Avir At River Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Corpus Christi, Texas.
- Location
- 3922 W River Dr, Corpus Christi, Texas 78410
- CMS Provider Number
- 675672
- Inspections on file
- 35
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 15 (1 serious)
Citation history
Health deficiencies cited at Avir At River Ridge during CMS and state inspections, most recent first.
The facility failed to implement an effective infection prevention and control program when EBP physician orders for two residents with wounds were written only for wound care rather than for all high-contact activities, despite care plans and facility policy requiring gown and glove use for broader high-contact care. In one observed case, an LVN performed wound care on a resident on EBP without donning a gown, did not have a trash bag in the room, placed contaminated dressings and gloves on a clean barrier with clean supplies, inadequately cleansed the wound, failed to perform hand hygiene between glove changes, washed hands for only a few seconds, and disposed of contaminated trash outside the room, all contrary to the facility’s EBP and hand hygiene policies and CDC PPE guidance.
Two residents were affected when staff failed to notify providers of significant clinical findings. For one resident with multiple comorbidities and pressure ulcers, a critical MRSA lab result was reported but not communicated to the physician, and no corresponding progress note documented provider notification. For another resident with an abdominal abscess and at risk for skin breakdown, a treatment nurse assessed a new dark lesion on the right great toe and only informed the charge nurse, without notifying the physician, NP, or on-call provider, despite the resident later reporting the issue directly to the NP. These actions were inconsistent with the residents’ care plans and the facility’s change in condition policy requiring prompt provider notification of critical results and new or worsening skin issues.
A resident admitted with an abdominal wall abscess and identified as at risk for pressure ulcers had an abdominal wound documented by an LVN on admission, including measurements, and a care plan noting actual skin impairment and the need for monitoring and treatment. However, the LVN did not obtain wound care orders to evaluate and treat the wound for several days after admission, despite facility policies requiring physician orders for wound care and notification for changes requiring altered treatment. The DON confirmed that wound care orders should have been obtained at the time of admission, and the report notes this failure could place residents at risk for wound care complications or not receiving necessary wound care.
The facility failed to maintain complete and accurate clinical records when wound care treatments were not documented on the TARs for two residents with significant skin conditions, including pressure ulcers and an abdominal abscess. One LVN reported completing ordered wound care for a cognitively impaired resident with multiple pressure ulcers but acknowledged forgetting to record the treatment. An RN reported performing wound care for another resident with an abdominal abscess over several days but did not document it due to unfamiliarity with the TAR documentation process. The DON confirmed that treatments should have been recorded in the medical record in accordance with facility policy requiring documentation of all treatments and services performed.
A resident with an unstageable sacral pressure ulcer and a Foley catheter did not receive wound care consistent with professional standards. The WCN performed wound care while the resident’s brief and old dressing were saturated with urine, failed to provide incontinence care before treatment, and did not follow hand hygiene or glove-change requirements when moving between contaminated and clean tasks or when re-entering clean supplies. The WCN also used incorrect wound cleansing technique, cleaning from the outside to the inside rather than from clean to dirty. The Foley catheter, ordered to aid wound healing, was reported by the WCN to be constantly leaking and leaving the brief wet, but this issue was not addressed or reported. The NP was not informed of significant changes in the wound’s size or condition, and the DON confirmed that these practices did not follow facility wound care and hand hygiene policies.
Surveyors found that the facility failed to maintain an effective infection prevention and control program, including proper implementation of Enhanced Barrier Precautions (EBP) and hand hygiene. Multiple rooms housing residents on EBP had PPE supplies but lacked required EBP signage on doors or walls outside the rooms, despite facility policy. During observed wound and incontinent care for a resident with a stage 3 sacral wound, sepsis, CHF, and an indwelling catheter, a nurse and a CNA did not perform hand hygiene or change gloves when moving from dirty to clean tasks, re-entered a clean wipes container with contaminated gloves, used improper wound-cleaning technique, and the CNA carried a wipes container accessed with dirty gloves out of the room. Staff interviews and policy review confirmed that these practices were inconsistent with the facility’s EBP, perineal care, hand hygiene, and glove-use policies and could result in cross-contamination and infection, as acknowledged by the DON, NP, and involved staff.
A resident with severe cognitive impairment and right-sided paralysis was left in bed with the call light out of reach for about 10 minutes after being transferred from a wheelchair. The care plan and facility policy required the call light to be accessible, but staff failed to ensure this, leaving the resident unable to call for assistance.
A CNA failed to follow the care plan for a resident with severe cognitive impairment and osteoporosis by providing one-person assistance during transfers and incontinent care instead of the required two-person assist. This resulted in the resident sustaining acute fractures to the left lower leg. The CNA was unaware of the updated assistance level and did not check the Kardex, while nursing staff did not verify that the correct assistance was being provided.
A resident with severe cognitive impairment and a history of falls experienced a fall resulting in a head injury. Due to an electronic system outage, the MDS nurse documented the incident and interventions on paper but did not transcribe this information into the electronic care plan accessible to staff. As a result, the electronic care plan did not reflect the fall or updated interventions, and staff relied on incomplete information for ongoing care.
