Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At San Antonio during CMS and state inspections, most recent first.
Incomplete Comprehensive Care Plans for Multiple Residents The facility failed to develop and implement comprehensive person-centered care plans for multiple residents with varied medical and psychosocial needs. One resident had no comprehensive care plan despite severe cognitive impairment and multiple diagnoses, while others had care plans that were incomplete or limited to narrow issues such as wounds, falls, or oxygen therapy. A resident with amputations reported problems getting evening snacks, and another resident’s plan lacked interventions or tasks despite severe impairment and complex care needs. The MDS Coordinator and DON stated comprehensive care plans are used to guide resident care and should be completed within required timeframes.
Failure to Report Alleged Abuse Within Required Timeframe: A resident-to-resident altercation was reported to HHS after the required 2-hour timeframe had passed. The ADM confirmed responsibility for HHS reporting and acknowledged that alleged abuse must be reported within 2 hours, but the provider investigation report showed the incident was submitted late.
Failure to Revise Care Plan After Behavioral Change: A resident with Alzheimer's disease and moderate cognitive impairment was involved in a resident-to-resident altercation, but the care plan was not updated to reflect the incident. The MDS Coordinator and DON stated care plans should be revised when there is a change in condition or behavior, and both agreed the resident's plan should have been updated after the altercation.
A resident with major depressive disorder and intact cognition had 2 pills left on her bedside table after medication administration. The resident said the meds were hers and she still needed to take them. The CMA stated the meds were left in the room during a transfer and acknowledged staff were supposed to watch her take them. An LVN and the DON stated staff should have observed the resident swallow all medication, and the facility policy required ensuring the customer swallows all medication(s).
A resident with an indwelling urinary catheter was observed with the catheter bag and tubing on the floor under the bed. The resident said staff had been in the room earlier and had transferred her to the bed, and staff interviews confirmed the bag and tubing should be secured to the bed, kept below the bladder, and kept off the floor. The DON also stated the bag and tubing should never touch the floor, and the facility policy required them to be kept off the floor.
A resident with multiple complex diagnoses did not have their comprehensive care plan reviewed or updated after both quarterly and annual MDS assessments. The last care plan update was several months prior, and this lapse occurred during a transition between EHR systems and changes in MDS coordinator staffing, despite coordinators having access to necessary records.
A resident with intact cognition and multiple health conditions was found to have ants in her bed, which led to ant bites on her thighs and flank. Staff discovered the ants after the resident reported a crawling sensation, and maintenance identified the source as the AC unit. The incident was documented through skin assessments, progress notes, and photographic evidence, confirming the presence of ant bites and the pest issue in the resident's room.
A resident with multiple neurological conditions was found with ant bites on her thighs and flank after ants were discovered in her bed. Staff documented the incident and the resulting injuries, but the required report to the state survey agency was not made within the mandated timeframe, as confirmed by record review and staff interviews.
Unsafe supervision of resident smoking and smoking while on oxygen. Two residents with smoking privileges were found outside the facility’s smoking rules: one resident was observed smoking unsupervised and at unassigned times, with staff reporting she often had her own cigarettes and lighter, while another resident with COPD and continuous O2 was found smoking in his bathroom while using a nasal cannula and O2 concentrator on two occasions. The facility’s smoking policy required all smokers to be supervised and prohibited O2 equipment in smoking areas, but staff and leadership acknowledged the unsafe smoking behavior and that the incidents involving the resident on O2 were not reported to the state agency.
Failure to attempt GDR for antipsychotic medication: A resident with dementia, major depressive disorder with psychotic symptoms, and severe cognitive impairment remained on olanzapine 5 mg daily, and pharmacy review showed no GDR attempt over several months. The ADON confirmed the resident was on hospice, the medication was continued, and no GDR had been discussed with the hospice nurse, despite facility policy requiring antipsychotic dose reductions and monitoring per CMS guidelines.
A facility failed to report alleged neglect incidents involving two residents who were found smoking unsupervised and outside facility smoking rules. One resident with COPD and other chronic conditions was repeatedly observed smoking on the property with her own lighter and cigarettes, while another resident with COPD and an oxygen order was discovered smoking in his bathroom while on oxygen therapy. Staff and leadership knew about the incidents, but the events were not reported to the State Survey Agency.
A resident with DM and scheduled insulin had a critical glucose result of 40, but nursing documentation did not show assessment, physician notification, or other follow-up, and staff interviews confirmed the result was not acted on until surveyor intervention. In a separate case, an admitting LPN failed to transcribe transfer orders for yearly labs, adverse-effect monitoring for psychotropic and anticonvulsant meds, and assistance with an eye patch for a legally blind resident; the ADON and NP were unaware of the orders, and the resident had not used the eye patch at the facility.
Failure to Notify Practitioner of Critical Glucose Result: A resident with DM who was receiving insulin had a critical glucose lab value of 40 reported to an LVN, but there was no documentation that the NP, ADON, DON, or RP were notified. The record lacked evidence of an assessment, SBAR, or other response to the critical result, and interviews confirmed the NP and nursing leadership were unaware of the finding until surveyor intervention.
Improper Dumpster Waste Disposal: The facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed. Surveyors observed a large steel dumpster with the sliding doors open, a 30-gallon bag of trash placed beside the dumpster, and scattered trash around the dumpster area. The HK manager stated the dumpster was used by dietary, nursing, and housekeeping staff, and that all trash was expected to be placed in the dumpster with the doors closed when not in use.
Failure to Notify Physician of Critical Blood Sugar Result: An LVN received a critical lab showing a resident’s blood sugar was 40, but there was no documentation that he assessed the resident, notified the NP, completed an SBAR, or informed the ADON, DON, or responsible party. The resident had DM and was receiving insulin, yet the care plan did not reflect those needs. Interviews with the NP, LVN, ADON, and DON confirmed the expected notifications and actions were not documented or recalled.
MDS Did Not Reflect Resident’s Weight Loss: A resident with moderate cognitive impairment and total ADL dependence had a quarterly MDS that did not include her recent weight loss, even though her care plan documented significant unplanned weight loss related to poor food intake. During observation, she was eating lunch and said she did not like the food and had family bring takeout. The MDS coordinator stated the assessment needed to accurately reflect the resident’s status so staff would be on the same page about her weight loss and related interventions.
A resident with osteomyelitis, multiple wounds, a Foley catheter, MRSA wound infection, diabetes, and bed-bound status was admitted with extensive care needs, but the baseline care plan lacked diagnoses, code status, contact isolation, catheter instructions, goals, and interventions. Staff could not produce a complete plan during the survey, and the DON and ADON stated the facility did not have a baseline care plan policy and followed the RAI manual.
