Avir At Rose Trail
Inspection history, citations, penalties and survey trends for this long-term care facility in Tyler, Texas.
- Location
- 930 S Baxter, Tyler, Texas 75701
- CMS Provider Number
- 455429
- Inspections on file
- 45
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 23 (3 serious)
Citation history
Health deficiencies cited at Avir At Rose Trail during CMS and state inspections, most recent first.
A resident with multiple fractures and a history of pulmonary embolism was admitted from the hospital with orders for apixaban (Eliquis) 5 mg BID, but the MAR and nursing notes showed the evening and next-morning doses were not administered or documented. The resident’s family reported the anticoagulant was not given on those days, and the assigned LVN could not recall administering it, stating it would appear on the MAR if given. Although Eliquis was stocked in the facility’s E-kit and policies required timely administration and eMAR documentation of emergency medications, pharmacy and E-kit records confirmed no Eliquis was pulled during the relevant shifts, resulting in significant medication errors.
Sensitive documents containing PHI, including care plans, PIRs, and resident identifier sheets with details such as diagnoses, treatments, and SSNs, were found in a public binder in the facility lobby. Facility leadership confirmed these documents should not have been publicly accessible and acknowledged staff responsibility to safeguard PHI, despite existing policies and training.
Two residents with complex medical and cognitive needs were admitted without baseline care plans being developed or implemented within 48 hours, as required. Record reviews and interviews confirmed that no care plans were initiated, and staff cited recent transitions and unclear responsibilities as contributing factors.
The facility did not develop or implement comprehensive care plans for four residents with complex medical and cognitive needs. Care plans were missing or incomplete, failing to address current diagnoses, care levels, and required interventions, including hospice and wound care. Staff interviews revealed confusion over responsibilities and cited recent staff transitions as contributing factors.
Two residents with tracheostomies did not receive respiratory care and suctioning using sterile technique, as required by professional standards and facility policy. Multiple nurses, including LVNs and the Interim DON, performed tracheostomy care and suctioning without sterile gloves or proper sterile technique, and in some cases did not change gloves or perform hand hygiene between procedures. One resident in respiratory distress was not reassessed or suctioned when requested, and another received care with contaminated gloves and non-sterile supplies. Staff competency check-offs were missing, and not all staff had been educated on sterile technique for tracheostomy care.
Staff failed to use sterile technique during tracheostomy care and suctioning, and did not consistently apply enhanced barrier precautions when caring for residents with indwelling devices, wounds, or infections. Multiple nurses and CNAs performed procedures without proper PPE or sterile supplies, sometimes due to unavailability, and not all staff were trained or competent in infection control practices. Several residents with complex medical needs and active infections were affected by these lapses.
A facility failed to immediately report an allegation of verbal abuse when a resident threatened another resident, despite staff and the Ombudsman advising that the incident be reported to authorities. The Administrator, who was also the abuse coordinator, separated the residents but did not document or report the incident to the state agency as required by policy and regulation.
A resident with a Foley catheter and neuromuscular bladder dysfunction did not have a care plan addressing the catheter or its securement, despite being fully dependent on staff. Multiple observations showed the catheter was not secured, and staff interviews confirmed the care plan was incomplete and not updated as required.
Two residents with indwelling Foley catheters did not have their catheters properly secured as required by physician orders and facility policy. Despite documentation indicating that securement devices were checked, direct observations on multiple occasions showed that the catheters were not secured. Staff interviews confirmed that nurses were responsible for this task, but the lack of securement was overlooked.
A facility failed to update a care plan for a resident with a stage 4 pressure ulcer, dementia, and multiple sclerosis. The care plan did not reflect the completion of vitamin C, multivitamin with minerals, and zinc supplements, which were crucial for wound care. Interviews revealed that the facility had a protocol for supplement re-evaluation after 90 days, but the care plan was not updated accordingly. The DON and Administrator highlighted the importance of accurate and timely care plan updates.
A facility failed to ensure proper wound care for a resident with a stage 4 pressure ulcer on the sacrum. The resident was found without a dressing, contrary to physician orders, and the treatment nurse confirmed the dressing should be changed if wet. The resident reported the night shift removed the wet dressing but did not replace it. The wound care doctor and DON expected nurses to reapply dressings to prevent infection, but the facility lacked a specific policy on physician orders.
A Treatment Nurse in an LTC facility failed to perform hand hygiene between glove changes while providing wound and incontinent care to two residents. Despite the facility's infection control policy requiring hand hygiene, the nurse did not adhere to these practices, potentially risking cross-contamination. Interviews with the nurse, DON, and Administrator highlighted a misunderstanding of the protective role of gloves and the importance of hand hygiene.