A facility's kitchen inspection revealed multiple deficiencies in food storage and sanitation practices. Unlabeled and undated drinks and pureed bread were found in the refrigerator, with several food items left open to air in the freezer. Sanitation issues included gnats, personal items on prep tables, and dirty dishes on the clean rack. Eroded non-stick pans and a chipped spatula posed contamination risks, while improper grease disposal was noted. Staff interviews highlighted a lack of adherence to labeling, dating, and proper storage protocols.
A facility failed to follow its abuse reporting procedures when a CNA allegedly abused a resident with severe cognitive impairment. The LVN who witnessed the incident did not notify the resident's RP or physician immediately, as required by policy. The DON later discovered the RP had not been informed, highlighting a lapse in communication and adherence to protocol.
The facility failed to conduct accurate PASRR screenings for two residents, leading to deficiencies in their care. One resident with severe cognitive impairment and multiple mental health diagnoses was admitted without an accurate PASRR Level 1 screening, risking their access to necessary services. Another resident with moderate cognitive impairment and a history of schizoaffective disorder and bipolar disorder also lacked an accurate screening, potentially delaying appropriate care. Staff interviews revealed procedural oversights in ensuring accurate PASRR evaluations.
A resident with a history of stroke and dementia experienced significant changes in her condition, including the removal of a tracheostomy and changes in feeding methods, which were not reflected in her care plan. The facility failed to update the care plan to reflect these changes, leading to a deficiency in care management. Interviews with staff revealed a lack of awareness and communication regarding the resident's current condition.
A medication cart on the 200-hall was found unlocked and unattended, allowing access to medications. LVN D admitted to leaving the cart unsecured while assisting a resident, acknowledging the importance of keeping it locked. The DON confirmed the cart should not have been left unlocked, as it posed a safety risk. Facility guidelines require medication carts to be secured and within sight when not in use.
A facility failed to ensure proper infection control practices when an LVN did not wear the required PPE during wound care for a resident with significant wounds. Despite the presence of signs and available PPE, the LVN forgot to gown up, potentially compromising the resident's wound care. Interviews revealed that the oversight was due to forgetfulness and the absence of a PPE cart as a reminder.
A resident under hospice care experienced a fall, leading to a significant increase in pain and a delayed diagnosis of a displaced femur fracture. The facility failed to promptly notify the physician of the resident's condition change and critical x-ray findings, resulting in a delay of approximately 15 hours. This lack of timely communication potentially contributed to inadequate medical intervention.
A resident in a LTC facility experienced a significant increase in pain after a fall, but the facility failed to promptly notify the physician of critical x-ray findings showing a displaced femur fracture. The delay in communication and action potentially contributed to the resident's decline and eventual death.
A resident with dementia and under hospice care fell in the dining room, resulting in a displaced femur fracture. The facility delayed ordering an x-ray and failed to promptly notify the physician of the critical results, contrary to policy. Staff interviews revealed inconsistencies in handling and communicating diagnostic results, contributing to the deficiency.
A facility failed to maintain a comprehensive care plan for a resident, omitting critical information such as DNR status and allergy details. The resident, with multiple health issues including dementia and chronic kidney disease, experienced several falls that were not reflected in the care plan. Staff interviews revealed confusion and delays in updating the care plan, potentially impacting the resident's care.
A facility failed to develop a comprehensive care plan within the required timeframe for a resident with complex health needs, including dementia and chronic kidney disease. The care plan was not updated with necessary information after revisions, and staff interviews revealed confusion about responsibilities for updating care plans. This deficiency could impact the resident's individualized care.
Failure to Implement Enhanced Barrier Precautions and Proper Wound Care Infection Control
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program, including proper implementation of Enhanced Barrier Precautions (EBP) for residents with wounds. For one male resident with a disrupted external surgical wound, physician orders specified EBP only for wound care once daily and did not include a general EBP order or directions for use during all high-contact activities. His care plan indicated EBP for a midline IV access and a right leg wound, with instructions that staff must use gowns and gloves during high-contact resident care activities that could result in transfer of multidrug-resistant organisms (MDROs), but the physician orders did not align with this broader requirement. For a female resident with a non-pressure chronic ulcer of the back and a sacral surgical wound, physician orders also limited EBP use to once-daily wound care, while her care plan called for EBP for both a colostomy stoma and sacral wound, again specifying gown and glove use during high-contact activities. The Director of Nursing later acknowledged that EBP was intended for high-contact activities such as wound care, dressing, bathing, transferring, and changing linens, and that the EBP orders for both residents were written too narrowly, specifying only wound care instead of all high-contact activities as outlined in the facility’s EBP policy and CDC guidance. During an observed wound care procedure for the female resident on EBP, an LVN failed to don the required PPE gown before entering the resident’s room and did not bring a trash bag into the room, where no trash bag was available. The LVN removed the old dressing and dirty gloves and placed them on the clean barrier with clean wound care supplies, instead of disposing of them in a trash bag. She performed inadequate wound cleansing by dabbing the wound a few times with Dakins-soaked gauze and dry gauze rather than cleansing from the cleanest to dirtiest area, and she failed to perform hand hygiene between glove changes. After completing wound care, she washed her hands with soap for only 4–5 seconds, below the facility policy requirement of at least 20 seconds, and disposed of contaminated trash outside the resident’s room. These observed actions did not comply with the facility’s EBP policy, hand hygiene policy, or CDC recommendations for PPE availability and use.
