been sent to the hospital after the accident and reported that, upon arrival back at the facility, the resident had to crawl out of the side of the van due to a non-functioning wheelchair ramp. The family member also reported bruising to the resident’s right index finger and left cheek and eye area the day after the accident. Resident #1 himself stated that EMS only asked from the front of the van if he was alright, that he reported feeling fine at that time, that no one asked if he wanted to go to the hospital, and that he had to crawl over a seat to exit the van when he returned to the facility. Resident #2, an older male with diagnoses including malignant neoplasm of the colon, history of transient ischemic attack and cerebral infarction, and age-related cognitive decline, had a significant change MDS showing severe cognitive impairment with a BIMS score of 3 and required supervision/touching assistance with walking. EMS documentation for Resident #2 on the day of the accident also indicated no visible injuries, denial of loss of consciousness, denial of head strike, and no use of blood thinners. A nursing progress note by LVN A documented that the van was rear-ended, that police and EMS were called, that EMS evaluated and treated the resident, and that no injuries or pain were reported, with the NP and responsible party notified. However, similar to Resident #1, there was no documented nursing assessment for injury upon return to the facility immediately after the accident. A skin assessment for Resident #2 was not completed until several days later and showed no skin issues. In interviews, Resident #2 reported that no one checked him at the scene or upon return to the facility and that he was sore for a few days after the wreck. Staff interviews confirmed that facility nursing staff did not perform post-accident assessments on the residents when they returned from the MVA. LVN A stated that she did not assess either resident for injury upon return because she believed EMS had evaluated and cleared them at the scene. The ADON reported that she received a call about the wreck, was told the residents were okay, and asked if they had been checked, but there was no documentation of an immediate post-accident assessment by facility nurses. The transporter, a CNA serving as a backup driver, stated that she was instructed by the administrator and DON to have EMS check the residents, that she was speaking with police and could not see whether EMS evaluated the residents, and that EMS told her they were free to go. She also confirmed that the back of the van would not open and that she and CNA C had to get Resident #1 out through the side door. The Administrator stated she believed the residents were evaluated at the scene and cleared with no injuries and referenced skin assessments she believed were done, though none were provided prior to surveyor exit. The facility’s policies on transportation and change in a resident’s condition required procedures for safe transportation and nursing observation and documentation when there is a change in condition, but the records showed that immediate post-accident assessments were not completed for the two residents involved in the MVA.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that a resident was free from physical abuse when another resident stomped on his foot in the dining room. The incident occurred when one resident, who had a history of behavioral symptoms directed at others and required secure unit placement, exhibited aggressive behavior by stomping or kicking another resident's foot. The affected resident had diagnoses including schizoaffective disorder, autistic disorder, and cognitive communication deficit, and was assessed as having moderately impaired cognition. The aggressor had diagnoses of intellectual disability, cognitive communication deficit, and bipolar disorder, with severely impaired cognition and a documented history of behavioral symptoms toward others. Staff observations and interviews confirmed that the aggressive resident attempted to stomp on the other resident's foot multiple times before staff could intervene and separate them. The resident who was stomped on moved his feet away and later denied pain or discomfort, with a light bruise noted on his right foot. Staff present at the time reported the incident and performed an assessment, confirming the injury. The aggressive resident admitted to stomping on the other resident's foot out of meanness and expressed emotional distress related to missing his parents and wanting to leave the facility. Review of care plans and staff interviews indicated that interventions for monitoring and redirecting the aggressive resident were in place, and staff had received training on abuse, neglect, and resident-to-resident altercations. However, despite these measures, the incident occurred, resulting in physical abuse and a bruise to the affected resident. The facility's policy prohibits and aims to prevent abuse, neglect, and exploitation, but the failure to prevent this altercation led to the deficiency.
