Avir At Portland
Inspection history, citations, penalties and survey trends for this long-term care facility in Portland, Texas.
- Location
- 221 Cedar Dr, Portland, Texas 78374
- CMS Provider Number
- 675850
- Inspections on file
- 34
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Avir At Portland during CMS and state inspections, most recent first.
A resident with essential hypertension had an order for Metoprolol 12.5 mg PO four times daily with parameters to hold the dose if SBP was below 110 or DBP below 60, yet nursing staff repeatedly administered the medication without documenting blood pressure readings at the time of dosing. The MAR listed scheduled administration times but lacked corresponding BP values, and vital sign records showed no BPs taken to coincide with many Metoprolol doses over several days. Facility staff, including the NP, ADON, RNC, and DON, acknowledged that BPs should have been checked before giving antihypertensive medications, and the facility’s medication administration policy required verification of vital signs when necessary.
Surveyors found that two residents did not have comprehensive, person-centered care plans with measurable objectives and timeframes documented in their records, despite completed MDS assessments and a facility policy requiring such plans. One resident with hypertension and moderately impaired cognition and another receiving surgical aftercare with intact cognition both lacked comprehensive care plans in the electronic care plan tab. The MDS nurse reported she could not open care plans herself and relied on an RN or the DON to create them, and stated she had notified the team that these care plans needed to be opened. The DON confirmed that only certain RNs closed care plans, that baseline care plans existed for both residents, but that comprehensive care plans could not be located, and acknowledged responsibility for ensuring their completion.
A resident receiving post-surgical aftercare for a right foot wound did not receive wound care consistent with the facility’s infection prevention and control policies. During an observed treatment, an NP and a WCN donned only gloves instead of required gown and gloves under EBP, did not place a clean barrier between the wound and soiled linens, and the NP leaned over the wound with hair falling around the site. The WCN cleansed the wound from outer to inner areas, wiped the unclean bottom of the foot and then continued care without changing gloves or performing proper hand hygiene, and did not fully rub alcohol-based hand rub until dry. Contaminated trash was placed on a surface holding clean supplies, and a dirty treatment tray was carried through the facility to locate sanitizing wipes instead of being cleaned at the point of care, contrary to the facility’s EBP and hand hygiene policies.
The facility failed to meet professional standards for food service safety, with deficiencies in food storage, preparation, and cleanliness. Thermometers were missing from refrigerators and freezers, temperatures were not logged as required, and food items were improperly stored and labeled. The kitchen was infested with bugs, and utensils were hazardous. Expired food was found in resident nutrition rooms, and staff interviews revealed a lack of adherence to food safety protocols.
The facility failed to maintain an effective pest control program, resulting in live roaches in the kitchen. Observations revealed roaches on food preparation surfaces and clean dishware. Interviews indicated awareness of the issue and a crack in the ceiling, which had been noted but not repaired. Pest control measures were ineffective, with longstanding issues documented in work orders and invoices.
The facility failed to protect the privacy of two residents' medical information. A resident's lab results were left visible on a medication cart, and another resident's medical information was displayed on an unattended computer screen. Staff acknowledged these as HIPAA violations, emphasizing the importance of confidentiality.
A facility failed to provide written notification of transfer or discharge to a resident, their representative, and the Ombudsman. The resident, with multiple health issues, was transferred to the hospital without written notice, contrary to facility policy. Staff confirmed that only verbal notifications were given, especially in emergencies.
The facility failed to complete accurate PASRR evaluations for two residents with mental health diagnoses, leading to incorrect screenings that did not reflect their conditions. This oversight was acknowledged by the responsible RN, who attributed the errors to a previous employee. The facility's policy requires timely and accurate PASRR screenings to ensure residents receive necessary services.
A resident with severe cognitive impairment and multiple medical conditions experienced a fall resulting in injury. The facility failed to update the resident's care plan to include necessary fall precautions and interventions, despite the resident being on anticoagulant medications. Interviews with staff confirmed the oversight, highlighting a lapse in adhering to the facility's policy for updating care plans with significant changes.
