Avir At Rose Trail

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store, prepare, distribute, and serve food under sanitary conditions in the main kitchen. During observation, a half-size stainless steel sheet pan on the pan rack next to the prep sink was heavily caked with black carbon and burned black, and the DM stated it was the emergency pan and could still be used for baking potatoes. The microwave was observed to be soiled inside with food splatters and food debris. In the dry pantry, a 16 oz. bag of potato chips was open and placed inside an opened zippered bag, and a bulk sugar bin contained a 4 oz. plastic dessert cup in the sugar. In the walk-in cooler, one 46-oz. container of nectar thick sweetened tea was opened but not marked with an open date, despite the packaging stating it could be kept up to 7 days under refrigeration after opening. On return observation the next day, the same dry pantry issues were still present, including the open potato chips bag inside an opened zippered bag, the dessert cup in the sugar bin, and the unmarked opened nectar thick sweetened tea container. During interview, the DM stated staff were to re-close and seal food packages placed in zippered bags, not leave scoops inside bulk bins, and date items when opened.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an infection prevention and control program for 3 of 3 residents reviewed for infection control. Resident #72 had Enhanced Barrier Precautions (EBP) signage and PPE available at the room entrance, but on observation CNA E and CNA F entered the room to provide ADL care without sanitizing their hands before entry and without donning gowns. During interview, both CNAs stated they did not put on gowns to provide care because the resident did not like it when they wore gowns, although both had previously signed the Staff - Enhanced Barrier Questionnaire dated 10/3/2025. Resident #72 stated she never told any CNA not to wear a gown and said she was not okay with them not wearing one. RN D was observed providing care to Resident #5, who was on isolation/EBP, and was cleaning around the tracheostomy site without wearing a mask or gown despite EBP signage and PPE being present at the room entrance. RN D was also observed providing enteral feeding to Resident #62 without wearing a mask or gown, again despite EBP signage and PPE being available. During interview, RN D stated she did not notice she had not put on a gown for either resident but was aware of the EBP and what she should have done when providing care. The EBP signage specified gown and glove use for care activities including device care or use such as feeding tubes and tracheostomy care, and the facility’s EBP policy dated 03/2024 stated that targeted gown and glove use is required in addition to standard precautions during high-contact resident care activities.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to treat a resident with respect and dignity when an LVN handled the resident’s oxygen nasal cannula in a rough and abrupt manner during care. The resident was a moderately cognitively impaired female with diagnoses including atrial fibrillation, vasomotor rhinitis, muscle weakness, monoplegia of the lower left limb, acute respiratory failure with hypoxia, schizophrenia, mood disorders, acute kidney failure, and hypertension. Her care plan directed that she be cared for with dignity and that interventions promote safety, well-being, and a positive self-image. The resident stated that the charge nurse came into her room to change her nasal cannula and abruptly hit the bed with the tubing, which she said coincidentally struck her on the nose above her lip. She reported that the LVN appeared frustrated, that the action hurt, and that it made her feel the nurse did not want to care for her. The resident said the incident was witnessed by a CNA and her roommate, and that both reported it to the RN weekend supervisor. She also stated that the LVN later returned and apologized, saying she had been stressed and very busy, and the resident denied any injury beyond momentary discomfort but said she felt disrespected. The roommate confirmed the interaction described by the resident and said it was reported to the RN weekend supervisor. The CNA stated the resident requested a replacement nasal cannula, that the LVN responded the resident could get it later, and that when the LVN later entered the room she snatched the old cannula off the oxygen concentrator and flung it onto the bed before placing the new cannula on the resident and walking out. The RN weekend supervisor stated the LVN refused to give the resident the cannula and described the LVN as mean, rude, and tired of her attitude. The day shift RN, ADON, and Administrator each stated staff should not appear frustrated or irritated during resident care, and the Administrator said this was the first time she had learned of the incident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with diagnoses of schizophrenia and depression had an accurate PASARR Level 1 Screening. Record review showed the resident was admitted with these psychiatric diagnoses, had a BIMS score of 0 indicating