The facility failed to accurately complete MDS assessments for four residents, leading to incorrect coding for dialysis and ventilator use. Two residents with end-stage renal disease were not coded for their regular dialysis treatments, while two others with chronic respiratory failure were incorrectly coded as receiving ventilator therapy instead of humidified oxygen therapy. These inaccuracies were attributed to a former MDS Nurse, and the facility's policy on comprehensive assessments was not followed.
The facility failed to provide adequate pharmaceutical services, resulting in incomplete medication orders and unavailability of prescribed medications for three residents. One resident received an unspecified dose of Vitamin C due to an incomplete order, another missed doses of Vitamin B12 and eye drops due to unavailability, and a third continued an antibiotic beyond the intended stop date due to a lack of a stop order.
The facility failed to provide accurate PASRR Level 1 screenings for two residents with mental health disorders. One resident with bipolar disorder, anxiety, and depression was admitted without a serious mental illness indicated on her PASRR, despite her medical history and medication use. Another resident with similar diagnoses also had an inaccurate PASRR, with no serious mental illness noted, despite severely impaired cognition. The MDS nurse acknowledged the inaccuracies and the absence of the responsible staff member.
The facility exceeded the acceptable medication error rate, reaching 9% due to errors involving two residents. One resident received Vitamin C without dose verification, while another did not receive prescribed Vitamin B12 and Brimonidine due to unavailability. The facility's policies on medication administration were not adhered to, contributing to these errors.
A resident with a gastrostomy tube was put at risk when an RN used a syringe that had been on the floor to administer medications and water. The RN failed to change gloves or perform hand hygiene after handling a contaminated plastic bag, compromising the sterility of the syringe. This action violated the facility's infection prevention and control policies.
A resident with multiple health conditions did not receive ordered laboratory services, specifically a urinalysis, due to a failure in the facility's process. The resident's electronic health records lacked documentation of the UA results, and staff interviews indicated that the sample might not have been picked up by the lab company during a transition period. The VP of Clinical Operations confirmed the absence of results and noted the responsibility of the previous DON in ensuring lab orders were completed.
A facility with 172 beds failed to employ a qualified social worker full-time since May 2024, as required by policy. Interviews with the Administrator, DON, and other staff confirmed the absence of a social worker, with the DON attempting to cover some duties without proper licensing. Despite job postings, the position remained unfilled, impacting the provision of essential social services to residents.
A resident with severe cognitive impairment and multiple medical conditions was physically abused by a CNA, who slapped her arm, resulting in a large bruise. The incident was reported, and the CNA was terminated and arrested. Staff confirmed that hitting a resident is considered abuse and is unacceptable.
A resident alleged that an LVN slapped at her hand and cursed at her during wound care. The facility's investigation was terminated prematurely based on an alleged denial by the resident, which she later contradicted. The LVN was briefly suspended but returned to work within 30 minutes, and the social worker's safety surveys indicating negative responses were not fully considered.
A facility failed to provide ordered wound care and report changes in a resident's condition, leading to infection, hospitalization, and surgical intervention. The resident's wound care was inconsistently performed, and redness on the abdomen was not reported, resulting in cellulitis and panniculitis requiring IV antibiotics.
A facility failed to ensure proper catheter care for a resident, resulting in the urinary catheter bag being found on the floor multiple times. The resident reported that she could not reach the bag to hang it properly, and staff confirmed that the bag should not be on the floor to prevent infection and damage. This lapse in care placed the resident at risk for infection and other complications.