Incomplete Care Plans for ADL Dependence and Diabetes Management: The facility failed to develop comprehensive person-centered care plans for two residents. One resident’s care plan did not include her dependence on staff for all ADLs despite MDS findings and staff-assisted care, and another resident’s care plan did not include DM or regular insulin use despite MDS and MAR/flowsheet documentation showing scheduled and sliding-scale insulin. The MDS Coordinator/LVN stated the care plan should include all problem areas so staff would be on the same page and residents would receive needed care and services.
Failure to apply ordered splint for a resident with right-hand contracture. A resident with vascular dementia, severe cognitive impairment, and ROM impairment had a care plan and OT plan calling for a right-hand splint as tolerated to help reduce progression of contracture and support joint alignment. However, staff observations over several days showed the resident without a splint or hand roll, staff reported they had not seen her wear one, and the DON stated the resident had refused it, while the resident later nodded yes when asked if she was willing to wear it.
Expired thickened orange juice was found stored in the kitchen pantry and available for residents. The cook acknowledged the product was past its best-if-used-by date and should not have been stored for service, and the FSM stated the staff member responsible for the pantry failed to ensure foods were within expiration dates.
A resident with a stage 4 sacral pressure ulcer, colostomy, urostomy, and dependence on staff for transfers and personal care was provided high-contact care and transferred without the required EBP gown use. OT and CNA staff were observed wearing gloves but no gowns while assisting with care and moving the resident to a chair, despite a door sign and care plan directing gown and glove use for high-contact activities such as transferring and wound-related care. Both staff later acknowledged they knew the EBP requirement, and the DON confirmed the PPE should have been worn.
A facility failed to keep survey, certification, and complaint investigation results from the previous 3 years available for resident and visitor review. During a resident council meeting, 7 residents said they did not know where to find the survey results, and the survey binder in the lobby contained only the 2023 results. The ADM said she had removed the 2024 results to review with the DON and forgot to put them back.
Disorganized and decentralized resident medical records affected all 92 residents after the facility stopped using its prior EMR and switched to paper charts while waiting for a new system. Staff kept consents, assessments, orders, MARs, and code status records in different locations across the facility, and nurses, CNAs, therapy staff, and medical services providers were observed handling records in multiple areas without centralized charts. Some LVNs reported no formal training on organizing paper charts, and the NP stated the facility had not developed centralized paper charts.
Failure to send discharge notices to the State Ombudsman: The BOM did not provide the Ombudsman with the July discharge list, and the Ombudsman reported receiving notices only through the prior month. The BOM stated she delayed sending the notices because of a company buyout, and acknowledged that facility-initiated discharge notices should be sent at the same time the resident receives the notice so the resident can seek Ombudsman assistance with an appeal.
A resident with intellectual disabilities and communication deficits was discharged without receiving a written transfer notice, a 30-day discharge notice, or documentation of the reason for transfer in the medical record. The responsible party did not receive notification in their primary language, and the ombudsman was not informed of the discharge. Facility staff demonstrated confusion about discharge notice requirements and failed to document whether the discharge was resident- or facility-initiated.
BIMS and PHQ assessments were completed for four residents while they were hospitalized and not present for interview, resulting in inaccurate documentation. A social worker completed these assessments based on direction from the MDS Nurse, despite not interviewing the residents, and the facility lacked a specific policy for resident assessments.
Surveyors found that the facility did not consistently implement Enhanced Barrier Precautions (EBP) for multiple residents with conditions such as colostomies, pressure ulcers, and indwelling catheters. Required signage and PPE carts were often missing from resident rooms, and staff did not always use PPE during high-contact care activities, including invasive procedures like IV insertion, despite care plan directives and facility policy.
Night nurses failed to initial crash cart supply verification sheets on multiple occasions, and a medication aide did not document exact medication administration times for a resident with multiple chronic conditions. These actions resulted in incomplete medical records, contrary to facility policy and professional standards.
Two residents with severe cognitive impairment and complex medical conditions did not receive wound care as ordered due to a lack of re-approach after refusals, failure to communicate missed treatments to other staff, and inadequate documentation by the Treatment Nurse. These actions resulted in scheduled wound care being missed and dressings remaining unchanged, with staff interviews confirming inconsistent communication and follow-through.
A resident with dysphagia was mistakenly given a mechanical soft diet instead of a pureed diet, leading to a choking incident. An agency CNA, unfamiliar with the facility, fed the resident the wrong meal tray. The error was discovered when the resident showed signs of distress, prompting immediate medical intervention. The facility's policy requiring licensed staff to check meal trays was not effectively followed.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing their medical needs. A resident had bed rails without a care plan or orders, while two others had catheters not reflected in their care plans. The facility's policy requires comprehensive care plans, but this was not followed, resulting in inadequate care planning.
The facility failed to assess and document the use of bed rails for three residents, leading to potential safety risks. Staff interviews revealed a lack of awareness and documentation regarding bed rail use, with the DON and Administrator not considering the assistive devices as bed rails.
A LTC facility reported a medication error rate of 62.96%, involving three residents who did not receive medications on time or as prescribed. A resident with myocardial infarction and atrial fibrillation received late medications, another with atrial fibrillation and lymphedema did not receive bumetanide due to a misread order, and a third with depression received an incorrect sertraline dosage. The LVN involved was not familiar with the day shift and did not seek help, leading to these errors.
The facility failed to maintain a safe and sanitary environment in the laundry room due to improper disposal and maintenance of lint in the dryers. Observations revealed thick lint accumulation, and interviews indicated a lack of tracking logs and policies for cleaning lint traps. The laundry aide did not clean the traps as required, posing a potential fire risk.
The facility failed to accurately complete MDS assessments for two residents, leading to potential inadequate care. One resident with severe cognitive impairment and multiple diagnoses had an indwelling catheter not documented in his care plan or MDS. Another resident with heart failure and renal disease was not accurately assessed for dialysis and oxygen therapy on her MDS. The MDS Regional Consultant acknowledged these oversights, highlighting the importance of accurate documentation for staff to meet residents' care needs.
The facility failed to coordinate PASRR assessments for two residents, leading to deficiencies in their care. One resident with dementia and multiple mental health diagnoses was admitted without an accurate PASRR Level 1 Screening, while another resident with dementia and a psychotic disorder lacked an updated screening. These oversights could prevent residents from receiving necessary assessments and specialized services.