severely impaired cognition, and the MDS listed depression and schizophrenia as active diagnoses. However, the PASARR section of the admission MDS indicated the resident did not have a serious mental illness, and the PASARR Level 1 Screening completed by the referring entity on 06/24/2025 also stated that the resident did not have evidence of mental illness. The record also included psychoactive medication consents for Depakote, Sertraline, and Olanzapine, with Olanzapine identified as an antipsychotic used to treat schizophrenia. Physician orders current as of 12/03/2025 included Sertraline for depression and Olanzapine for schizophrenia. During interviews, the MDS nurse stated the PASARR Level 1 Screening should have indicated depression and schizophrenia, the ADM stated residents with psychiatric diagnoses should have a completed PASARR Level 1 Screening reflecting those diagnoses, and the interim DON stated the facility did not have a policy on the PASARR screening process and followed federal and state guidelines.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a baseline care plan within 48 hours of admission and failed to provide the resident and/or the resident representative with a summary of that baseline care plan for Resident #90. Review of the resident’s face sheet and physician’s orders showed that Resident #90 was a [AGE] year-old female admitted on [DATE] with diagnoses including schizophrenia, mild neurocognitive disorder, and cognitive communication disorder. Review of the electronic record on 12/01/2025 showed no documentation of a baseline care plan for the resident. During an interview on 12/03/2025 at 11:10 AM, the VP of Clinical Operations stated the baseline care plan was not present in the clinical record for Resident #90 and said it was not done. She stated the baseline care plan should have been initiated when the resident admitted to the facility on [DATE] and completed on 11/28/2025. She also stated the RN in charge, usually the DON, should initiate the baseline care plan, the interdisciplinary team should add to it, and then it should be presented to the resident and/or responsible party for review and signature, with documentation in the clinical record. A facility policy titled Care Plans - Baseline, revised March 2022, stated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission, that the resident and/or representative are provided a written summary of the baseline care plan, and that provision of the summary is documented in the medical record.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for Resident #34 that included measurable objectives and time frames related to sexually inappropriate behavior. Resident #34 was a male admitted with diagnoses including senile degeneration of brain, weakness, and unspecified lack of coordination, and his quarterly MDS reflected a BIMS score of 10, indicating mild cognitive impairment. The care plan dated 8/14/2024 and revised 10/17/2025 did not include any indication of sexually inappropriate behavior or any interventions for that behavior. The record contained progress notes documenting inappropriate behavior. A note dated 11/26/2024 stated Resident #34 was noted with multiple complaints of sexual inappropriateness, and a note dated 11/03/2025 stated the SW spoke with him about inappropriate touching of staff and provided education. During interviews, multiple staff members stated they were aware of his inappropriate behavior and described interventions such as close observation, redirection, notifying the physician and family, and providing education. The ADON, SW, ADM, and MDS nurse each stated that the behavior should have been care planned. The facility also failed to include Resident #71’s enteral feeding status in the comprehensive care plan. Resident #71 was a male with diagnoses including GERD without esophagitis and oropharyngeal dysphagia, and his quarterly MDS reflected a BIMS score of 0, indicating severely impaired cognition. The MDS showed he was dependent for all functional abilities and used a feeding tube for nutritional approaches. Physician orders included enteral feed every shift related to attention to gastrostomy, and the MAR showed Jevity 1.5 via gastrostomy tube, down time, flushes, and enteral site care each shift. The care plan dated 06/24/2025 and revised 10/16/2025 did not indicate his enteral feeding status, and staff including the treatment nurse, DON, and MDS nurse stated it should have been included.