Two residents with indwelling urinary catheters were observed with their catheter bags and tubing improperly positioned, leading to potential infection risks. One resident's catheter tubing was dragging on the ground, while another's catheter bag was resting on the floor. Staff interviews confirmed that such practices could lead to contamination and infection, highlighting a failure to adhere to the facility's care protocols.
A resident with COPD and emphysema was found self-administering nebulizer treatments and using leftover medication, contrary to physician orders requiring nurse administration every six hours. Despite staff awareness, there was no documented follow-up, and the resident continued accessing medication independently, indicating a lapse in the facility's medication administration procedures.
A resident with multiple health conditions was hospitalized after receiving Clonidine outside of physician-ordered parameters. The medication, intended for high blood pressure, was administered 166 times incorrectly due to a misinterpretation of the order as scheduled rather than PRN. This error was discovered after the resident exhibited low blood pressure, prompting a hospital transfer.
The facility did not promptly inform the physician about a resident's significant wounds upon admission, including skin tears and a pressure injury on the coccyx. This delay continued when the resident's wound worsened, leading to a lack of timely medical interventions. The facility's policy on Changes in Resident Condition mandates notifying the medical provider of significant changes, but staff interviews revealed communication and documentation discrepancies. This resulted in delayed physician notification and potential risks to the resident's health.
A resident with multiple wounds and complex medical conditions, including a displaced intertrochanteric fracture, rib fractures, muscle wasting, spinal stenosis, COPD, and malnutrition, did not receive a thorough head-to-toe assessment upon admission. This led to a failure to accurately identify, describe, and document wounds. Wound care orders were delayed by 11 days, and there was no consultation with the physician to reconcile hospital discharge wound treatment orders. Inconsistent documentation and lack of timely care plan updates were noted, along with gaps in communication and assessment practices among nursing staff. These issues highlighted systemic problems in wound management, assessment, documentation, and communication processes.
The facility failed to develop and implement a comprehensive care plan for a resident with multiple medical conditions, including surgical wounds, oxygen therapy, fall risk, and pain. The care plan was not updated when the resident's condition worsened, leading to potential risks for the resident.
The facility failed to develop and implement a comprehensive care plan for a resident, neglecting to address surgical wounds, oxygen therapy, fall risk, and pain management. Despite the resident's multiple medical conditions and documented needs, the care plan lacked necessary interventions, leading to inadequate care planning.
Failure to Assess Blood Pressure Prior to Metoprolol Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to administration of an antihypertensive medication, Metoprolol. The resident was an [AGE]-year-old female with a diagnosis of essential primary hypertension, admitted on 02/24/2026 and discharged on 03/11/2026. A physician order dated 02/24/2026 directed Metoprolol 12.5 mg by mouth four times daily for hypertension, with instructions to hold the dose if the systolic blood pressure was less than 110 or the diastolic blood pressure was less than 60. The resident did not have a comprehensive care plan in place, and the March 2026 MAR reflected the Metoprolol order and administration times (9:00 AM, 12:00 PM, 5:00 PM, and 9:00 PM) but did not include corresponding blood pressure readings. Record review of the resident’s vital signs showed that blood pressures were not taken at times that coincided with Metoprolol administration on multiple dates in February and March 2026, despite the order requiring blood pressure parameters prior to dosing. Specifically, there were no blood pressure measurements documented at the scheduled administration times on numerous dates between 02/25/2026 and 03/10/2026. The RNC was only able to locate a few blood pressure readings in the MAR and vital signs that coincided with the Metoprolol doses, and those readings were associated with another medication being administered, not with Metoprolol. Interviews with facility staff confirmed that blood pressures should have been checked before administering the blood pressure medication. The NP stated that blood pressures should be checked prior to giving antihypertensive medications to determine if the resident actually needed the dose. The ADON stated that nurses should have checked blood pressures before administering the medication because it was required, and acknowledged that nurses had previously been in-serviced on this topic. The RNC and DON both stated that blood pressures should be assessed prior to administering blood pressure medications, and confirmed that only a few coinciding blood pressure readings could be found for this resident. The facility’s “Administering Medications” policy, revised April 2019, required that vital signs be checked or verified, if necessary, prior to administering medications, and external clinical guidance from the National Library of Medicine emphasized the importance of accurate blood pressure assessment for diagnosis and management of hypertension.