Failure to Notify Providers of Critical Lab Result and New Skin Lesion
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify physicians of significant clinical findings for two residents, contrary to professional standards, the residents’ care plans, and the facility’s own change in condition policy. For the first resident, an older female with multiple serious diagnoses including sepsis, severe sepsis without septic shock, stage 3 sacral pressure ulcer, unstageable coccyx wound, cognitive communication deficit, and other local skin infections, a critical laboratory result indicating Methicillin Resistant Staphylococcus aureus (MRSA) was reported on 02/16/2026 at 08:22 AM. Review of the resident’s progress notes for that date showed no documentation that the physician was notified of this critical MRSA result. The resident’s care plan required staff to observe, document, and report changes in skin integrity and to report improvements and declines to the physician, and the facility’s policy required physician notification for significant changes and discovery of injury or need to alter treatment. For the second resident, an older female admitted with a cutaneous abscess of the abdominal wall and requiring wound care, the facility failed to notify the physician or NP when a new skin irregularity was identified on the right great toe. The resident, who had moderate cognitive impairment and was at risk for pressure ulcers, reported a black area on her right great toe to the NP on 02/20/2026 and stated she had informed the wound care nurse approximately two days earlier. The treatment nurse confirmed in interview that on 02/18/2026 she had been made aware of the toe lesion, assessed it as a blood blister, and then informed the charge nurse but did not notify the physician, NP, or on-call provider. She stated that notifying the physician was not within her scope and that it was the charge nurse’s responsibility, despite her role including performing skin assessments and wound care. Additional interviews and record reviews further clarified the failures in notification. An LVN who worked on 02/16/2026 stated she was never made aware of the MRSA lab result for the first resident and that, during her shift, she reviewed the resident’s chart but did not see any critical lab results. The NP later discovered the critical MRSA result dated 02/16/2026 while reviewing labs on 02/18/2026 and reported that she had not been notified by the facility. The NP also reported that when she questioned the treatment nurse about the second resident’s toe lesion, the nurse acknowledged knowing about it since 02/18/2026 and had not sought orders. The facility’s change in condition policy required prompt notification of the attending physician or on-call physician when there was a significant change in condition or discovery of injury, but in both residents’ cases, the required physician notification did not occur as expected.
Failure to Obtain Wound Care Orders for Abdominal Abscess
Penalty
Summary
The deficiency involves the facility’s failure to obtain and implement wound care treatment orders for a resident’s abdominal wound in accordance with professional standards of practice and the resident’s person-centered care plan. The resident, an older female admitted with a cutaneous abscess of the abdominal wall and coded as being at risk for developing pressure ulcers, had a care plan initiated that identified an actual impairment to skin integrity of the abdomen related to the abscess. The care plan included monitoring and documenting the location, size, and treatment of the skin injury and reporting abnormalities or failure to heal to the physician. On admission, an LVN completed a head-to-toe assessment and documented the abdominal wound, including measurements, but did not obtain wound care orders to evaluate and treat the wound from the time of admission. Record review showed that the resident’s abdominal wound was present and measured on admission and again on a later skin assessment, with measurements indicating the wound was resolving and decreasing in size. However, there were no wound care orders in place for several days following admission, despite the facility’s wound care policy requiring verification of a physician’s order for wound care procedures and the change in condition policy requiring physician notification for discovery of injury of unknown source or significant changes requiring alteration of medical treatment. During interview, the LVN acknowledged forgetting to place wound care orders after identifying and documenting the abdominal wound on admission, and the DON confirmed that wound care orders should have been obtained at that time. The report states that this failure could place residents at risk for wound care complications or at risk of not receiving necessary wound care.
Failure to Accurately Document Wound Care Treatments on TARs
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for two residents receiving wound care, as required by professional standards and facility policy. For Resident #1, who had multiple complex medical conditions including severe sepsis, pressure ulcers (including a stage 3 sacral wound and unstageable coccyx ulcer), and significant functional and cognitive impairment, the Treatment Administration Record (TAR) for February 2026 showed no documentation of wound care on 02/16/2026. The resident’s care plan required observation and documentation of skin injury location, size, and treatment, as well as provision and documentation of wound treatments and weekly measurements. For Resident #2, who had a cutaneous abscess of the abdominal wall and was at risk for pressure ulcers, the TAR for February 2026 lacked documentation of wound care on 02/15/2026, 02/16/2026, and 02/17/2026. This resident’s care plan required monitoring and documentation of the abdominal skin abscess, including location, size, treatment, and reporting of abnormalities or signs of infection. Skin measurement assessments dated 02/12/2026 and 02/18/2026 showed decreasing wound size with no concerns noted, but there was no corresponding TAR documentation for the three specified dates. In interviews, LVN A stated she completed wound care for Resident #1 on 02/16/2026 after being notified by the treatment nurse that the care needed to be done, but acknowledged she likely forgot to document the completed treatment on the TAR or in a progress note. RN A stated she completed wound care for Resident #2 on 02/15/2026 through 02/17/2026 but did not document it because she was unfamiliar with how to chart on the TAR. The DON confirmed that both nurses should have documented the wound care in the TAR or progress notes and that the facility’s policy requires documentation of treatments or services performed in the resident medical record.