Failure to Immediately Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than two hours, as required. Specifically, an incident occurred in which one resident stomped or kicked another resident's foot, resulting in a bruise. The incident was witnessed by a CNA, who reported it to an RN, but neither the CNA nor the RN reported the incident to the Administrator (ADM) immediately. The ADM was not notified of the incident until the following day, well beyond the required reporting timeframe. The resident who was the victim of the incident had a history of schizoaffective disorder, autism, and cognitive communication deficits, with moderately impaired cognition. The resident who committed the act had a history of intellectual disability, cognitive communication deficit, and bipolar disorder, with severely impaired cognition and a documented history of behavioral symptoms directed at other residents. The incident was documented in event reports by the RN, and the victim was assessed and found to have a bruise but denied pain or discomfort. The perpetrator admitted to the act during an interview, stating it was done out of meanness. Interviews with staff revealed that the CNA and RN involved were aware of the requirement to report abuse but did not notify the ADM as required. The RN stated she had not received training on abuse reporting at the time of hire and was unaware of the requirement to notify the ADM. However, training records indicated that required abuse and neglect training had been completed by the staff involved. Facility policy required immediate reporting of suspected abuse to the administrator and other officials according to state law and guidelines.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to provide privacy for a male resident with severe cognitive impairment and significant self-care deficits during incontinent care. The resident, who required maximal assistance with toileting and hygiene due to dementia and muscle atrophy, was left exposed on his bed, naked from the waist down, with the privacy curtain open and the door to the hallway left ajar. This allowed the resident to be visible from the hallway when the CNA exited the room to retrieve additional supplies. Interviews with the CNA, Assistant Director of Nursing (ADON), and Administrator (ADM) confirmed that facility policy and staff training require privacy to be maintained during personal care by closing curtains, doors, and covering the resident if the caregiver must leave the room. The CNA acknowledged forgetting to provide privacy in this instance, despite having completed annual skills checks and being aware of the expectations. Facility documentation and policy also supported the requirement for privacy during such care.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions that led to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, during July and August 2024. Specifically, there was no RN coverage on four days in July and one day in August. This deficiency was identified through a review of the RN punch detail hour report and the CMS Payroll Based Journal (PBJ) report, which confirmed the absence of RN hours on specific dates. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility had been experiencing staffing issues, and the ADON was responsible for scheduling nurses and nurse aides. The DON acknowledged that her hours worked as a nurse aide or charge nurse did not count towards the required RN hours. The Administrator was aware of the staffing challenges and the missed RN hours during the fourth quarter of 2024, attributing the issue to staff turnover. The facility's policy, revised in September 2023, mandates the use of a registered nurse for at least eight consecutive hours daily, seven days a week, to ensure resident safety. Despite this policy, the facility did not meet the requirement, potentially leaving staff without supervisory coverage for RN-specific nursing activities and coordination of emergency care and disasters.
Sanitation and Thawing Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and distributed under sanitary conditions in the kitchen. During an observation, the dish machine was found to have a wash temperature of 120 degrees Fahrenheit and a rinse temperature of 125 degrees Fahrenheit, but the sanitizer did not register on the test strip. The Dietary Aide, who was trained on sanitizer testing, did not always use the test strips and relied on visual confirmation of the solution. The Dietary Manager confirmed that she had tested the machine earlier and found no issues, but the sanitizer tubing was later found unattached, preventing proper sanitation. Additionally, the facility did not ensure that raw foods were thawed appropriately. Bags of frozen food items, including peas and carrots, mashed potatoes, gravy mix, and chicken breast, were observed thawing in the kitchen sink. The proper method of thawing, which involves using a refrigerator or cold running water, was not followed. The Dietary Manager acknowledged seeing the food thawing improperly and admitted that the cook had been trained on the correct process. These lapses in food handling could potentially lead to foodborne illnesses among residents.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to provide a safe, clean, and sanitary environment for residents, particularly in the Women's locked unit and the Men's locked unit, as well as in the main dining room and its patio. Specifically, Resident #8's room in the Women's locked unit was found to have a stained mattress and walls smeared with substances, with exposed sheetrock in the bathroom and a non-working soap dispenser. The resident, who has severe cognitive impairment and ambulated independently, reported vomiting at night and wiping it on the wall, which had not been cleaned regularly. Observations revealed that the hallways in both the Women's and Men's locked units had gouged and marred doors and doorways, with missing paint and exposed sheetrock. The Men's unit also had vinyl flooring that was torn and pulling apart, creating a trip hazard. The main dining room had a sagging ceiling with old water damage, dirty vents, and missing tiles on the patio, posing a risk of falls. Staff interviews indicated a lack of awareness and action regarding the maintenance and cleanliness of these areas, with maintenance requests not being logged or addressed. The facility's policy emphasized maintaining a clean, sanitary, and homelike environment, but the observations and interviews highlighted significant lapses in adhering to this policy. The maintenance man and staff acknowledged the issues but cited a lack of funds and unclear responsibilities for addressing the deficiencies. The administrator confirmed the policy's intent but noted that corporate funding was awaited for necessary repairs, indicating systemic issues in maintaining the facility's environment.