Failure to Develop and Implement Comprehensive Care Plans for Two Residents
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents. For Resident #1, a female with essential primary hypertension admitted in late February and discharged in early March 2026, record review showed an admission MDS with a BIMS score of 09 (moderately impaired cognition), completed on 03/04/2026. However, review of the care plan tab on 03/18/2026 revealed there was no comprehensive care plan in the record. The facility’s policy required that the IDT, with the resident and/or representative, develop a comprehensive care plan within seven days of completion of the required MDS assessment. For Resident #2, a male with a diagnosis of encounter for surgical aftercare following circulatory system surgery and an original admission in mid-February with a readmission in early March 2026, review of the care plan tab on 03/19/2026 also showed no comprehensive care plan. His BIMS evaluation showed a score of 15, indicating intact cognition. In interviews, the MDS nurse stated that if there was no care plan under the care plan tab, one had never been opened or created, and reported she had mentioned in morning meeting that care plans for these residents needed to be opened because she could not open them herself. She explained that only one RN besides the DON could open or create a care plan and that she typically followed a three-day rule after admission to have comprehensive care plans opened. The DON stated that any IDT member could initiate or create a care plan but it was closed by the DON or another RN, and while he was able to locate baseline care plans for both residents, he could not find their comprehensive care plans and was unsure why they were not completed, acknowledging that responsibility for verifying completion rested with him.
Inadequate Infection Control During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program during wound care for Resident #2. Resident #2 was an adult male with an original admission date of 02/17/2026 and a current admission date of 03/06/2026, with a pertinent diagnosis of encounter for surgical aftercare following surgery on the circulatory system. Physician orders dated 03/09/2026 directed specific wound care to the right foot surgical site, including cleansing with Dakin’s solution, rinsing with normal saline, patting dry, applying adaptic and alginate AG, lightly packing the wound bed if needed, covering with an ABD pad, wrapping with Kerlix, and securing with tape. There was also an order to practice Enhanced Barrier Precautions (EBP) when in contact with the wound and/or PICC line. Record review showed Resident #2 did not have a comprehensive care plan in the electronic record. On 03/19/2026, during an observation of wound care, the Wound Care Nurse (WCN) and Nurse Practitioner (NP) performed multiple infection control breaches. After performing hand hygiene, both staff donned only gloves and did not put on disposable gowns before providing wound care, despite the EBP order and facility policy requiring gown and glove use for high-contact activities such as wound care. No clean barrier was placed between the resident’s right foot wounds and the dirty bed sheet. The NP leaned over the wound, allowing her hair to fall around the wound area. The WCN cleansed the wound from the outside to the inside, contrary to best practice and facility expectations to cleanse from the inner (cleanest) to outer (dirtiest) area. Additional lapses occurred in hand hygiene and handling of contaminated materials. After wiping the bottom of the resident’s unclean foot when medicated gel ran down, the WCN continued wound care without performing hand hygiene and changing gloves. She also did not rub alcohol-based hand sanitizer over all hand surfaces until dry between glove changes. The WCN placed trash from the wound care onto the same clean barrier used for clean wound care supplies, and then performed hand hygiene and donned clean gloves before picking up the dirty tray to clean it. She carried the contaminated tray through the facility in search of sanitizing wipes, as none were available on her cart, instead of immediately cleaning it at the point of care. Interviews with the NP, WCN, and ADON confirmed that appropriate PPE (gown and gloves), correct wound cleansing technique, proper hand hygiene, and correct handling of contaminated equipment and surfaces were expected per the facility’s Enhanced Barrier Precautions and Hand Hygiene policies, but were not followed during this wound care episode.