Improper Wound Care and Hand Hygiene for Resident With Unstageable Sacral Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards for a female resident with an unstageable sacral pressure ulcer and an indwelling Foley catheter. The resident, who had diagnoses including sepsis, CHF, and wasting syndrome, was moderately cognitively impaired and dependent for toileting hygiene. Her care plan identified an actual impairment to skin integrity with a sacral wound initially documented as stage 3 and later as unstageable, with specific orders to cleanse the coccyx pressure ulcer with wound cleanser, dry with gauze, apply Thera Honey and calcium alginate, and cover with bordered silicone gauze daily and as needed. An order was also in place for a urinary catheter for 30 days to aid wound healing. During an observed wound care procedure, the WCN removed an old sacral dressing that was saturated with urine and did not ensure the resident had a clean brief prior to performing wound care. The WCN failed to perform proper hand hygiene and glove changes when moving between dirty and clean tasks. She did not sanitize or wash her hands and change gloves before re-entering a package of clean wipes after handling contaminated areas, and she touched a urine- and feces-soaked brief during wound care without subsequently cleaning her hands or changing gloves. The WCN also applied an inadequate amount of hand sanitizer and did not allow it to dry before donning gloves. The WCN did not use proper wound cleansing technique, cleaning the sacral wound from the outside to the inside and wiping from top to bottom instead of from the inside to the outside (clean to dirty) in a circular motion as described by the DON. The WCN acknowledged that the Foley catheter, ordered to assist with wound healing, constantly leaked and that the resident’s brief stayed wet, but she did not address this issue during care. She stated she should have ensured a clean brief before wound care and recognized that her wound cleansing technique and handling of contaminated items could have caused cross-contamination. The NP reported she had not seen the wound and had not been notified of significant changes in the wound’s size or condition, other than the request for a Foley catheter order, despite the wound measurements fluctuating and the development of slough. The DON confirmed that re-entering clean supplies with contaminated gloves, improper wound cleansing technique, and failure to report the leaking Foley catheter were inconsistent with facility policies on wound care and hand hygiene.
Failure to Implement Enhanced Barrier Precautions and Proper Hand Hygiene During Wound and Incontinent Care
Penalty
Summary
The deficiency involves the facility’s failure to establish and maintain an effective infection prevention and control program, including proper implementation of Enhanced Barrier Precautions (EBP) and hand hygiene practices. Surveyors identified that 12 residents were on EBP, yet multiple rooms on several halls, including the room of Resident #50, had PPE containers but no EBP signage posted on the doors or walls outside the rooms. The facility’s own EBP policy required signs to be posted on the door or wall outside the resident room indicating the type of precautions and PPE required. The DON stated she believed signs posted inside the rooms were sufficient and did not realize they also had to be posted outside the rooms. Resident #50 was a female resident with sepsis, congestive heart failure, and wasting syndrome, with an admission MDS showing moderately impaired cognition (BIMS score of 10), dependence in toileting hygiene, an indwelling catheter, and at least one unhealed pressure ulcer. Her care plan documented a stage 3 sacral wound and a Foley catheter related to skin breakdown. During an observation of wound and incontinent care for this resident, the WCN did not perform hand hygiene or change gloves when moving from dirty to clean tasks. Specifically, the WCN failed to sanitize hands and don clean gloves before re-entering a package of clean wipes, and did not perform hand hygiene or change gloves after touching a urine- and feces-soaked brief during wound care. The WCN also applied an inadequate amount of hand sanitizer and did not rub her hands long enough to allow the sanitizer to dry before putting on gloves, contrary to product directions. She cleansed the sacral wound from the outside to the inside, wiping from top to bottom, instead of working from the inside to the outside (clean to dirty) in a circular motion. After wound care, both the WCN and CNA-H re-entered the clean container of wipes with contaminated gloves while performing incontinent care. CNA-H continued incontinent care and placed a clean brief under the resident without changing gloves or performing hand hygiene until all care was completed, and then carried the container of wipes, which had been accessed with contaminated gloves, out of the resident’s room. In interviews, the WCN, DON, NP, and CNA-H acknowledged that these practices, including re-entering clean supplies with contaminated gloves and handling dirty briefs during wound care without hand hygiene, could cause cross-contamination and contribute to infection and wound worsening. Record review showed the facility had existing policies on EBP, perineal care, and hand hygiene, as well as an in-service on standard precautions and glove use, which required glove changes and hand hygiene between tasks and when moving from soiled to clean body sites. In addition, CNA-H reported not recalling being in-serviced on hand washing and glove changes between tasks on the same resident when going from dirty to clean. The NP stated that the observed failures in hand hygiene and wound care technique, including performing wound care while the resident remained in a urine-soaked brief with feces and touching the brief during wound care, could contribute to cross-contamination and wounds not healing or worsening. The DON confirmed that staff were not supposed to take items into the rooms of residents on precautions and then bring them back out, and that re-entering a package of clean wipes with gloves contaminated by urine and feces, as well as improper wound cleaning technique and failure to change gloves after touching a dirty brief, could cause cross-contamination and lead to infection and worsening of wounds. Record review of the facility’s policies showed that EBP required signs on the door or wall outside the resident room indicating the type of