The facility failed to update care plans for two residents after significant changes in their conditions. One resident's care plan was not revised after an MDS assessment showed dependency on staff for ADL care, while another resident's care plan was not updated after developing a venous ulcer. Interviews confirmed the care plans did not reflect the residents' current needs, potentially affecting the care provided.
A resident with a history of falls was improperly transferred by CNAs and an LVN who failed to use a gait belt correctly, compromising the resident's safety. The CNAs placed the gait belt over the resident's chest instead of the waist, and the LVN did not use a gait belt at all during a transfer. The facility's policy requires the use of a gait belt around the waist for safe transfers.
The facility failed to provide adequate catheter care for two residents, leading to potential infection risks. One resident's catheter was observed touching the floor and stepped on by staff, while another resident had a catheter without documented physician orders or inclusion in the care plan. Despite the lack of documentation, staff reportedly provided daily care. The facility's policy on incontinent care was not followed.
The facility failed to employ a Dietary Manager with the necessary qualifications and certifications to manage the food and nutrition services. The DM lacked national certification and had only completed a short course before passing the Texas Food Safety Manager Certification Examination. Additionally, the facility's RD was contracted, not a full-time employee, potentially impacting the quality of food service management.
The facility failed to coordinate and document hospice care for two residents, resulting in incomplete Physician Certification of Terminal Illness forms and missing hospice care plans and orders. Staff interviews revealed awareness of these documentation gaps, and the absence of a hospice policy was noted.
The facility failed to maintain an effective infection prevention and control program, as evidenced by a resident's fall mat being visibly stained and an LVN not performing hand hygiene between glove changes during a bolus tube feeding. The facility's policies on infection control and enteral feeding were not adhered to, potentially placing residents at risk for infections.
Incomplete Comprehensive Care Plans for Multiple Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for 5 of 5 residents reviewed. The report states that Resident #1 and Resident #5 did not have comprehensive care plans, while Residents #2, #3, and #4 did not have completed comprehensive care plans that addressed their identified needs. The deficiency was identified through observation, interview, and record review. Resident #1 was an [AGE]-year-old male admitted with diagnoses including sepsis, chronic pain syndrome, type 2 diabetes mellitus without complications, encephalopathy, chronic kidney disease stage 3, and chronic pancreatitis. His admission MDS showed a BIMS score of 1, indicating severe cognitive impairment, and he required minimal to maximal assistance with various ADLs. The record did not show a comprehensive care plan, which was due no later than 05/03/26. Resident #2 was a male with diagnoses including gangrene, bipolar disorder with psychotic features, type 2 diabetes mellitus with diabetic neuropathy, schizophrenia, and bilateral below-knee amputations. His care plan only addressed wound management and did not include instructions for mental health medications and treatment, ADL care, dietary needs, or activities. During observation and interview, he stated his wounds were almost healed, he was receiving double portions, but he still had problems getting evening snacks, and he could get himself to the bathroom without using his call light much. Resident #3 was a male admitted with leukemia in relapse, autoimmune hemolytic anemia, and Alzheimer’s disease with late onset. His admission MDS showed severe cognitive impairment. His baseline care plan included ADLs, communication, dietary orders, and therapy goals, but the comprehensive care plan only included gas exchange related to end-stage disease, fall risk, and a prior fall with no injury. The surveyor was informed that he discharged to another nursing facility on 05/07/26. Resident #4 was a male with hemiplegia and hemiparesis following cerebral infarction, aphasia, dysphagia, obstructive and reflux uropathy, altered mental status, and an acquired absence of the left leg above knee. His MDS indicated severe impairment in daily decision making. The comprehensive care plan found for him contained only a wound management focus with no interventions or tasks listed, and no other focus items or goals were documented to show how staff would communicate with or care for him. Resident #5 was a female admitted with dislocation of an internal left hip prosthesis. Her MDS showed intact cognition, but the care plan report contained no data found. The MDS Coordinator stated comprehensive care plans for new admissions should be completed 7 days after the initial MDS assessment and acknowledged that Resident #5's comprehensive care plan should have been completed by then. The DON stated comprehensive care plans are completed upon admission and quarterly and are used by staff to know how to care for residents and address interventions. The facility policy stated resident care plans are developed according to the timeframes established by S483.21, which requires a comprehensive care plan within 7 days after completion of the comprehensive assessment.
Failure to Report Alleged Abuse Within Required Timeframe
Penalty
Summary
The facility failed to ensure that an alleged abuse incident was reported immediately, but not later than 2 hours after the incident occurred. Record review of the provider investigation report dated 02/27/2026 showed a resident-to-resident altercation that occurred on 02/20/2026 at 9:30 a.m. The report also showed that the incident was reported to HHS on 02/20/2026 at 12:30 p.m., which was after the 2-hour reporting timeframe. During interview, the ADM stated they were responsible for reports made to HHS and confirmed that alleged abuse must be reported within 2 hours. The ADM acknowledged that the provider investigation report for the resident-to-resident altercation was submitted to the state after the 2-hour mark from when the incident occurred. The facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, stated that allegations must be investigated and reported within federal timeframes, and the HHSC provider letter stated that abuse must be reported immediately, but not later than 2 hours after the incident occurs or is suspected.
Failure to Revise Care Plan After Behavioral Change
Penalty
Summary
The facility failed to have the comprehensive care plan reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for 1 of 5 residents reviewed for comprehensive care plans. Resident #7 was a male with a primary diagnosis of Alzheimer's disease with early onset, documented with progressive memory loss, cognitive decline, and behavioral changes, and his MDS assessment showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. Record review showed a provider investigation report dated 02/27/2026 documenting a resident-to-resident altercation involving Resident #7 that occurred on 02/20/2026 at 9:30 a.m. Resident #7's care plan revised on 05/05/2026 did not mention the resident-to-resident altercation. The psychiatry progress note dated 03/03/2026 documented an order to discontinue Trazodone. The behavior monitoring document following the altercation showed 72 hours of monitoring with 15-minute checks and no recorded behaviors during that period. During interview, the MDS Coordinator stated care plans should be revised when a resident has a change of condition or behavior and said Resident #7's care plan should have been updated after the altercation. The DON also stated care plans should be updated when there is a change with the resident and agreed Resident #7's care plan should have been updated after the incident.