Missed Anticoagulant Doses for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to the administration of apixaban (Eliquis), an anticoagulant prescribed to treat and prevent blood clots. The resident, an adult male with multiple traumatic fractures and a documented history of pulmonary embolism, was admitted from an acute hospital stay with orders to receive apixaban 5 mg by mouth twice daily. The hospital discharge summary showed the last dose was given on the morning of 1/1/26, and the physician order at the facility, with a start date of 1/2/26, also directed apixaban 5 mg twice daily. The MDS indicated the resident was cognitively intact, able to make himself understood, and had received anticoagulant therapy during the look-back period, but his care plan dated 1/5/26 did not address anticoagulant administration. Record review of the January 2026 MAR showed the resident did not receive his scheduled evening dose of apixaban on 1/1/26 or his morning dose on 1/2/26. Nursing progress notes for those dates contained no documentation that apixaban was administered for those missed doses. During interview, the resident’s family member reported that the resident had not been given his anticoagulant medication on those two days while at the facility, although the family member stated the resident did not develop a blood clot while there. LVN A, who cared for the resident on 1/1/26 (6:00 a.m. to 6:00 p.m.) and 1/2/26 (6:00 a.m. to 6:00 p.m.), stated she did not administer apixaban on 1/1/26 because the resident arrived late in the shift and could not recall if she administered it on 1/2/26, adding that any administration should have been documented on the MAR. Facility staffing records showed the resident was assigned to LVN C on the 6:00 p.m. to 6:00 a.m. shift spanning 1/1/26 to 1/2/26, but LVN C could not be reached for interview. The ADON and DON explained that for new admissions, significant medications such as apixaban are available through the pharmacy-supplied E-kit once orders are entered and a code is provided by the contracted pharmacy, and that Eliquis was stocked in the E-kit. Review of the E-kit inventory confirmed that Eliquis 2.5 mg doses were in stock at the facility. The pharmacy consultant reported that no Eliquis was pulled from the E-kit on 1/1/26 or 1/2/26. The facility’s policies on administering medications and emergency medication ordering required that medications be administered safely, timely, as prescribed, and that emergency or STAT medications obtained from emergency drug kits be entered into the EHR and documented on the eMAR. Despite these policies and the availability of Eliquis in the E-kit, there was no evidence that the resident’s ordered apixaban doses for the evening of 1/1/26 and the morning of 1/2/26 were obtained or administered, resulting in the identified medication errors.
Failure to Protect Resident Privacy and Confidentiality of Medical Records
Penalty
Summary
The facility failed to protect the personal privacy and confidentiality of residents' medical records for 10 out of 13 residents reviewed. Surveyors observed that care plans containing protected health information (PHI), including diagnoses, treatments, and Social Security Numbers (SSNs), were left in a public survey binder located in the facility's lobby. Additionally, the binder contained a Post-Investigation Review (PIR) with PHI for two residents, including names, SSNs, Medicaid and Medicare numbers, and health diagnoses. A resident identifier sheet and corresponding survey with PHI for four other residents were also found in the same public binder. Interviews with facility leadership confirmed that these documents should not have been accessible to the public. The administrator acknowledged that only survey tags and plans of correction should have been in the binder, and that care plans, PIRs, and resident identifier sheets containing PHI were not appropriate for public access. The administrator was unaware of who placed these documents in the binder but confirmed that it was the responsibility of all staff to safeguard PHI. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) both stated that staff were trained to protect PHI during onboarding and through regular in-service training. They emphasized the importance of maintaining resident privacy and confidentiality, as outlined in the facility's HIPAA policy, which restricts access to personal medical information to authorized personnel only. Despite these policies and training, the presence of sensitive documents in a publicly accessible area constituted a failure to ensure the confidentiality of residents' medical information.
Failure to Develop Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement baseline care plans for two residents within 48 hours of admission, as required. For both residents, there was no documentation of a care plan that included current diagnoses, care levels, measurable objectives, or timetables to address their physical, psychosocial, and functional needs. This omission was identified through observation, interviews, and record reviews, which confirmed that no baseline care plans had been initiated since their respective admissions. One resident was a 58-year-old female with multiple complex medical conditions, including acute respiratory failure, schizophrenia, pressure ulcers, and severe cognitive impairment, who was totally dependent on staff for activities of daily living. Interviews with the resident's daughter revealed that no care plan meeting had occurred. The other resident was a 63-year-old male with diagnoses such as hypertension, dementia with behavioral disturbances, diabetes with neuropathy, and a stage 3 pressure ulcer, who also exhibited moderate cognitive impairment. Observations and interviews confirmed that neither resident had a baseline care plan in place. Staff interviews indicated a lack of awareness and accountability regarding the completion of care plans. The administrator and social worker were not aware of the missing care plans and attributed the issue to recent staff transitions, including an interim DON and a new MDS nurse who was out sick. The ADON stated that care planning was the responsibility of the MDS nurse (RN), and as an LVN, she did not assume this responsibility. The facility's policy required comprehensive care plans to be developed within a specific timeframe, but this was not followed for the two residents in question.