precautions and PPE required, that perineal care procedures required removal of heavily soiled items, glove removal, handwashing, and then new hand hygiene and gloves before proceeding, and that hand hygiene was required before touching a resident, before aseptic tasks, after contact with body fluids or contaminated surfaces, before moving from a soiled to a clean body site on the same resident, and immediately after glove removal. The in-service on standard precautions and glove use required clean gloves to be put on between tasks and procedures involving the same resident. The observed practices by the WCN and CNA-H, and the lack of required EBP signage outside resident rooms, were inconsistent with these written policies and contributed to the cited infection control deficiency. Interviews further clarified staff understanding and acknowledgment of the issues. The WCN stated she knew which residents were on EBP from the chart and a sign inside the room, but was unsure about the requirement for signage outside the room, though she agreed it would make sense so anyone entering would know the proper PPE to use. She also acknowledged she should have ensured the resident had a clean brief before wound care, should not have touched the dirty brief during wound care, and that her wound cleaning technique and re-entering clean wipes with contaminated gloves could have caused cross-contamination and infection. CNA-H acknowledged that reaching into a clean wipes container with contaminated gloves and touching clean linens or briefs with dirty gloves could cause cross-contamination. These observations and statements formed the basis of the surveyors’ finding that the facility failed to maintain an effective infection prevention and control program for all residents reviewed for infection control practices.
Call Light Placement Out of Reach for Resident with Hemiplegia
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, right-sided flaccid hemiplegia, aphasia, and dysphagia was found in bed with the call light placed out of reach. The resident's care plan specifically indicated a risk for falls and included an intervention to keep the call bell within reach. During observation, the call light was located under the bed remote on the left side of the bed, but the resident was unable to stretch far enough to access it, despite being able to use the bed remote with her left hand. Interviews with staff revealed that the nursing assistant who last attended to the resident did not realize the call light was out of reach and acknowledged that it should have been left accessible, especially considering the resident's right-sided paralysis. The facility's policy also required that call lights be placed within easy reach of residents. The resident was left without access to the call light for approximately 10 minutes after being transferred from her wheelchair to her bed.
Failure to Follow Care Plan for Resident Transfers and Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the care plan for a resident with severe cognitive impairment, Alzheimer's disease, osteoporosis, and a history of fractures. The resident was care planned to require two-person physical assistance for transfers, bed mobility, and incontinent care. Despite this, the CNA performed a one-person transfer from wheelchair to bed and provided one-person assistance during incontinent care on multiple occasions. The CNA was unaware that the resident's assistance level had changed and had been providing one-person assistance since returning from leave, without checking the current care plan or Kardex. Following these transfers and care episodes, the resident began to complain of pain in her left leg, which was initially not accompanied by visible abnormalities. Over the course of the night and early morning, the resident's pain increased and discoloration developed on her left lower leg. Subsequent assessments and imaging revealed acute proximal and mid left lower leg fractures. The CNA stated she did not use a gait belt during the transfer and was not aware of the updated assistance requirements, citing issues with accessing the electronic care plan system. Nursing staff and the DON confirmed that the resident required two-person assistance and that the CNA did not follow the care plan as required. Interviews with nursing staff revealed a lack of clear communication and monitoring regarding changes in residents' assistance levels. The charge nurse and other staff assumed the CNA was aware of the resident's needs and did not verify that the correct level of assistance was being provided. The facility's policy and training documentation did not clearly specify the requirement to follow the care plan, and there was no written evidence of prior in-service training for the CNA on this topic. The failure to provide the appropriate level of assistance as outlined in the care plan resulted in the resident sustaining significant injuries.
Failure to Accurately Update Electronic Care Plan Following Resident Fall
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident. Specifically, after a resident experienced a fall that resulted in a head injury, the responsible MDS nurse documented the incident and related interventions on a paper care plan due to an electronic system outage. However, this information was not subsequently transcribed into the resident's electronic care plan, which was the version accessible to staff for ongoing care and reference. The resident involved was an elderly female with significant medical issues, including legal blindness, osteoporosis, repeated falls, and severe cognitive impairment as indicated by a low BIMS score. The fall in question was documented on paper, but the electronic care plan, which staff relied upon, did not reflect the incident or the interventions implemented. The care plan only included general fall risk factors and did not mention the specific fall event or the updated interventions following the incident. Interviews with the MDS nurse and the DON confirmed that the omission occurred because the system was down and the paper documentation was not uploaded into the electronic record. Both staff members acknowledged that falls and related interventions should be included in the care plan and that the facility's process required such updates. The facility's policy on care planning did not specify what should be included in the care plan, and there was no documentation available to confirm recent training for the MDS nurse on care plan development.