Medication Left in Resident Room
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist was not met for Resident #6. Resident #6 was admitted with diagnoses including major depressive disorder, recurrent unspecified, and had an MDS assessment documenting a BIMS score of 15, indicating intact cognition. Her care plan identified risk for harm related to self-directed or other-directed anxiety and depression and included a goal to administer medications as prescribed. During an observation and interview, a cup containing 2 pills was found on Resident #6's bedside table, and Resident #6 stated the pills were her medications that she was still needing to take. She stated the medication aide did not usually leave them in the room, but on this occasion she was busy and asked the medication aide to set them down. An LVN stated staff should watch the resident take all medication before leaving the room and should not leave medication in a resident's room because the resident could overdose, not take it, or the roommate could take it. The CMA stated they left the medication in the room because the resident was being transferred and they asked for another staff member to ensure she took it, but acknowledged they were supposed to watch her take it. The DON also stated the nurse or medication aide should have watched the resident take the medication. The facility policy stated to ensure the customer swallows all medication(s).
Urinary catheter bag and tubing left on the floor
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained when Resident #6’s indwelling urinary catheter bag and tubing were observed touching the floor. Resident #6 was admitted with diagnoses including major depressive disorder and had an MDS assessment documenting a BIMS score of 15 and an indwelling catheter. The resident’s care plan directed that the catheter bag and tubing be positioned below the level of the bladder and away from the entrance room door, and the order summary included a directive to check foley catheter tubing secure device placement every shift, with leg strap use permitted to secure the foley in place. During observation, the catheter bag and tubing were on the floor under the bed. The resident stated staff had been in the room earlier and had transferred her to the bed, and it could have occurred then. CNA A stated the catheter bag should be attached to the bed and should not touch the floor, and that this would be a contamination issue. LVN B and the DON both stated the catheter bag should hang below the bladder and never touch the floor, and that contact with the floor could lead to contamination or infection control concerns. The facility policy titled Catheter Care, Urinary stated that catheter tubing and the drainage bag should be kept off the floor.
Failure to Review and Revise Comprehensive Care Plan After Required Assessments
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was reviewed and revised by the interdisciplinary team after each required assessment for a resident. Specifically, the resident's comprehensive care plan was not reviewed or updated following both a quarterly and an annual Minimum Data Set (MDS) assessment, despite the resident having multiple complex diagnoses including Alzheimer's disease with early onset, vascular dementia, schizoaffective disorder - bipolar type, Parkinson's disease, and hallucinations. The last documented review and update of the resident's care plan occurred several months prior to these assessments. Interviews with facility leadership revealed that the care plan should have been updated after each MDS assessment, but this did not occur. The facility had recently transitioned between electronic health record (EHR) systems, and during this period, some records were managed manually. Despite this, no updated care plan could be located for the resident. Staffing changes, including the termination of the prior MDS coordinator and reliance on part-time and regional coordinators, were also noted, but the MDS coordinators had full access to the EHR and were responsible for care plan updates.
Failure to Maintain Pest-Free Environment Resulting in Resident Ant Bites
Penalty
Summary
A deficiency occurred when the facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the presence of ants in the resident's room and bed. On the morning of 9/5/25, staff were notified of ants found under the resident's sheets, and maintenance was called to address the issue. Despite these actions, the resident was exposed to ants, which were observed coming from the window or AC unit area. The resident, who had intact cognition and required assistance with personal care due to muscle weakness and polyneuropathies, reported feeling something crawling on her shoulder, and staff subsequently discovered numerous ants on her bed. Following the incident, the resident developed ant bites on her bilateral inner thighs and right flank area, which were documented as red, raised areas with fluid-filled pustules. These findings were confirmed through skin assessments, progress notes, and photographic evidence submitted to the regulatory agency. The resident did not initially report pain or discomfort from the bites, but the presence of the bites was verified by both the resident and the treatment nurse during a later assessment, with small circular scars noted in the affected areas. Interviews with staff, including the DON, LVNs, CNA, and maintenance staff, confirmed the timeline of events and the presence of ants in the resident's room. The facility's maintenance logs also documented the report of ants in the resident's bed. The administrator acknowledged the importance of monitoring for pests and ensuring a pest-free environment, and staff interviews indicated that the ants were traced to the AC unit. The facility's policy emphasized the right of residents to a homelike environment, but this was not upheld in this instance due to the pest infestation and resulting ant bites.
Failure to Timely Report Resident Injury from Ant Bites
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, specifically not later than 2 hours after the allegation was made, as required when the events resulted in serious bodily injury. In this case, a resident with a history of muscle weakness, polyneuropathies, and other nervous system disorders was found to have ants in her bed, which led to ant bites on her bilateral inner thighs and right flank area. Documentation showed that staff were aware of the ant presence and bites, with progress notes and skin assessments recording the incident and subsequent injuries. The resident, who had intact cognition, reported the presence of ants and resulting bites, and staff observed and documented fluid-filled pustules and redness on the affected areas. Despite these findings and the facility's policy requiring prompt reporting of such events, there was no evidence that the incident was reported to the state survey agency as required. Review of the facility's intake records confirmed that no self-reported incident was submitted regarding the ant bites. Interviews with staff and the administrator confirmed awareness of the pest issue and the resulting injuries, but the required reporting procedures were not followed in this case.
Unsafe Supervision of Resident Smoking and Smoking While on Oxygen
Penalty
Summary
The facility failed to keep the resident environment as free of accident hazards as possible and failed to provide adequate supervision for residents who smoked. Resident #9, a female admitted for LTC with diagnoses including COPD, left lower leg amputation, intermittent explosive disorder, and diabetes mellitus II, was documented as a smoker with support for safe supervised smoking and a BIMS score of 15/15. Her care plan directed staff to instruct her on smoking risks and facility smoking rules, notify the charge nurse if she violated the smoking policy, and observe for cigarette burns. Despite this, nursing notes documented her going into another resident’s room and taking that resident out to smoke, and later being observed smoking in the courtyard with another resident outside of assigned smoking times. A nurse later stated Resident #9 often smoked unsupervised, often had her own cigarettes and lighter, and would obtain another lighter after surrendering one. Resident #63, a male admitted for LTC with diagnoses including malnutrition, anxiety, pain, hypertension, muscle spasms/weakness, reflux, and COPD, was also identified as a smoker with support for safe supervised smoking and had a BIMS score of 11/15. He had a physician order for continuous oxygen therapy every shift every day and night. His care plan identified him as an intermittent smoker and noted he was noncompliant with the smoking policy and had smoked in his bathroom. Event reports documented that he was discovered smoking in his bathroom while receiving oxygen therapy via nasal cannula and oxygen concentrator on two occasions. During interviews, staff stated he was found smoking in his bathroom while on oxygen, and the resident stated he did not participate in supervised smoke breaks because he could not do so without his oxygen therapy. The facility’s smoking policy stated that all residents who smoke would be supervised, smoking would be allowed only in designated safe areas, oxygen equipment was not permitted in smoking areas, and residents not complying with the policy could be discharged. Interviews with staff and leadership confirmed that both residents had histories of smoking unsupervised and at unassigned times, and the Administrator stated the facility could no longer meet their needs for safe smoking and non-compliant behavior. The report also states that the incidents involving Resident #63 smoking while on oxygen therapy were not reported to the state agency.