Failure to Develop and Implement Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for four residents, as required by policy and regulation. For each resident, there was a lack of documentation, development, or implementation of care plans that addressed current diagnoses, care levels, measurable objectives, and timetables to meet their physical, psychosocial, and functional needs. This was identified through observation, interviews, and record reviews, which revealed that care plans were either missing or incomplete for all four residents reviewed. One resident, a 58-year-old female with multiple complex diagnoses and severe cognitive impairment, had no documented care plan since admission, and her family had not participated in a care plan meeting. Another resident, a 63-year-old male with significant medical and cognitive issues, also lacked a documented care plan addressing his current needs. For a female resident with severe cognitive impairment and on hospice care, there was no care plan reflecting her hospice services, goals, or interventions, despite evidence of ongoing hospice involvement. Additionally, a resident with hepatic encephalopathy and a stage 4 pressure ulcer had no updated care plan following an interdisciplinary team (IDT) meeting with her mother, nor documentation of interventions related to wound care and family involvement. Interviews with facility staff, including the administrator, DON, ADON, social worker, and wound care nurse, revealed confusion and lack of clarity regarding responsibility for care plan completion and updates. Staff cited recent transitions in key positions, such as the DON and MDS nurse, as contributing factors to the deficiency. Despite daily meetings to address care plan issues, the required comprehensive care plans were not completed or updated in accordance with facility policy and regulatory requirements.
Failure to Provide Sterile Tracheostomy Care and Suctioning
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care, including tracheostomy care and suctioning, consistent with professional standards of practice, the residents' care plans, and their preferences. Specifically, staff did not use sterile technique during tracheostomy care and suctioning for two residents with tracheostomies. Observations and video evidence showed that multiple nurses, including LVNs and the Interim DON, performed tracheostomy suctioning and care without sterile gloves or proper sterile technique. In some cases, staff did not change gloves or perform hand hygiene between procedures, and sterile supplies were reportedly unavailable at times. The facility's own policy required sterile technique for these procedures, but this was not followed. One resident, a male with tracheostomy status and dependent on staff for all ADLs, exhibited signs of respiratory distress, including abdominal retractions and audible gurgling. Despite a family member's request, an LVN refused to reassess the resident or provide tracheal suctioning, arguing with the family member and leaving the room without performing the necessary care. The resident was later found to have bacteremia and was transferred to the hospital. Another resident with anoxic brain damage and acute respiratory failure, also dependent for all ADLs and with a tracheostomy, was observed receiving tracheostomy care from an RN who contaminated her sterile gloves and continued the procedure without reapplying them, using non-sterile supplies and breaking sterile field throughout the process. This resident had a history of recurrent pneumonia and was being treated for an active infection at the time. Additionally, the facility failed to provide competency check-offs for several nurses on tracheostomy care and suctioning, and there was no evidence that all staff had been educated on the required sterile technique. Interviews with staff confirmed a lack of consistent sterile supplies and incomplete training. The facility's failures were identified through observations, interviews, record reviews, and video evidence, and were found to be inconsistent with both facility policy and professional standards of practice.
Failure to Maintain Infection Control Program and Use Sterile Technique
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple instances where staff did not follow sterile technique during tracheostomy care and suctioning, and did not use enhanced barrier precautions as required. Observations and video reviews revealed that several nurses and CNAs performed tracheostomy care and suctioning on residents with tracheostomies without using sterile gloves or maintaining a sterile field, despite facility policy and standard clinical guidelines requiring sterile technique for these procedures. In some cases, staff touched non-sterile surfaces or equipment and continued with the procedure without changing gloves or performing hand hygiene. Additionally, staff did not consistently wear gowns or other PPE required for enhanced barrier precautions when providing care to residents with indwelling devices, wounds, or infections. Interviews with staff and review of records indicated that there was confusion and inconsistency regarding the use of sterile technique and enhanced barrier precautions. Some staff members reported that PPE and sterile supplies were not always available, and in such cases, they proceeded with care without the required equipment. The Interim DON and other staff acknowledged that they sometimes performed procedures without proper PPE or sterile supplies due to unavailability. Furthermore, not all staff were able to demonstrate knowledge of how to access PPE and sterile supplies, and some staff had not received adequate training or competency checks on infection control practices, including tracheostomy care and enhanced barrier precautions. The residents involved included individuals with complex medical needs, such as tracheostomies, feeding tubes, Foley catheters, wounds, and active infections. For example, one resident with a tracheostomy and multiple indwelling devices was observed receiving care without sterile technique or enhanced barrier precautions, and another resident with a Foley catheter and wound was cared for by CNAs who did not wear gowns as required. Medical records showed that several residents had active infections, including pneumonia, bacteremia, and catheter-associated urinary tract infections, and some had been recently hospitalized for these conditions. The facility's failure to follow its own infection control policies and procedures was confirmed through interviews, record reviews, and direct observation.
Removal Plan
- RN/DON A, Regional Nurse Consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one.
- RN/DON A was serviced by Facility Respiratory Therapist with documented competencies on file at the facility and kept in binders in the DON's office and Administrator's office.
- Nursing staff will be in-serviced on the proper procedure for enhanced barrier precautions and the policy and procedure for enhanced barrier precautions.