Food Storage and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, and sanitation, as observed during a kitchen inspection. Unlabeled and undated prepared drinks and pureed bread were found in the service refrigerator, with the bread left open to air and containing a scoop. Additionally, several containers of spices and a large bag of cereal were left open to air, and various food items in the freezer were unsealed, including garlic bread sticks, sliced carrots, and hamburger patties. A bag of vegetable blend in the freezer was found to be discolored and covered in ice crystals, indicating improper storage. The kitchen was also found to have several sanitation issues, including the presence of gnats, personal items on prep tables, and dirty dishes on the clean rack. The ice machine had a removable brownish-red substance on the ice chute, and non-stick pans and a spatula were found to be eroded, flaking, and chipped, posing a risk of contamination. Six cases of frozen food were improperly stored on the floor of the walk-in freezer, and a large vat of used grease was found on the floor under the sink, indicating improper disposal practices. Interviews with kitchen staff revealed a lack of adherence to labeling and dating protocols, as well as improper handling and storage of food items. The cook acknowledged the potential risks of leaving spices and food items open to air and admitted to not discarding eroded pans and spatulas. The dietary aide identified mold or bacteria on the ice machine and noted improper storage of peanut butter and jelly. The dietary manager confirmed that staff should have been aware of proper food storage and sanitation practices, and expressed concern over the improper disposal of used grease, which could pose a risk to staff and the environment.
Failure to Implement Abuse Reporting Procedures
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically in the case of a resident with severe cognitive impairment and major depressive disorder. An incident occurred where a CNA was alleged to have abused the resident by telling her to 'shut up' and covering her mouth. The LVN who witnessed the incident did not follow the facility's abuse policy, as she only reported the incident to the DON and did not notify the resident's responsible party (RP) or the physician immediately, as required by the facility's policy. The investigation revealed that the LVN was new to the facility and unsure of the reporting process, leading to a delay in notifying the RP. The DON instructed the LVN to call the RP, but this was not done, and the RP was only informed of the incident after being contacted by the surveyor. The facility's policy mandates immediate notification of the alleged victim's practitioner and family or RP, which was not adhered to in this case, potentially placing residents at risk of abuse and neglect.
Failure to Conduct Accurate PASRR Screenings for Two Residents
Penalty
Summary
The facility failed to ensure that PASRR evaluations were completed for two residents, leading to deficiencies in their care. Resident #48, a male with severe cognitive impairment and multiple mental health diagnoses, was admitted without an accurate PASRR Level 1 screening. His medical records indicated a history of bipolar disorder, dementia, and anxiety, yet the PASRR screening incorrectly noted no evidence of mental illness. This oversight placed him at risk of not receiving necessary specialized therapy and equipment services. Similarly, Resident #25, a female with moderate cognitive impairment and a history of schizoaffective disorder and bipolar disorder, was also admitted without an accurate PASRR Level 1 screening. Her medical records showed active diagnoses of anxiety, epilepsy, and dementia, and she was on multiple psychotropic medications. However, her PASRR screening also failed to recognize her mental illness, potentially delaying her access to appropriate care and services. Interviews with facility staff revealed a lack of proper procedures in place to ensure accurate PASRR screenings. The MDS nurse acknowledged the oversight and mentioned being re-educated on PASRR requirements. The RDCR nurse confirmed the absence of necessary documentation for Resident #48 and recognized the need for a positive PL1 for Resident #25. The facility's policy on comprehensive assessments emphasized the importance of pre-admission screenings, yet these were not adequately conducted, leading to the deficiencies noted in the report.
Failure to Update Resident Care Plan After Significant Changes
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment for a resident. The resident, who had a history of nontraumatic stroke, anoxic brain damage, vascular dementia, tracheostomy, and gastrostomy, experienced several significant changes in her condition that were not reflected in her care plan. These changes included the self-removal of her tracheostomy tube, the removal of tracheostomy sutures, the discontinuation of pleasure feeding, and a change to a pureed diet, as well as the discontinuation of enteral feedings. The resident's care plan, dated and revised shortly after her admission, did not include updates for gastrostomy care, dietary changes, or tracheostomy management. Despite the resident's significant changes in condition, such as the removal of her tracheostomy and the transition to oral feeding, the care plan remained outdated. The Director of Nursing (DON) acknowledged that care plans should be updated to reflect changes in resident conditions and that there was no real monitoring in place to ensure this was done. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's current condition and care needs. The Activities Director (AD) was unaware that the resident could speak after the removal of her tracheostomy, indicating a disconnect between the resident's care plan and her actual condition. The facility's policy required care plans to be updated with significant changes in conditions, but this was not adhered to, leading to a deficiency in the resident's care management.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as evidenced by an unlocked and unattended medication cart on the 200-hall. During an observation, the surveyor found the medication cart unlocked, with multiple blister packs and bottles of medication accessible. LVN D, who was responsible for the cart, admitted to leaving it unlocked while assisting a resident, acknowledging the importance of keeping the cart secured to prevent unauthorized access by residents, visitors, or staff. The Director of Nursing (DON) confirmed that the medication cart should not have been left unlocked, as it posed a safety risk. The DON noted that in-services on keeping medication carts locked are conducted quarterly, with the last one held in July 2024. LVN D received one-on-one training following the incident, and all staff were reminded of the importance of securing medication carts. The facility's guidelines emphasize that medication carts should be kept closed, secured, and within the line of sight when not in use.