Failure to Attempt GDR for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that Resident #60 was free from unnecessary psychotropic medication use and failed to ensure a gradual dose reduction was attempted for Zyprexa (olanzapine). Resident #60 was admitted with diagnoses including vascular dementia without behavioral disturbance, major depressive disorder with psychotic symptoms, mood disorder due to a known physiological condition with mixed features, and generalized anxiety disorder. Her history and physical documented a BIMS score of 0 out of 15, reflecting severe cognitive impairment. A prescription order dated 1/4/24 showed she was prescribed olanzapine 5 mg orally once daily, and consolidated orders from 7/29/25 to 8/29/25 continued the medication for a physiological condition with mixed features. Review of pharmacy records from January 2025 through August 2025 showed no attempt to complete a gradual dose reduction for Zyprexa. During interview, the ADON stated she was responsible for tracking pharmacy reviews and monitoring GDRs for psychotropic medications, and acknowledged that no gradual dose reduction had been attempted for Resident #60. The ADON stated the resident was on hospice services and the medication had been continued, but also stated she had not discussed a gradual dose reduction with the hospice nurse. The facility policy stated antipsychotic medications were to be used per CMS guidelines and dose reductions were to be performed and monitored as required by regulation.
Failure to Report Smoking-Related Neglect Incidents
Penalty
Summary
The facility failed to ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment were reported to the administrator and other officials, including the State Survey Agency, within 24 hours when the events did not involve abuse and did not result in serious bodily injury. This deficiency involved 2 of 8 residents reviewed for allegations of neglect, Resident #9 and Resident #63, whose smoking-related incidents were documented in the record but were not reported to the state agency through the facility’s established procedures. Resident #9 was admitted for LTC with supports for safe supervised smoking and had diagnoses including COPD, left lower leg amputation, intermittent explosive disorder, and diabetes mellitus II. Her care plan directed staff to instruct her on smoking risks and the facility smoking policy, notify the charge nurse if she violated the policy, and observe for cigarette burns. Nursing notes documented that she was seen going into another resident’s room and taking that resident out to smoke, and later was observed smoking outside in the courtyard with another resident and was redirected. Staff interviews indicated she often smoked unsupervised, had her own cigarettes and lighter, and would obtain another lighter. The ADON stated the smoking incidents were not reported to the state agency. Resident #63 was admitted for LTC with supports for safe supervised smoking and had diagnoses including malnutrition, anxiety, pain, hypertension, muscle spasms/weakness, reflux, and COPD. He had a physician order for continuous oxygen therapy and a care plan revision noting he was noncompliant with the smoking policy and was smoking in his bathroom. Facility event reports documented that staff discovered him smoking in his bathroom while receiving oxygen therapy via nasal cannula and oxygen concentrator on two occasions. Interviews confirmed the ADON, DON, Administrator, and nursing staff were aware of the incidents, and the Administrator stated the facility did not consider them reportable to the state agency.
Failure to Respond to Critical Glucose Result and Transcribe Transfer Orders
Penalty
Summary
Facility staff failed to identify, respond to, and act upon a critical glucose result for a resident with Type 2 diabetes mellitus who was receiving scheduled insulin. The resident’s record showed a lab call reporting a glucose level of 40, an order to call the MD if blood sugar was under 70, and insulin administration documentation for the day. However, the nursing progress notes and monitoring documentation did not reflect that the critical result was addressed, that the physician was notified, or that follow-up assessment occurred. The resident’s care plan also did not reflect his diabetes or insulin use. Interviews with the NP, the LVN, the ADON, and the DON showed that none of them were aware of the critical glucose result until surveyor intervention. The NP stated he did not receive a call about the critical blood sugar and would have expected the nurse to assess the resident, obtain vitals and an Accu-Chek, and provide information about blood sugar values, meal intake, and insulin administration. The LVN stated he would have been expected to complete an SBAR, notify the NP, ADON, DON, and responsible party, but he did not recall any events related to the critical lab. The ADON and DON stated they were not aware of the result and that immediate action was expected when a resident had a change in condition. Facility staff also failed to follow transfer physician orders for another resident admitted from a previous SNF. The transfer discharge report included orders for yearly labs, monitoring for adverse effects of antidepressant, antianxiety, and anticonvulsant medications, and assistance with wearing an eye patch to the left eye. The admission physician orders in the facility did not include these items. The admitting LVN stated she reviewed the transfer documents but failed to recognize and transcribe the orders for the eye patch, labs, and medication monitoring. The ADON and NP stated they were unaware of these orders, and the resident stated he had used an eye patch in the past but had not used one at the facility.
Failure to Notify Practitioner of Critical Glucose Result
Penalty
Summary
The facility failed to promptly notify the ordering practitioner of a critical laboratory result for Resident #91, whose diagnoses included Type 2 diabetes mellitus and major depressive disorder. The resident’s admission MDS reflected a BIMS score of 13 of 15 and that he received insulin injections on a regular basis, but his care plan did not reflect diabetes mellitus or insulin use. Physician orders included instruction to call the MD if blood sugar was under 70, and the resident was receiving Humalog before meals plus sliding scale insulin. A lab report dated 8/13/25 showed a critical glucose level of 40, and the record stated LVN W received a call from the lab company at about 2:30 AM. The nursing progress notes did not document any assessment or response tied to that critical result, and the available documentation showed only routine entries, meal intake, vital signs monitoring, and insulin administration. The diabetic flowsheet showed the resident’s blood sugar was 117 at 2100 and that no insulin was given at that time, but there was no documentation that the critical lab result was addressed. During interviews, the NP stated he did not receive a call about the critical glucose result and would have expected the nurse to assess the resident, obtain vital signs and an Accu-Chek, and provide information about blood sugars, meal intake, and insulin administration. LVN W stated he could not recall receiving the lab call and described the actions he would have been expected to take, including completing an SBAR and notifying the NP, ADON, DON, and responsible party. The ADON and DON both stated they were unaware of the critical lab until surveyor intervention and that immediate action and notification were expected when a resident had a change in condition.