Food Safety and Storage Deficiencies in Facility
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, resulting in multiple deficiencies in the storage, preparation, distribution, and serving of food. Observations revealed that the facility did not have thermometers in the reach-in refrigerators and freezers, nor in the dry storage room, as required by facility policy. Additionally, refrigerator and freezer temperatures were not recorded three times daily, as stipulated. Food and drink items were improperly stored, labeled, and dated, with some items found to be expired. Dirty eating utensils were placed on clean surfaces, and scoops were improperly stored inside containers. Cleaned dishes were found with food or beverage residue, and the kitchen area was infested with bugs. The kitchen's physical environment was also in disrepair, with ceilings and walls showing signs of damage. The kitchen area was not free of bugs, and serving utensils were found to be hazardous. Appliances and food preparation areas were not clean, and the dishwasher temperatures were not logged daily. These conditions posed a risk of food contamination and foodborne illnesses to residents. Interviews with staff revealed a lack of adherence to cleaning schedules and food safety protocols, with some staff unaware of the importance of proper food storage and labeling. In the resident nutrition rooms, expired food items were found, and some snacks were improperly stored and exposed to air. Staff interviews indicated a lack of clarity regarding responsibilities for checking expiration dates and ensuring proper storage. The facility's policies and procedures for food storage and safety were not consistently followed, leading to potential health risks for residents. The deficiencies were observed during a survey, highlighting significant lapses in the facility's food service operations.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of multiple live roaches in the kitchen. Observations on 08/14/24 revealed live roaches on the floor, food preparation surfaces, and clean dishware throughout the kitchen area. Specific instances included a live roach on a blue two-handled cup and several roaches on prep tables and the kitchen floor. Interviews with the Dietary Manager (DM) and Registered Dietitian (RD) indicated awareness of the pest issue and a crack in the ceiling of the dish room, which had been noted since 5/23/24 but remained unrepaired. The facility was on a twice-monthly pest control schedule, but the pest control measures appeared ineffective, as noted by the DM. The facility's work orders and pest control invoices revealed longstanding issues contributing to pest entry, such as openings at plumbing and electrical points, cracks along baseboards, and inadequate sealing of door levelers. These conditions had been documented in pest control invoices over several years, indicating a persistent problem with pest control management.
Privacy Breach of Residents' Medical Information
Penalty
Summary
The facility failed to ensure the privacy of residents' personal and medical records, resulting in two specific incidents involving Resident #33 and Resident #70. In the first incident, a printed sheet of paper containing Resident #70's laboratory values was left unsecured and visible to the public on a medication cart near the nurse's station. This occurred at 4:17 PM on 08/15/2024, with several residents present in the lobby area nearby. The sheet remained exposed for about one minute before RN A was informed of the situation. RN A acknowledged the presence of HIPAA-protected information on the paper and expressed concern about the potential embarrassment and disappointment Resident #70 might feel if he learned of the breach. In the second incident, RN A left a computer screen displaying Resident #33's personal medical information unattended while administering medication in Resident #33's room. This occurred at 8:13 AM on 08/16/2024, with the monitor facing the room and remaining on for approximately one minute. RN A admitted to accidentally leaving the screen on and recognized the information as HIPAA-protected. She expressed concern about the potential embarrassment and disappointment Resident #33 might experience if she became aware of the privacy breach. Interviews with other staff members, including LVN D, CNA E, the DON, and the ADM, confirmed that both incidents constituted HIPAA violations. They emphasized the importance of maintaining the confidentiality of residents' personal information and the potential mental distress that could result from such breaches. The facility's policy on resident rights also highlighted the right to have personal information kept confidential.
Failure to Provide Written Notification of Transfer or Discharge
Penalty
Summary
The facility failed to provide written notification of transfer or discharge to a resident, their representative, and the Office of the State Long-Term Care Ombudsman. This deficiency was identified for a resident who was transferred to the hospital due to acute kidney failure and a urinary tract infection. The facility's policy requires written notice of transfer or discharge, but in this case, only verbal notification was given to the resident's family representative. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the facility's practice was to notify families verbally, especially in emergencies, without providing written documentation. The resident involved was an elderly male with multiple diagnoses, including unspecified dementia, Alzheimer's disease, end-stage renal disease with heart failure, and chronic kidney disease stage 4. The resident was transferred to the hospital and later returned to the facility. Despite the facility's policy stating that written notice should be provided and documented, the facility did not adhere to this requirement, as confirmed by interviews with the ADON, DON, and Administrator (ADM). The lack of written notification could potentially affect residents by limiting their access to advocacy services and appeal processes.