Failure to Use PPE During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the area of hand hygiene and the use of personal protective equipment (PPE). During an observation, LVN E did not wear the required PPE, such as a gown, while performing wound care on a resident who required enhanced barrier precautions due to an arterial ulcer and other medical conditions. This oversight was noted despite the presence of a sign indicating the need for enhanced barrier precautions and the availability of PPE on a cart in the hallway. Interviews with the Director of Nursing (DON) and LVN E revealed that the failure to wear PPE was due to forgetfulness and the absence of a visible PPE cart, which usually served as a reminder. The DON emphasized the importance of following doctor's orders and wearing appropriate PPE to prevent infection. The facility's infection prevention and control policy outlined the necessity of enhanced barrier precautions for residents with significant wounds, yet this protocol was not followed in this instance.
Failure to Notify Physician of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's condition. The resident, who had a history of dementia and was under hospice care, experienced a fall in the facility's dining room, landing on her left side. Despite the fall, the resident initially denied pain, and no immediate x-rays were conducted. However, two days later, the resident reported a substantial increase in pain in her left leg and shoulder, which was not communicated to the physician. The resident's condition worsened, and an x-ray conducted three days after the fall revealed a displaced fracture of the left femur neck. The facility received the x-ray results via email, but the physician was not notified until the following morning, resulting in a delay of approximately 15 hours. Interviews with facility staff revealed a lack of clear communication and documentation regarding the notification of significant findings to the physician. The delay in notifying the physician of the resident's increased pain and the significant x-ray findings potentially contributed to a lack of timely medical intervention. The facility's policies did not specify a timeframe for notifying physicians of critical results, which may have contributed to the oversight. The resident was eventually sent to the emergency room, but no treatment for the fracture was provided, and the resident was discharged home, where she later passed away.
Delayed Notification of Critical X-ray Results
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The deficiency involved a resident who experienced a substantial increase in pain following a fall in the facility's dining room. Despite the resident's significant pain and a subsequent x-ray revealing a displaced fracture of the left femur neck, the facility did not immediately notify the resident's physician of these critical findings. The resident, who had severe cognitive impairment and was under hospice care, fell on her left side in the dining room. Initially, the resident denied pain, and no immediate x-rays were conducted. However, the resident later exhibited signs of pain, and an x-ray was ordered three days after the fall. The x-ray results, which indicated a significant fracture, were not communicated to the physician until the following day, resulting in a delay in addressing the resident's condition. Interviews with facility staff revealed a lack of clear communication and documentation regarding the notification of critical x-ray results. The DON admitted to receiving an email about the significant findings but did not open it, and there was no immediate follow-up to ensure the physician was informed. This delay in communication and action potentially contributed to the resident's decline and eventual death, as noted by the medical examiner.
Delayed Notification of Critical X-ray Results
Penalty
Summary
The facility failed to promptly notify the ordering physician of critical x-ray results for a resident who had a displaced fracture of the left femur neck. The resident, who had a history of dementia and was under hospice care, fell in the facility's dining room. Despite the fall occurring on November 25, 2023, the x-ray was not ordered until November 28, 2023, and the results were not communicated to the physician until the following morning, November 29, 2023. This delay in notification was contrary to the facility's policy, which required immediate notification of significant findings. Interviews with staff revealed a lack of clarity and consistency in the process for handling and communicating critical diagnostic results. The Director of Nursing (DON) admitted to receiving an email with the x-ray results but did not open it, and there was no documentation of a call to the facility to report the significant findings. The facility's contracted radiology company had attempted to fax the results, but the fax failed, and there was no follow-up call to ensure the results were received. Additionally, there was no specific policy in place detailing the timeframe for notifying the physician of critical results, leading to a significant delay in the resident receiving appropriate care. The resident's family member reported that the resident was in pain following the fall, but the facility did not conduct an x-ray until three days later. The facility's staff, including the DON and other nurses, were unclear about the procedures for notifying physicians of critical results, and there was a lack of documentation regarding the notification process. The delay in notifying the physician and the lack of a clear protocol for handling critical diagnostic results contributed to the deficiency identified by the surveyors.