Improper Dumpster Waste Disposal
Penalty
Summary
Dispose of garbage and refuse properly. Based on observation and interview, the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for disposal of garbage. During an observation on 8/28/2025 at 10:13 AM, the facility's dumpster concrete pad had a large steel dumpster with the sliding doors opened. Further observation revealed a 30-gallon plastic bag filled with garbage placed beside the dumpster and scattered trash surrounding the dumpster area. During an interview on 8/28/2025 at 10:22 AM, the HK manager stated the dumpster was used by dietary staff, nursing staff, and housekeeping staff, and that the expectation was for all trash to be placed in the dumpster, the doors to be closed when not in use, and the surrounding area to be cleaned so all trash was placed in the dumpster. The HK manager also stated the potential risk for residents could be reduced morale.
Failure to Notify Physician of Critical Blood Sugar Result
Penalty
Summary
The facility failed to immediately consult the resident’s physician when Resident #91 had a significant change in physical status. Resident #91 was admitted with Type 2 diabetes mellitus and major depressive disorder, had a BIMS score of 13 of 15, and the admission MDS indicated he received insulin injections on a regular basis. However, his care plan did not reflect diabetes mellitus or insulin injections. On 8/13/25 at about 2:30 AM, LVN W received a critical lab result showing Resident #91’s blood sugar was 40. The nursing progress notes showed the last entry before that time was at 10:00 PM on 8/13/25, and the next entry was not until 9:00 AM on 8/14/25. There were no progress notes entered between the time the critical lab was received and the next morning. The record review did not show that LVN W assessed the resident, checked his blood sugar, completed an SBAR, or documented any action related to the critical result. During interview, the NP stated he did not receive a call from the facility and would have expected notification, assessment of the resident, and blood sugar information to guide new orders. LVN W stated he was expected to complete an SBAR for a change in condition and to call the NP, ADON or DON, and the resident’s responsible party for a critical blood sugar of 40, but he could not recall taking any action. The ADON and DON stated they were not aware of the critical lab and expected immediate action, including assessment, physician notification, and notification of the responsible party. The facility policy required informing the resident, physician, and responsible party of significant changes in condition and notifying the attending physician as soon as possible.
MDS Did Not Reflect Resident’s Weight Loss
Penalty
Summary
The facility failed to ensure that Resident #76’s assessment accurately reflected her status when the MDS Coordinator/LVN did not include that she had lost weight in the last 6 months. Resident #76’s record showed she was admitted with diagnoses including generalized muscle weakness, unsteadiness on feet, and other lack of coordination. Her quarterly MDS showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment, and that she was dependent on staff for all ADLs, but it did not reflect her July 2025 weight loss. Her care plan documented a significant unplanned/unexpected weight loss related to poor food intake. During observation, she was seen eating lunch and stated she did not like the food and had a family member bring her takeout. The MDS Coordinator stated the assessment needed to accurately reflect the resident’s status so staff would be on the same page regarding identified problems, goals, and approaches related to her weight loss, and stated that otherwise staff would not know what interventions to implement.
Failure to Complete Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident who arrived by ambulance on a stretcher with multiple complex needs. The resident’s admission documentation listed osteomyelitis and showed a right above-knee amputation with staples, a sacral wound, a left lower extremity wound, and an indwelling Foley catheter. Hospital discharge paperwork also identified bilateral heel osteomyelitis, constipation, MRSA to the sacral wound, right AKA, diabetes mellitus, and bed-bound status. The resident’s history and physical further documented stroke with right-sided deficit, bowel and bladder incontinence, pulmonary embolism history, asthma, hyperlipidemia, sacral pressure ulcer, acute respiratory failure, pneumonia, and anemia. The baseline care plan dated 8/23/25 did not include the resident’s diagnoses, code status, MRSA wound infection, contact isolation, urinary catheter, goals, or interventions. The care plan form contained only limited check-box entries, including incontinence, sacral/LLE skin problems, amputations, intake/output, wound dressing, and decubitus/stasis ulcers, with blank lines where instructions should have been entered. A second page of the admission care plan was blank. The weekly skin assessment documented multiple wounds and staples, and physician telephone orders included Foley care, Foley changes as needed, contact precautions, wound dressing orders, and weekly skin assessments. During the survey, staff could not produce a complete baseline care plan. An LVN stated she had made the baseline care plan but could not locate it, and the MDS nurse, ADON, and MR V each indicated the resident’s records were elsewhere or still being scanned and renamed. The DON stated the resident had been admitted late on a Friday night and that the nurse had made the baseline care plan, and also stated the baseline care plan had been completed. The DON and ADON stated the facility did not have a baseline care plan policy and followed the RAI manual.
Incomplete Care Plans for ADL Dependence and Diabetes Management
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for 2 of 6 residents reviewed. Resident #76 was admitted with diagnoses including generalized muscle weakness, unsteadiness on feet, and other lack of coordination. Her MDS showed a BIMS score of 12 of 15, reflecting moderate cognitive impairment, and that she was dependent on staff for all ADLs. However, her care plan dated 7/16/25 did not reflect that she had a self-care performance deficit or that she was dependent on staff for all ADLs. During observation, she was sitting in a wheelchair eating lunch, and she stated that staff assisted her with ADLs. Resident #91 was admitted with diagnoses including Type 2 diabetes mellitus and major depressive disorder, recurrent, mild. His admission MDS showed a BIMS score of 13 of 15, reflected diabetes mellitus, and indicated he received insulin injections on a regular basis. His diabetic flowsheet showed orders for Humalog insulin before meals in addition to sliding scale insulin. However, his care plan dated 7/29/28 did not reflect that he had diabetes mellitus or that he was receiving insulin injections. The MDS Coordinator/LVN stated that the care plans did not include these problem areas and that the information was important so all staff would be on the same page and the residents would receive the care and services as needed.