- All nursing staff will be in-serviced prior to them arriving to the facility for their next shift.
- The Director of Nursing, Regional nurse consultant, and VP of Clinical Operations will deliver all following in service education to nurses one on one.
- All facility staff will receive training on enhanced barrier precautions.
- Any staff who did not receive training on enhanced barrier precautions will receive this education prior to their next scheduled shift on the floor caring for residents.
- Residents #2, #3, #4, and #5 were assessed for complications and are currently being treated with antibiotics for active infections. The Interim DON performed new assessments for residents 3, 4, and 5.
- All nurses will be trained in suctioning and care of tracheostomy per sterile technique and suctioning of tracheostomy by RN/DON A who has been trained by the facility respiratory therapist and by the facility respiratory therapist.
- All nurses will be trained before they accept residents for their next scheduled shift.
- All nursing staff will be in-serviced prior to them arriving at the facility for their next shift.
- All facility staff will receive training on enhanced barrier precautions.
- Any staff who did not receive training on enhanced barrier precautions will receive this education prior to their next scheduled shift on the floor.
Failure to Timely Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse or mistreatment were reported immediately, as required by federal and state regulations. Specifically, an incident occurred in which one resident verbally threatened another resident, stating she would push her out of a window as she had done to a family member. This threat was overheard by staff, including Human Resources, who reported the incident to the facility Administrator, who also served as the abuse coordinator. Despite being informed of the threat, the Administrator did not document the incident or report it to the Health and Human Services Commission (HHSC), as required. The residents involved had significant medical and psychosocial histories. The resident who was threatened was severely cognitively impaired, dependent on staff for most activities of daily living, and had a history of anxiety and bipolar disorder. The resident making the threat was cognitively intact but had a history of bipolar disorder, depression, anxiety, and was known to refuse care. Staff interviews confirmed that the threatening resident had a pattern of verbally abusive behavior toward the other resident, and that this specific incident was reported to the Administrator immediately after it occurred. Despite the facility's written policy requiring immediate investigation and reporting of abuse allegations, the Administrator only contacted the Ombudsman and separated the residents, but did not fulfill the obligation to report the incident to HHSC. The Ombudsman also advised that the incident should be reported to HHSC. The lack of timely reporting and documentation of the abuse allegation constituted a failure to follow established procedures and regulatory requirements.
Failure to Develop and Implement Comprehensive Care Plan for Foley Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with an indwelling Foley catheter and leg band strap stabilizer. Despite the resident's medical history of acute kidney failure and neuromuscular dysfunction of the bladder, and being dependent on staff for all activities of daily living, the care plan did not address the presence of the Foley catheter or the need for securement. Multiple observations over several days confirmed that the resident's Foley catheter was not secured to his leg, and no securement device was in use, despite physician orders for catheter care and the use of a leg strap. Interviews with facility staff, including the Administrator, MDS Coordinator, ADON, and interim DON, revealed that the care plan was not updated to reflect the resident's current needs. Staff acknowledged that the care plan should have included the Foley catheter and its securement, and that comprehensive care plans were not being consistently completed or updated. The facility's policy required care plans to be developed and implemented within specific timeframes, but this was not followed for the resident in question.
Failure to Secure Foley Catheters for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with indwelling Foley catheters received appropriate treatment and services to prevent urinary tract infections. For both residents, observations on multiple occasions revealed that their Foley catheters were not secured to their legs, and no securement devices were in place as required by physician orders and facility policy. Documentation indicated that staff had marked the securement device as checked and in place on the treatment administration records, despite direct observations to the contrary. One resident, a male with neuromuscular dysfunction of the bladder and dependent on staff for all activities of daily living, had a care plan that did not address securing his Foley catheter. His physician orders specified Foley catheter care every shift and allowed for the use of a leg strap to secure the tubing. However, video evidence showed that his catheter was not secured during an observation. The treatment administration record indicated daily checks, but these were not consistent with the actual condition observed. The second resident, also a male with acute kidney failure and neuromuscular dysfunction of the bladder, was similarly dependent on staff and had an indwelling catheter. His care plan did not mention the catheter, and observations on several dates showed his Foley catheter was not secured. Staff interviews confirmed that nurses were responsible for ensuring catheters were secured, but the lack of securement was overlooked. The facility's policy required catheters to be secured with a leg strap to prevent movement and reduce infection risk, but this was not followed for these residents.