Removal Plan
- Resident #21 was assessed and being monitored by the nurses prior to being sent to the hospital. Per hospital report, resident did not receive any treatment for fracture and was discharged home with family.
- Director of Nursing/Assistant Director of Nursing conducted an audit of all residents to identify any abnormal x-rays to ensure the MD and family representatives have been notified and appropriate interventions are in place and prescribers orders have been carried out as ordered.
- The Regional Nurse (DCO) conducted an in-service to the Director of Nursing/Assistant Director of Nursing regarding the process for ensuring that abnormal x-ray have been identified, x-ray portals are being checked during shift to identify pending results, and the results are reported to the medical provider, orders provided should be implemented as ordered and nursing should document in the electronic health record the notification of abnormal x-ray results to the MD/NP/PA as well as any prescribed orders.
- Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses regarding: a. The process for ensuring that abnormal x-rays have been identified, x-ray portals are being checked once in first half of shift and once in second half of shift to identify pending results, and the results are reported to the medical provider upon receipt of abnormal x-ray findings, orders provided should be implemented as ordered and nursing should document in the electronic health record the notification of abnormal x-ray results to the MD/NP/PA as well as any prescribed orders.
- If the x-ray company is unable to reach the nursing staff on duty, they will place a call to the Director of Nursing/Administrator or Regional Nurse DCO (contact information provided) so that timely notification to the MD/NP/PA. This has been communicated to the X-ray company and confirmed by them via email and telephone call.
- Charge Nurses will report abnormal x-ray findings to DNS/ADNS via in person or telephonic communication.
- Nurses will communicate during change of shift nursing report any pending x-rays results or changes in condition such as increased pain needs and ensure proper interventions are in place and notifications to the MD/NP/PA have been completed.
- Charge Nurses educated to follow HHSC guidance that indicates that the nurse should conduct a post fall assessment following the fall event. The nurse will continue ongoing monitoring of the resident following a fall event and should conduct follow up assessments upon any changes in condition identified. The nurse should then notify the medical provider upon identifying the change in condition or abnormal findings.
- DNS/ADNS (Director of Nursing / Assistant Director of Nursing) will review during the clinical meeting abnormal x-ray results, both pending and resulted in order to validate appropriate interventions are in place, proper follow up and notifications to MD/NP/PA has been made in order to ensure patient care needs are met, and documentation is noted within the medical record.
- Administrator and Director of Nursing conducted an Ad Hoc QAPI meeting with the Medical Director to review plan of removal / immediate corrective action plan implemented.
- The facility will conduct a monthly QAPI meeting to review the status and compliance notification to MD/NP/PA abnormal x-ray results, ensuring appropriate intervention and orders are implemented as ordered and appropriate documentation is in noted within the E.H.R. Findings of audits and status of compliance will be reviewed to the Administrator and the QAPI committee during the monthly meetings.
Failure to Maintain Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, which included not retaining the resident's Do Not Resuscitate (DNR) status in the care plan when the resident was transferred to the hospital. Additionally, the DNR status was not included in the care plan when it was signed by the physician, and the care plan was not updated to reflect multiple falls experienced by the resident. Furthermore, the resident's latex allergy was not retained in the care plan upon transfer to the hospital. The resident involved was an elderly female admitted to the facility with a primary diagnosis of palliative care, alongside other significant health issues such as congestive heart failure, dementia, and chronic kidney disease. The resident had a history of breast and colon cancer, but recent scans showed no cancer. The resident's family member indicated that the resident's kidney disease was stable, and the admission to the facility was due to the progression of dementia. Interviews with facility staff revealed a lack of clarity and responsibility regarding the updating and maintenance of the resident's care plan. The Director of Nursing (DON) and other staff members were unsure why the DNR status was marked as resolved and reverted to full code, and there was no set schedule for DNR audits. The Social Worker (SW) and other staff members acknowledged delays in updating the care plan, which could lead to potential issues with the resident's plan of care.
Failure to Timely Develop Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment for a resident, which is a requirement to ensure individualized care. The resident, an elderly female, was admitted with a primary diagnosis of palliative care and other significant health issues, including congestive heart failure, dementia, and chronic kidney disease. Despite these complex needs, the comprehensive care plan was not completed within the required timeframe, potentially impacting the resident's care. The report highlights that the initial care plan was created upon admission and revised multiple times, but it lacked necessary updates and information. The Director of Nursing (DON) revised the care plan after the resident's hospital visit, but crucial information was either not retained or added. Interviews with staff revealed a lack of clarity and responsibility regarding who should update the care plan, leading to inconsistencies and omissions in the resident's care documentation. Interviews with various staff members, including the DON, Social Worker (SW), and Nursing Assistant Coordinator (NAC), revealed systemic issues in the care planning process. The SW was on leave during the resident's admission, which contributed to delays in updating the care plan. The NAC admitted to not knowing when or how the comprehensive assessment should be completed, indicating a lack of training or communication within the team. These deficiencies in the care planning process could lead to inadequate care for residents, as their needs and preferences may not be accurately reflected in their care plans.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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