Failure to Apply Ordered Splint for Resident With Right-Hand Contracture
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. Resident #54 was admitted with diagnoses including vascular dementia and muscle wasting and atrophy, and her quarterly MDS documented severe cognitive impairment with range of motion impairment in one upper and one lower extremity, including the upper extremity. Her care plan identified that she had polyneuropathy and was at risk for increased pain, contractures, and skin breakdown, with an approach stating she may utilize a right hand splint as tolerated to assist with decreasing the risk of progression of contracture. The resident’s OT plan of care stated she was referred for therapy due to risk of decline without intermittent therapy and that without therapeutic intervention she was at risk for decline in ROM. The OT goal was for the resident to tolerate application of a right hand splint for 60 minutes to facilitate maximum ROM and joint alignment and prevent deformity and pain. However, review of August 2025 progress notes did not show that the resident refused splint application, and observations on multiple days showed the resident sitting in a wheelchair without a hand roll or splint on her right arm/wrist despite having a right-hand contracture. During interviews, CNA Y stated she had never known the resident to wear a splint and could not find one in the resident’s closet or drawers. LVN Z stated he had seen the resident with a splint a couple of weeks earlier but that she did not tolerate it for long. The DON stated the resident had refused to wear a splint since she started working at the facility about 2 months earlier and that the splint would help with contracture and joint alignment. On the final observation, the resident nodded yes when asked if she was willing to wear a splint and nodded yes when asked if anyone had tried to put one on, while the DON stated she could not find the splint.
Expired Thickened Orange Juice Stored in Pantry
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for expired foods. During an observation on 8/26/2025 at 9:15 AM, the kitchen pantry was found to contain 13 containers of 46-ounce thickened orange juice with manufacturer labeling showing a best-if-used-by date that had expired by 17 days. During an interview at 9:18 AM, the cook stated the thickened orange juice was stored in the pantry and available for residents, and acknowledged that all staff were responsible for reviewing foods for expiration dates. The cook reviewed the product and stated it was expired and should not have been stored and available for service. During a later interview, the FSM stated the thickened orange juice had been ordered before his tenure and that the staff member responsible for the pantry failed to ensure foods were within expiration dates.
Failure to Use EBP PPE During High-Contact Care
Penalty
Summary
Provide and implement an infection prevention and control program was not maintained for Resident #30, who had sacral spina bifida with hydrocephalus, colostomy status, a urostomy, and a stage 4 sacral pressure ulcer. The resident’s MDS showed a BIMS score of 14 out of 15, use of a manual wheelchair, and dependence on staff for lying to sitting, transferring, personal care, and bathing. The care plan included EBP during contact care because of wounds and ostomies, with interventions directing staff to use appropriate PPE during ADLs, transfers, linen changes, incontinent care, wound care, and care involving tubes, catheters, and tracheostomy-related activities. During observation, OT U was at the resident’s bedside wearing gloves but no gown while waiting to assist with care. A sign on the door directed staff to wear gloves and a gown for high-contact resident care activities, including dressing, bathing, transferring, changing linens, providing hygiene, and any skin opening requiring a dressing. The resident stated she was waiting for the CNA after reporting that the urostomy bag was leaking, and the CNA entered with a mechanical lift. In a later observation, CNA P and OT U were on either side of the resident’s bed wearing only gloves and no gowns while providing care and transferring the resident to a chair. The resident was then observed leaving the room in her wheelchair, and CNA P and OT U acknowledged they had provided high-contact care and transferred the resident without wearing gowns for EBP. In telephone interviews, CNA P and OT U both stated they had been trained on EBP and knew they should have worn a gown and gloves, but said they were nervous and forgot. The DON stated they should have worn a gown and gloves for the resident’s care and transfer and had been trained previously and again recently. Review of the facility’s EBP policy indicated targeted gown and glove use during high-contact resident care activities, including transferring and wound care.
Survey Results Not Available for Resident Review
Penalty
Summary
The facility failed to ensure reports of surveys, certifications, and complaint investigations from the previous 3 years, along with any plan of correction in effect, were available for residents, families, legal representatives, and other individuals to review upon request. During a resident council meeting, 7 unsampled residents stated they did not know where to review the survey results and did not know where they were located. Observation in the lobby showed a sign directing people to a survey binder in the first drawer of the chest underneath the timeclock, but review of the binder found only the 2023 survey results filed inside. Further review showed that results of previous investigations or surveys were not in the binder. The ADM stated she had removed the 2024 survey results the prior week to review with the DON and forgot to put them back, and said the survey results should be readily accessible for residents and visitors.
Disorganized and decentralized resident medical records
Penalty
Summary
The facility failed to ensure medical records were maintained complete, accurate, readily accessible, and systematically organized for 92 of 92 residents reviewed. On 7/31/2025, the facility stopped adding data to the prior electronic medical record database and began using paper charts while waiting for access to a new electronic medical record platform. By 8/26/2025, the facility’s census was 92 residents and the medical records were described as disorganized and decentralized. The DON and ADON stated they had created a system in which resident paper records were spread throughout the facility and handled by different staff members. Consents were kept by the ADON, assessments were given to the MDS nurse, orders and MARs were maintained at two nurses’ stations, and code status records were kept in two separate binders at two separate nurses’ stations. During observations from 8/26/2025 through 8/30/2025, nurses, CNAs, therapy staff, and medical services providers were seen generating and maintaining records in various locations without centralized charts. LVN A and LVN E stated they had not received formal training on developing centralized organized paper charts, and NP C stated the facility had not developed centralized paper charts and had relied on records available throughout the facility for continuation of care.
Failure to Send Discharge Notices to State Ombudsman
Penalty
Summary
The facility failed to notify and send a copy of residents’ discharge notices to a representative of the Office of the State Long-Term Care Ombudsman when residents were transferred or discharged. Review of the facility transfer/discharge log from January 2025 through July 2025 showed that the list of residents transferred during July 2025 was not available as part of the notices sent to the State Ombudsman. The deficiency was identified for 1 of 6 months reviewed for discharge notices. During interview, the facility State Ombudsman stated she had received discharge notices through June 2025 but had not received the discharge notices for July 2025, and she had not received discharge notices for any facility-initiated discharge. The BOM stated she usually sent a list of residents by mid-month of the month after discharge, but because of a company buyout she waited until the end of August 2025 to ensure the list was complete and accurate. She also stated she understood that for facility-initiated discharges, the notice should be provided to the State Ombudsman at the same time the resident received the discharge notice so the resident would have the opportunity to seek assistance with an appeal if desired.