Failure to Update Care Plan for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident with a stage 4 pressure ulcer, dementia, and multiple sclerosis. The resident's care plan was not updated to reflect the completion of vitamin C, multivitamin with minerals, and zinc supplements, which were initially prescribed for wound care. This oversight was identified during a review of the resident's records, which showed no current physician orders for these supplements, despite their importance in managing the resident's skin integrity issues. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility had a protocol for supplements related to wound care, which required re-evaluation after 90 days. However, the care plan was not updated to reflect the discontinuation or reinstatement of the supplements. The DON acknowledged the importance of updating care plans for accuracy and to ensure they matched each resident's needs. The Administrator also emphasized the need for care plans to be updated quarterly and as needed to communicate changes in residents' needs effectively.
Failure to Maintain Proper Wound Care for Resident
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of pressure injuries for a resident with a stage 4 pressure ulcer on the sacrum. The resident, who was severely cognitively impaired, had a physician's order for specific wound care, including cleansing with normal saline or wound cleanser, applying collagen powder, packing with kerlix dampened with Dakin's solution, and covering with a foam dressing daily and as needed for saturation or dislodgement. However, during an observation, the resident was found without a dressing on the sacral wound, and the treatment nurse acknowledged that the dressing should be changed if it became wet. The resident reported that the night shift staff removed the dressing when it was wet but did not apply a new one. Interviews with the wound care doctor and the Director of Nursing (DON) revealed that there was an expectation for nurses to reapply a dressing if it became soiled or wet to prevent bacteria and soilage from entering the wound. The DON stated that if a dressing became saturated or dislodged, CNAs should report it to the nurses, who should then change or reapply the dressing promptly. The facility did not have a specific policy regarding physician orders, and the comprehensive care plan policy indicated that qualified staff should be notified of their roles and responsibilities for carrying out interventions specified in the care plan.
Inadequate Hand Hygiene Practices by Treatment Nurse
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of a Treatment Nurse during wound care and incontinent care for two residents. The Treatment Nurse did not consistently perform hand hygiene between glove changes while providing care to the residents. Specifically, during the care of the first resident, the nurse changed gloves multiple times without performing hand hygiene, even after handling potentially contaminated areas and applying various treatments. Similarly, while caring for the second resident, the nurse again failed to perform hand hygiene between glove changes, despite handling wounds and applying dressings. Interviews with the Treatment Nurse, the Director of Nursing (DON), and the Administrator revealed a lack of adherence to the facility's infection control policies. The Treatment Nurse acknowledged the importance of hand hygiene but incorrectly believed that gloves provided complete protection against contamination. The DON and Administrator both expressed expectations for staff to perform hand hygiene before, during, and after resident care, and between glove changes, to prevent the transfer of germs and bacteria. The facility's policy emphasized the importance of hand hygiene as part of standard precautions, yet these practices were not consistently followed by the staff involved.
Inaccurate MDS Assessments for Dialysis and Ventilator Use
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for four residents, which could potentially impact the care and services they receive. Residents with end-stage renal disease, who were dependent on dialysis, were not accurately coded in their quarterly MDS assessments. Specifically, two residents had physician's orders for dialysis treatments three times a week, yet their MDS assessments indicated they had not received any dialysis during the observation period. Interviews with these residents confirmed their regular attendance at a dialysis center. Additionally, two other residents with traumatic brain injury and chronic respiratory failure were incorrectly coded as receiving ventilator therapy in their comprehensive MDS assessments. However, physician's orders and observations revealed that these residents were receiving humidified oxygen therapy via a tracheostomy collar, with no ventilator present in their rooms. Interviews with facility staff, including a Registered Nurse Consultant and an LVN MDS Nurse, confirmed the inaccuracies in the MDS coding, attributing them to the previous MDS Nurse who was no longer employed at the facility. The facility's policy on MDS 3.0 Completion, which emphasizes the importance of accurate and comprehensive assessments, was not adhered to in these cases. The RAI Version 3.0 Manual outlines the significance of correctly coding special treatments and procedures, as they can significantly affect a resident's health status and quality of life. The failure to accurately code these assessments could place residents at risk of not receiving the appropriate care and services necessary for their well-being.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for three residents, leading to deficiencies in medication administration. For one resident, the physician's order for Vitamin C was incomplete, lacking the specific dosage to be administered. Despite the order being initiated in May 2022, the facility's pharmacy did not address this incomplete order in their reviews for several months, resulting in the resident receiving an unspecified dose of Vitamin C. Another resident did not receive prescribed medications, including Vitamin B12 and Brimonidine tartrate ophthalmic solution, due to their unavailability. The medications were not found in the medication cart or rooms, and the resident missed multiple doses as documented in the Medication Administration Record (MAR). Additionally, the resident did not receive a scheduled dose of Latanoprost ophthalmic solution, further indicating a lapse in medication management. A third resident continued to receive an antibiotic beyond the intended stop date due to the absence of a stop order. The nurse responsible for transcribing the orders admitted to not reading the hospital discharge summary and failing to obtain a stop date from the hospital physician or medical director. This oversight was acknowledged by the facility's staff, including the Director of Nursing, who confirmed that all antibiotics should have a stop date according to facility policy.