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Resident #60, who was admitted with a diagnosis of respiratory failure and had an intact BIMS score of 15, had a physician order for oxygen at 2 LPM as needed for shortness of breath to keep oxygen saturation above 92%. Her care plan also directed oxygen at 2 LPM as needed to keep oxygen saturation above 92%. However, during observations on three consecutive days, Resident #60 was found receiving oxygen via nasal cannula at 3.5 LPM instead of the ordered 2 LPM. During an interview, Resident #60 stated she wore oxygen all the time, did not adjust the settings herself, and could not reach the oxygen concentrator from the bed to change the controls, relying on nurses to regulate the oxygen settings. The resident’s December 2025 NMAR had a section for oxygen saturation and oxygen administration, but it was blank. Review of the October 2025 and November 2025 NMARs also showed no documentation of oxygen saturation checks or oxygen therapy administration. The Treatment Nurse stated nurses were responsible for monitoring oxygen therapy and checking settings during rounds, and the President of Clinical Operations stated charge nurses were responsible for monitoring oxygen administration and documenting oxygen saturation checks and oxygen administration on the NMAR. The facility’s Oxygen Administration Policy required assessment of oxygen saturation, adjustment of the oxygen delivery device to the proper flow, and documentation of the date, time, flow rate, route, rationale, frequency, and duration after oxygen setup or adjustment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 5 residents reviewed for pharmacy services. Resident #61 had diagnoses including end stage kidney disease and GERD, and Resident #74 had epilepsy and severe cognitive impairment. Both residents had physician orders for scheduled medications: Pantoprazole 40 mg twice daily for Resident #61 and Tegretol 300 mg twice daily for Resident #74. During medication administration observation, MA-A found that neither resident had the ordered medication available in the medication cart. She checked the overflow cart for each medication and did not find either one. After not locating the medications, she returned to her cart and continued preparing medications for other residents rather than notifying the nurse at that time. MA-A later documented that she had administered Pantoprazole to Resident #61 and Tegretol to Resident #74, even though she had not had the medications available when she first checked. Interviews showed MA-A said she did not tell the nurse that the medications were unavailable and could not explain why she documented them as given. LVN-C stated the medication aide was supposed to notify the charge nurse when a medication was not available, and that the charge nurse would check the secure medication cabinet or contact pharmacy if needed. LVN-C later found Resident #74's Tegretol in the medication room and obtained Resident #61's Pantoprazole from emergency supply, then said the physician was informed and instructed administration. The facility's policy required medications to be administered according to prescriber orders and for the administering individual to initial the MAR after giving each medication.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to keep the medication error rate below 5 percent, with 2 errors out of 27 opportunities for a 7 percent error rate involving two residents. Resident #61 had diagnoses including end stage kidney disease and GERD, and her physician orders included pantoprazole 40 mg twice daily. During medication administration observation, MA-A did not have pantoprazole available in the medication cart, checked the overflow cart, did not find it there, and then moved on to prepare medications for another resident without notifying the nurse that the medication was unavailable. Resident #74 had a diagnosis of epilepsy and physician orders for Tegretol 300 mg twice daily. During the same medication pass observation, MA-A did not have Tegretol available in the medication cart, checked the overflow cart, did not find it there, and then continued preparing medications for other residents without informing the nurse. LVN-C later stated she had not been informed that either resident had missed a scheduled medication, and the President of Clinical Operations stated medication aides were expected to notify the charge nurse when a medication was not available for administration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident with epilepsy was free from a significant medication error when the scheduled Tegretol dose was not available at the medication cart and was not promptly obtained or administered. Resident #74 had diagnoses including epilepsy, was severely cognitively impaired with a BIMS score of 5, was non-ambulatory, and was dependent on staff for most activities of daily living. The physician order required Tegretol 300 mg, one tablet twice daily at 9:00 AM and 5:00 PM to help prevent seizures related to epilepsy. During medication administration observation, the medication aide stated the resident did not have Tegretol tablets in the medication cart and checked the overflow cart without finding any. After that, the medication aide returned to the cart, stated she did not have any Tegretol, and began preparing medications for other residents. The charge nurse was not informed that the medication was unavailable, and the medication was not administered until after surveyor intervention, at 11:50 AM, which was 2 hours and 50 minutes after the scheduled 9:00 AM time. The facility's policy stated medications are to be administered in accordance with prescriber orders, including any required time frame.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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.