Failure to Complete Accurate PASRR Evaluations
Penalty
Summary
The facility failed to ensure that PASRR evaluations were completed for two residents, Resident #34 and Resident #3, either prior to or after their admission. Resident #34, a female with a diagnosis of schizoaffective disorder, was admitted and readmitted with active diagnoses of schizophrenia and depression. Despite these diagnoses, her PASRR Level 1 screening incorrectly indicated no evidence of mental illness. Similarly, Resident #3, who had multiple mental health diagnoses including major depressive disorder, schizophrenia, and bipolar disorder, also had an incorrect PASRR Level 1 screening that initially did not reflect her mental illness. The PASRR screenings for both residents were not conducted accurately, which was acknowledged by RN B, who was responsible for ensuring the screenings and referrals were completed. RN B admitted that the screenings were done incorrectly and should have been marked positive for mental illness. The error was attributed to a previous employee who conducted the initial screenings, and there was no clear answer as to why the mistakes occurred. The facility's policy requires PASRR screenings to be conducted within fourteen days of admission and when there is a significant change in the resident's condition. The facility's administration acknowledged that the admissions department initially held responsibility for the accuracy of PASRR screenings, but it was ultimately a team effort. The ADM and RN B both recognized that incorrect PASRR screenings could place residents at risk of not receiving necessary specialized services. The facility's policy emphasizes the importance of accurate pre-admission screenings to ensure residents receive the appropriate level and scope of services required by their medical and mental conditions.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #41, which is consistent with the resident's rights and includes measurable objectives and timeframes. This deficiency was identified during a review of care plans for residents, where it was found that the care plan for Resident #41 was not updated following a fall with injury. The resident, who has severe cognitive impairment and requires assistance for all activities of daily living, experienced a fall on 08/11/24, resulting in a laceration and bruising. Despite the incident, the care plan was not revised to include updated fall precautions and specific interventions to prevent future falls. Resident #41 has a medical history that includes unspecified dementia, lack of coordination, osteoporosis, high blood pressure, muscle wasting, insomnia, overactive bladder, and abnormal gait. The resident is on anticoagulant medications, which increase the risk of bleeding and bruising. The care plan, dated 08/05/24, did not reflect the necessary updates following the fall, such as placing the bed in a low position, ensuring the call light is within reach, and using a scoop mattress and fall mat. These interventions were implemented after the fall but were not documented in the care plan. Interviews with facility staff, including the Assistant Director of Nursing (ADON), revealed that it is the responsibility of the nursing staff to update care plans to ensure the well-being of residents. The ADON acknowledged that Resident #41's care plan should have been updated to reflect the unwitnessed fall and the specific fall precautions and preventions. The facility's policy requires care plans to be updated with significant changes in conditions, but this was not adhered to in the case of Resident #41.
Inadequate Catheter Care Leads to Potential Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, leading to potential risks of urinary tract infections. Resident #4 was observed with his catheter tubing dragging on the ground underneath his wheelchair in both the lobby and dining room areas. This improper handling of the catheter tubing was noted during multiple observations on the same day. Resident #4, who has severe cognitive impairment and requires a suprapubic catheter due to urinary retention, was not interviewable to provide further insight into the situation. Resident #70 was found with his catheter bag resting on the floor while lying in bed. Despite the resident's moderate cognitive impairment, he was able to communicate that the catheter bag was not usually on the floor and did not cause him discomfort. However, he did mention a previous leak in the bag that had been fixed. The care plan for Resident #70 included regular catheter care and monitoring for signs of infection, but the observation of the catheter bag on the floor indicates a lapse in adherence to these care protocols. Interviews with facility staff, including an LVN, CNA, DON, and ADON, confirmed that catheter bags and tubing should not be on the floor due to the risk of contamination and infection. Staff acknowledged the issue with Resident #4's catheter bag positioning and mentioned attempts to secure it more effectively, but these efforts were not successful. The facility's policies on routine resident care and infection prevention emphasize the importance of timely and proper catheter care, which was not upheld in these instances.