Inaccurate PASRR Screenings for Residents with Mental Health Disorders
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASRR) Level 1 screenings for two residents with mental health disorders. Resident #36, a female with diagnoses including bipolar disorder, anxiety disorder, depression, and seizures, was admitted with a PASRR Level 1 Screening that did not indicate a serious mental illness, despite her medical history and medication use suggesting otherwise. Her Minimum Data Set (MDS) assessments consistently showed diagnoses of depression and bipolar disorder, and she was receiving antidepressants and anxiolytic medications. Similarly, Resident #57, a female with bipolar disorder and anxiety disorder, was admitted with a PASRR Level 1 Screening that also failed to indicate a serious mental illness. Her MDS assessments revealed severely impaired cognition and diagnoses of depression and bipolar disorder, yet she had not received antipsychotic or anxiolytic medications during the assessment period. The MDS nurse acknowledged the inaccuracies in the PASRR screenings and noted that the responsible staff member was no longer employed at the facility, indicating a lapse in the review process.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a 9 percent error rate. This was observed during a medication administration review involving two residents. One resident, a female with multiple diagnoses including epilepsy and atrial fibrillation, received Vitamin C without the dose being verified by the medication aide. The physician's order for Vitamin C was incomplete, lacking the specific dosage, which the aide failed to notice. The aide admitted to not following the basic rights of medication administration, which include verifying the correct dosage. Another resident, a female with protein calorie malnutrition and glaucoma, did not receive her prescribed Vitamin B12 and Brimonidine ophthalmic solution during a medication pass. The RN responsible for administering the medications reported that these were not available in the facility's supply and could not be located. The RN was advised to contact the physician for dose verification and the pharmacy for immediate delivery of the missing medications. The facility's policies emphasize the importance of timely medication administration and adherence to the six rights of medication administration, which were not followed in these instances.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during medication administration for a resident with a gastrostomy tube. RN D was observed using a syringe that had been on the floor of the resident's room to administer medications and water through the gastrostomy tube. The syringe was initially sealed in a plastic bag, which RN D picked up from the floor, opened, and used without changing gloves or performing hand hygiene after handling the contaminated bag. The syringe plunger was placed on the contaminated plastic bag during the process, further compromising its sterility. The resident involved was an elderly female with a gastrostomy tube, protein calorie malnutrition, hypertension, heart failure, and dysphagia. RN D's actions, including using a contaminated syringe and failing to adhere to safe injection and medication administration practices, placed the resident at risk for exposure to communicable diseases and infections. The facility's policies on infection prevention and control and care of feeding tubes were not followed, as RN D did not use infection control precautions to minimize contamination risk.
Failure to Obtain Laboratory Services for Resident
Penalty
Summary
The facility failed to provide or obtain laboratory services as ordered by a physician for one resident, which could place residents at risk of not receiving necessary treatment. The resident, a male with a history of Type 2 diabetes mellitus, diabetic neuropathy, peripheral vascular disease, lack of coordination, and muscle weakness, had a physician's order for a urinalysis (UA) with culture and sensitivity to rule out a urinary tract infection. However, there was no documentation of the UA results in the resident's electronic health records, indicating that the laboratory services were not completed as required. Interviews with facility staff revealed that the UA was ordered but not documented, and there was uncertainty about whether the lab company picked up the sample. The facility was transitioning to a new lab company at the time, which may have contributed to the oversight. The VP of Clinical Operations confirmed the absence of UA results in the resident's chart and noted that the previous Director of Nursing (DON) was responsible for ensuring lab orders were completed. The facility's policy requires timely laboratory services and proper documentation, which was not adhered to in this case.