Failure to Remove Damaged Mechanical Lift Sling
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards by not removing a worn and damaged mechanical lift sling from service, which was used for a resident with significant medical conditions. The resident, who had a history of traumatic brain injury, hemiplegia, hemiparesis, and aphasia, was dependent on staff for transfers using a Hoyer lift. Observations over two days showed the resident sitting on a faded mechanical lift sling, which was not removed from use despite its condition. Interviews with staff revealed a lack of awareness and adherence to the facility's policy regarding the inspection and maintenance of lift slings. The CNA and Laundry Supervisor noted the sling's faded color and frayed tag, indicating it had been bleached against manufacturer instructions, which could lead to tears and potential hazards. The DON and Administrator were unaware of the sling's condition and the washing procedures, highlighting a gap in communication and oversight. The facility's policy required regular inspections and adherence to manufacturer guidelines, which were not followed, leading to the deficiency.
Failure to Post Nurse Staffing Information in a Prominent Location
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a location that was readily accessible to residents and visitors. On two consecutive days, the staffing information was not posted in a prominent place, as required. Instead, the postings were located on a wall by the nurse station, partially blocked by medication carts, making them not clearly visible. This was observed on 2/17/2025 and 2/18/2025, with the postings dated accordingly. The facility's policy requires that staffing levels for direct care be updated each shift and posted in a public area, which was not adhered to in this instance. Interviews with facility staff revealed a lack of awareness regarding the visibility and accessibility of the staffing postings. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both acknowledged the responsibility of the night charge nurse to post the staffing information. However, they did not recognize the inadequacy of the current posting location. The Administrator admitted that the location was not suitable for visitors to easily access the information and stated that it had been moved to the front entrance on the day of the interview. This oversight could potentially prevent residents, families, and visitors from being informed about the staffing levels and census each day.
Failure to Provide Timely CPR to Full Code Resident
Penalty
Summary
The facility failed to ensure that all residents were free from neglect, as evidenced by the case of a resident who was not provided with necessary life-saving measures. The resident, a male with a history of Parkinson's Disease, hypertension, and atrial fibrillation, was found unresponsive in his room. Despite being identified as a full code, meaning CPR should be initiated in the event of cardiac arrest, the registered nurse (RN A) did not initiate CPR or call 911 immediately upon discovering the resident's condition. RN A found the resident unresponsive at approximately 9:00 PM, noting that he had no pulse or respirations, and his pupils were fixed and dilated. Instead of initiating CPR, RN A contacted the facility's administration for guidance on funeral home notification, assuming the resident was already deceased. It was not until 9:29 PM, after speaking with a nurse practitioner, that RN A was directed to call 911. Emergency services arrived at 9:50 PM and began CPR, but the resident was pronounced deceased at 10:27 PM. The facility's policy required CPR to be initiated for any resident who is a full code unless there are obvious signs of irreversible death, such as rigor mortis. RN A, who was responsible for updating the resident code status book, was aware of the resident's full code status but did not follow the facility's emergency procedures. The facility's failure to provide timely life-saving measures resulted in the identification of an Immediate Jeopardy situation.
Removal Plan
- Ensure staff performed CPR for Resident #1 until emergency services arrived.
- Utilize the AED when Resident #1 was found unresponsive.
- Immediately call 911 when the resident was found unresponsive.
- Charge Nurse no longer works for the facility.
- Completed a DNR and Full Code audit to ensure all are matching and correct.
- Audit staff CPR cards to ensure proper number of certified employees present each shift.