Failure in Medication Administration for Resident with Respiratory Conditions
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medication for a resident with chronic respiratory conditions. The resident, who had a history of COPD, emphysema, and chronic respiratory failure, was observed self-administering nebulizer treatments and using leftover medication when experiencing shortness of breath. This practice was not in accordance with the physician's orders, which required the medication to be administered every six hours by a nurse. Interviews with staff revealed that the resident had been seen using the nebulizer independently, and although a CNA had informed a charge nurse about this, there was no follow-up action documented. The LVN confirmed that the medication was supposed to be locked up and administered by the charge nurse, and the resident was not authorized to self-administer medication. Despite this, the resident was able to access leftover medication, indicating a lapse in the facility's medication administration procedures. The Director of Nursing (DON) acknowledged the resident's independence and history of turning off the nebulizer during treatments. The DON stated that the resident was nearing the end of life and found comfort in having access to medication when needed. However, the facility's medication administration policy clearly stated that medications should not be left with residents unless they are approved for self-administration, which was not the case for this resident.
Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of Clonidine. The resident, an elderly female with a history of heart failure, chronic kidney disease, dementia, and chronic obstructive pulmonary disease, was prescribed Clonidine to be administered only if her systolic blood pressure was greater than 160 and diastolic blood pressure was greater than 100. However, the medication was administered outside of these parameters a total of 166 times over several months by various staff members, leading to the resident being transferred to the hospital due to low blood pressure. The deficiency was identified when the resident was noted to appear different by staff, with a blood pressure reading of 84/45, prompting a transfer to the hospital. Interviews with staff revealed that the medication order was misinterpreted as a scheduled medication rather than PRN, leading to its administration outside of the prescribed parameters. The resident's physician confirmed that the medication should not have been given outside of the specified parameters, as it could cause adverse effects such as lightheadedness. The facility's investigation found that the medication order was transcribed in a confusing manner, contributing to the error. The system used by the facility only flagged specific instances when medication was held, which did not adequately highlight the repeated errors in administration. This oversight resulted in the resident receiving Clonidine inappropriately, which could have led to the adverse health event experienced by the resident.
Delayed Physician Notification for Wound Care Management
Penalty
Summary
The facility failed to immediately inform the physician of Resident #1's wounds upon admission, leading to a lack of timely and appropriate medical interventions. Despite the presence of significant wounds upon admission, including skin tears and a pressure injury on the coccyx, the facility did not consult with Resident #1's physician to reconcile the hospital discharge wound treatment orders for specific wound care instructions. This failure to notify the physician continued when Resident #1's worsening wound was discovered on 12/24/23, with the facility neglecting to inform the physician promptly. The lack of communication and action in notifying the physician of Resident #1's deteriorating wound condition could have placed the resident at risk of a decline in their condition, the need for hospitalization, or even death. The facility's policy on Changes in Resident Condition clearly outlined the importance of notifying the resident, assigned medical provider, and resident representative of significant changes in the resident's physical status or the need to alter treatment significantly. However, the facility's failure to adhere to this policy resulted in a situation where Resident #1's worsening wound condition was not promptly addressed. Interviews with staff revealed discrepancies in communication and documentation processes, with nurses failing to contact the physician promptly upon identifying changes in the resident's condition, specifically related to wound care. This breakdown in communication and adherence to established policies and procedures contributed to the deficiency identified during the survey. The deficiency identified in the facility's failure to immediately inform the physician of Resident #1's worsening wound condition highlights a critical lapse in patient care and communication processes. The lack of timely notification to the physician, despite clear policies in place, resulted in a delay in appropriate medical interventions for Resident #1. The interviews conducted with staff further emphasized the need for consistent and accurate documentation of resident conditions and timely communication with physicians to ensure resident safety and well-being.