Facility Fails to Employ Full-Time Social Worker
Penalty
Summary
The facility, with a capacity of 172 beds, failed to employ a qualified social worker on a full-time basis since May 10, 2024. This deficiency was identified during a record review and interviews conducted on July 10, 2024. The absence of a qualified social worker could potentially affect residents in need of social services, placing them at risk of psycho-social decline and a poor quality of life. The facility's policy mandates that a facility with more than 120 beds must employ a qualified social worker full-time, which was not adhered to in this case. Interviews with the facility's Administrator, Director of Nursing (DON), Regional Director of Operations, and HR Director confirmed that the last social worker left the facility on May 10, 2024, and no replacement had been hired. The DON attempted to fulfill some of the social worker's responsibilities but was not licensed to do so. The facility had been using the DON and Administrator to meet the social work needs, which is not in compliance with the requirement for a qualified social worker. The facility's policy on social services, dated July 2022, outlines the responsibilities of a social worker, including advocating for residents, assisting with grievances, and providing or arranging for mental and psychosocial counseling services. Despite attempts to hire a new social worker, as evidenced by job postings on Indeed, the facility had not succeeded in filling the position, leaving a gap in the provision of essential social services to residents.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, a CNA physically abused a resident by slapping her arm, which resulted in a large bruise. The resident, who had severe cognitive impairment and multiple medical conditions, reported the incident, and the facility's investigation confirmed the abuse. The CNA was terminated and arrested by the police. The resident involved had a history of severe cognitive impairment, hypothyroidism, dysphagia, diabetes, mild protein-calorie malnutrition, high blood pressure, muscle weakness, lack of coordination, heart failure, and anxiety. She required substantial assistance with daily activities and was dependent on staff for toileting. The resident reported that the CNA slapped her arm when she was trying to show that her brief did not fit properly, resulting in a large bruise on her left forearm. Interviews with other staff members confirmed that hitting a resident is considered abuse and is unacceptable under any circumstances. The facility's acting DON and Administrator acknowledged the incident as abuse and stated that it would not be tolerated. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents' health, welfare, and rights, and prohibits any form of abuse.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation when a resident alleged that an LVN slapped at her hand and cursed at her during wound care. The resident, who had moderate cognitive impairment and multiple medical conditions including COPD, dysphagia, and chronic pain, reported the incident to her family member, who then informed the facility. The facility's investigation included interviews with the resident, the LVN, and other residents, but the investigation was terminated prematurely based on the resident's alleged denial of the incident, which she later contradicted in an interview with the surveyor. The resident consistently reported that the LVN had slapped at her hand and cursed at her during wound care, causing her discomfort and emotional distress. Despite this, the facility's investigation concluded without thoroughly addressing the resident's consistent statements. The LVN was briefly suspended but returned to work within 30 minutes, and the social worker's safety surveys, which indicated negative responses from other residents, were not fully considered in the investigation. Interviews with other residents and staff did not reveal any additional instances of abuse or neglect by the LVN, but the facility's failure to thoroughly investigate the initial allegation and consider all evidence, including the social worker's findings, resulted in an incomplete investigation. The facility's policy on abuse, neglect, and exploitation requires a comprehensive investigation, which was not fully adhered to in this case.
Failure to Provide Ordered Wound Care and Report Changes in Condition
Penalty
Summary
The facility failed to provide wound care to a resident's right lower extremity stump as ordered, resulting in infection and surgical debridement to rule out osteomyelitis. The resident, who had a history of morbid obesity, diabetes, and congestive heart failure, was readmitted to the facility with a right leg amputation and other conditions. Despite physician orders for daily wound care, the treatment was inconsistently performed, leading to a worsening of the wound and subsequent infection. Additionally, the facility failed to report redness on the resident's abdomen to the Nurse Practitioner or Wound Care Physician, resulting in hospitalization for cellulitis and panniculitis requiring intravenous antibiotics. The resident's care plan included interventions for skin integrity and infection, but these were not adequately followed. The lack of proper wound care and failure to report changes in the resident's condition contributed to the resident's hospitalization and need for further medical intervention. The facility also failed to document wound care assessments per its policy, which required weekly assessments and documentation of wound treatments. Interviews with staff and record reviews revealed that the facility had not had a treatment nurse for months, and wound care was not performed as ordered. This lack of documentation and communication with healthcare providers led to an Immediate Jeopardy situation, which was later addressed by the facility's corrective actions.
Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to ensure that a resident with a urinary catheter received appropriate treatment and services to prevent urinary tract infections and pain. Specifically, the urinary catheter bag of a resident was observed lying on the floor on multiple occasions. The resident, who was cognitively intact and had a BIMS score of 15, reported that she could not reach the catheter drain bag to hang it on the bed and that a staff member had stepped on the bag, causing it to burst. The facility's policies on indwelling catheter use and infection prevention were not followed, as the catheter bag was not kept off the floor, which is essential for infection control and preventing damage to the bag. Interviews with the ADON, CNA, DON, and Administrator confirmed that the catheter bag should not be on the floor and should be positioned below the level of the bladder to prevent infection and damage. Despite these expectations, the catheter bag was found on the floor, indicating a lapse in adherence to the facility's policies and procedures. The facility's failure to maintain proper catheter care placed the resident at risk for infection and other complications.
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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