- Ensured the crash cart has an updated list of full code and DNR residents.
- Educate all nurses regarding Emergency Management Code Procedure Policy.
- Educate all direct care staff over the abuse and neglect policy.
- Perform 1 mock code drill once a shift for each Charge Nurse shift to ensure proper reaction and that staff are following protocols.
- Conduct an ad hoc QAPI with Medical Director to review the IJ Template and the facility's plan to lower the immediacy.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
The facility failed to provide basic life support, including CPR, to a resident identified as a full code prior to the arrival of emergency medical personnel. The resident, a male with diagnoses including Parkinson's Disease, hypertension, and atrial fibrillation, was found unresponsive by RN A. Despite the resident's full code status, CPR was not initiated, and emergency services were not called immediately. RN A assessed the resident and found no pulse or respirations, but did not start CPR, believing the resident was already deceased. RN A contacted the facility's administration for guidance on funeral home notification instead of initiating life-saving measures. The nurse was aware of the resident's full code status but had not received training on emergency procedures or CPR from the facility. The facility's policy required CPR to be initiated unless a DNR order was in place or there were obvious signs of irreversible death. However, RN A did not follow this policy, and CPR was only initiated by emergency services upon their arrival. This failure to act according to the resident's code status and facility policy resulted in an Immediate Jeopardy situation being identified.
Removal Plan
- Charge Nurse no longer works for the facility.
- Completed a DNR and Full Code audit to ensure all are matching and correct.
- Audit staff CPR cards to ensure proper number of certified employees present each shift.
- Ensured the crash cart has an updated list of full code and DNR residents.
- All Nurses educated regarding Emergency Management Code Procedure Policy.
- Mock code drill to be performed for each Charge Nurse shift to ensure proper reaction and that staff are following protocols.
- Ad hoc QAPI performed with Medical Director to review the IJ Template and the facility's plan to lower the immediacy.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents involving three residents. Resident #1, who has severe cognitive impairment and a history of inappropriate behaviors, slapped Resident #2, leaving a red handprint on her cheek. This incident was unwitnessed, and both residents were monitored for 24 hours following the event. Resident #1's care plan included interventions to manage her behavior, but these measures were insufficient to prevent the altercation. In another incident, Resident #3, who also has severe cognitive impairment, pulled Resident #1 by her shirt collar, causing scratches on Resident #1's face. This altercation occurred when Resident #1 attempted to take food from Resident #3's tray. Staff intervened to separate the residents and monitored them for 24 hours. Despite existing interventions, such as serving Resident #1 first at meals, the facility's measures were inadequate to prevent this incident. Interviews with staff revealed that supervision on the secured unit was lacking, with only one CNA assigned to each hallway. The Director of Nursing acknowledged the risks associated with insufficient supervision, including physical injury and disruption. The facility's policy on abuse prevention emphasizes the residents' right to be free from abuse, yet the incidents indicate a failure to uphold this standard.
Failure to Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to implement their written policies and procedures to report an allegation of abuse as required for one of the residents reviewed for abuse. The resident, a male with diagnoses including Parkinson's disease, lack of coordination, reduced mobility, bipolar disorder, and generalized anxiety, alleged that a CNA and an LVN called him a racial slur. Despite the resident's clear and repeated allegations, the facility did not report the incident to the appropriate authorities as mandated by their policies. The resident's baseline care plan indicated that all accusations reported by the resident would be addressed by the administrator, DON, ADON, and social services. However, the facility's grievance form and subsequent interviews revealed that the allegations were not taken seriously. The administrator and other staff members focused on the resident's history of making false accusations and using abusive language towards staff, rather than investigating the claims of verbal abuse made by the resident. Interviews with various staff members, including the CNA and LVN involved, as well as other CNAs and the ADON, provided conflicting accounts of the events. Some staff members denied hearing or using any racial slurs, while others confirmed the resident's allegations. Despite this, the administrator did not consider the racial slur as verbal abuse and failed to report the incident to the state agency as required. This inaction led to a failure in protecting the resident from potential continued abuse and created a racially discriminatory environment, as evidenced by multiple staff members quitting in protest.
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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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