Inadequate Wound Care and Documentation Practices
Penalty
Summary
The facility failed to ensure appropriate treatment and care for Resident #1, who was admitted with multiple wounds and various medical conditions, including a displaced intertrochanteric fracture of the right femur, left rib fractures, muscle wasting, spinal stenosis, COPD, and malnutrition. Upon admission, a thorough head-to-toe assessment was not conducted, leading to a failure to identify, describe, and document the wounds accurately. Wound care orders were not provided until 11 days after admission, and there was a lack of consultation with the physician to reconcile the hospital discharge wound treatment orders. The facility also did not consistently assess and document the progress of Resident #1's wounds, leading to a failure to develop appropriate treatment plans and goals specific to her conditions. Documentation inconsistencies were noted, with discrepancies between the admission skin assessment and subsequent nursing notes regarding the presence and description of wounds. The facility did not update Resident #1's care plan promptly when her condition worsened, indicating a lack of immediate response to changes in her health status. Interviews with staff revealed gaps in communication and assessment practices, with nurses failing to accurately assess, document, and communicate about Resident #1's wounds. The lack of timely and appropriate wound care could have placed Resident #1 at risk of infection, sepsis, hospitalization, or even death, highlighting the severity of the deficiency in care provided to her. The facility's policies on skin and wound management, care planning, and changes in resident condition were not consistently followed, as evidenced by the failure to conduct comprehensive assessments, update care plans promptly, and communicate effectively with physicians and interdisciplinary team members. The deficiency in providing appropriate treatment and care to Resident #1 exposed systemic issues in the facility's processes related to wound management, assessment, documentation, and communication. The lack of adherence to professional standards of practice and person-centered care principles resulted in a failure to meet Resident #1's medical needs and ensure her well-being during her stay at the facility.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1, who was readmitted with multiple medical conditions including a displaced intertrochanteric fracture of the right femur, left rib fracture, and chronic obstructive pulmonary disease. Upon admission, Resident #1 had surgical and other wounds, was receiving oxygen therapy, and was at high risk for falls and pain. However, the care plan did not include objectives, goals, or interventions specific to these conditions, which were present upon her admission. Additionally, the facility did not update Resident #1's care plan when her condition changed, specifically when her wounds were found to be worse. The initial care plan created by the admitting nurse did not address surgical site care, skin or wound care, oxygen therapy, fall risk, or pain management. The MDS coordinator acknowledged that the care plans should be all-inclusive and specific to the resident's needs, and that any changes in condition should be documented and communicated to the interdisciplinary team. The facility's policies on care plans and changes in resident condition were not followed, as the care plan was not comprehensive and was not updated in a timely manner. This failure could place residents at increased risk of not having their individual needs met and decreased quality of life. The MDS coordinator admitted that the care plans were usually updated right away if there was a change in condition, but this did not occur in Resident #1's case.
Failure to Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident that included measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychosocial needs. Specifically, the facility did not address and include objectives, goals, and interventions for the resident's surgical and other wounds, oxygen therapy, fall risk, or pain upon her admission. The resident had multiple medical conditions, including a displaced intertrochanteric fracture of the right femur, left rib fracture, muscle wasting, chronic obstructive pulmonary disease, and mild protein-calorie malnutrition. Despite these conditions, the care plan lacked necessary focus and interventions for her wounds, oxygen therapy, fall risk, and pain management. Upon admission, the resident's records indicated she had a clinical condition of respiratory disease and was receiving oxygen therapy. The initial skin assessment revealed non-pressure skin impairments, including skin tears and an incision/surgical wound, as well as a Stage 1 pressure injury on the coccyx. The resident also experienced acute and frequent pain in her back and right hip, which was relieved by medication and frequent position changes. Despite these documented conditions, the care plan did not include specific interventions for surgical site care, skin or wound care, oxygen therapy, fall risk, or pain management. The facility's MDS coordinator acknowledged that the initial care plans for new admissions were created based on the admitting nurse's assessment and that care plans were usually updated immediately upon a change in condition. However, the resident's care plan was not updated when her wounds worsened. The facility's policies required comprehensive care plans to be developed within seven days of the comprehensive assessment and to be updated with any changes in the resident's condition. The failure to adhere to these policies resulted in a lack of appropriate care planning for the resident's needs.
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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.