Failure to Provide Required Discharge Documentation and Notification
Penalty
Summary
The facility failed to provide all required documentation and notifications related to a resident's transfer and discharge. Specifically, there was no written notification of transfer provided to the resident or the resident's responsible party/power of attorney (RP/POA) prior to discharge. The responsible party reported not receiving any notification and expressed a desire to have time to search for alternative facilities and to tour the new facility before the transfer occurred. The facility staff confirmed that written notices were not provided in the resident's or responsible party's primary language, and there was no documentation in the medical record regarding the reason for the transfer. Additionally, the facility did not issue a 30-day written discharge notice to the resident, the responsible party, or the ombudsman prior to the discharge, as required. Interviews with staff revealed a misunderstanding of when 30-day discharge notices are necessary, with several staff members indicating that such notices were only given for non-payment situations. The ombudsman confirmed that no 30-day discharge notices had been received from the facility for recent transfers, and staff acknowledged that they did not routinely notify the ombudsman of all discharges. The resident involved had moderate intellectual disabilities, a developmental disorder of speech and language, and required assistance with personal care. The medical record and discharge summary lacked documentation of the reason for transfer, and staff could not provide evidence of whether the discharge was resident-initiated or facility-initiated. The facility's policy required documentation of discharge details and confirmation that the resident and/or responsible party understood the discharge plan, but this was not completed in this case.
Inaccurate Resident Assessments Completed During Hospitalization
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status for four residents reviewed. Specifically, BIMS (Brief Interview for Mental Status) and PHQ (Patient Health Questionnaire) assessments were completed for these residents while they were hospitalized and not present in the facility, resulting in the resident interviews not being conducted. The assessments were documented as completed during the residents' hospital stays, as confirmed by census data and assessment dates. The residents involved had complex medical histories, including conditions such as anemia, atrial fibrillation, dementia, schizoaffective disorder, osteomyelitis, cerebral infarction, and other chronic illnesses. Interviews with facility staff revealed that the social worker completed the assessments during the residents' hospitalizations because the MDS Nurse indicated they were due, and the social worker was unsure how to complete discharge assessments when the resident was not available for interview. The administrator stated that assessments should be coded as not assessed if the resident is in the hospital, but believed the error was due to inaccurate data entry. The facility did not have a specific policy for resident assessments.
Failure to Implement Enhanced Barrier Precautions and PPE Use
Penalty
Summary
The facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for several residents requiring Enhanced Barrier Precautions (EBP). Surveyors observed that required signage indicating EBP was missing from the rooms of multiple residents with conditions such as dementia, colostomy, pressure ulcers, and indwelling catheters. In several cases, personal protective equipment (PPE) carts were not present either inside or outside the residents' rooms, despite physician orders and care plans specifying the need for EBP during high-contact care activities. Staff interviews confirmed awareness of the need for EBP but acknowledged the absence of signage and PPE carts, and the Director of Nursing (DON) was unaware that EBP required a PPE cart at each room. Additionally, the facility's infection control policy required signage to alert staff of precautions and the availability of PPE and alcohol-based handrub for staff. However, observations revealed that these requirements were not consistently met. For example, one resident with an indwelling catheter had a PPE cart near the bed but lacked appropriate signage, while another resident had signage but no PPE cart available. Staff interviews further revealed inconsistent understanding and implementation of EBP requirements, with some staff obtaining PPE from central supply rather than having it readily accessible at the point of care. In another instance, staff failed to don appropriate PPE while performing an invasive procedure, specifically the insertion of a peripheral IV for a resident with EBP orders and a care plan intervention explicitly listing IV sites as requiring PPE. The Assistant Director of Nursing (ADON) and other staff involved in the procedure did not use PPE, and the ADON stated that PPE was not typically used for IV initiation, despite the care plan's direction. The facility's infection control policy and care plans were not followed, resulting in lapses in infection prevention practices for residents at risk.
Incomplete Medical Record Documentation for Crash Cart Checks and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards and facility policy. Specifically, night nurses did not initial the crash cart supply verification sheet for the 100/200 hall crash cart on six separate days, despite being responsible for daily checks and documentation. Observations confirmed that the crash cart was stocked with required supplies, but the absence of initials on the verification sheet indicated a lack of documented confirmation that checks were performed as required. Interviews with the ADON and DON confirmed that the night nurses admitted to checking the supplies but forgot to initial the sheet, which was contrary to facility policy and expectations. Additionally, a medication aide did not document the exact times of medication administration for a resident prescribed Carvedilol for hypertension. The resident, who had diagnoses including type 2 diabetes, hypertension, hyperlipidemia, cellulitis, and kidney failure, was cognitively intact and independent in most activities of daily living. The medication administration record (MAR) for this resident showed that on three occasions, the times recorded did not reflect the actual administration times, and the aide admitted to charting after completing all medication passes rather than immediately after administration, as required by facility policy. Interviews with the ADON and DON confirmed that the medication aide should have documented the exact time of administration on the MAR immediately after giving the medication, in accordance with facility policy. The failure to document accurate times on the MAR could affect communication among healthcare professionals regarding the resident's medication schedule. Facility policies reviewed specified that crash carts must be checked and documented daily, and that medications must be administered and documented within 60 minutes of the scheduled time, with the MAR initialed by the person administering the medication.
Failure to Provide Wound Care per Orders and Care Plan
Penalty
Summary
The facility failed to provide wound care in accordance with physician orders and the residents' care plans for two residents. For one male resident with severe cognitive impairment and multiple comorbidities, including dementia, peripheral vascular disease, and lymphedema, wound care was not administered on two consecutive scheduled days. The Treatment Nurse documented a refusal on the first day but did not re-approach the resident or communicate the refusal to the next shift. The following day, the nurse did not attempt wound care or notify other staff, resulting in the resident's dressings remaining unchanged for several days. The resident expressed confusion about refusals and stated he wanted his wounds changed, while the regular charge nurse reported that refusals were not consistently communicated to her. For a female resident with severe cognitive impairment, peripheral vascular disease, chronic osteomyelitis, and diabetes, wound care was also missed on a scheduled day. The Treatment Nurse marked the treatment as not administered due to the resident being unavailable after dialysis but later acknowledged the resident had returned in time for the dressing change. The nurse made only one attempt to provide care, did not communicate the missed treatment to the next shift, and did not notify the physician. The nurse stated she typically left a note at the nurse's station but did not ensure verbal communication with other staff. Interviews with facility staff revealed a lack of consistent communication and documentation regarding wound care refusals and missed treatments. The Assistant Director of Nursing confirmed that the expectation was for multiple attempts and clear communication with other staff when wound care could not be completed. The Treatment Nurse did not consistently follow these expectations, leading to lapses in care for residents requiring wound management.
Resident Choking Incident Due to Incorrect Meal Texture
Penalty
Summary
The facility failed to provide food prepared in the correct form to meet the needs of a resident, leading to a choking incident. The resident, a female with a history of Alzheimer's Disease, aphasia, dysphagia, and other conditions, was supposed to receive a pureed diet with nectar thickened liquids. However, on the day of the incident, she was mistakenly given a mechanical soft diet, which was not in accordance with her physician's orders. This error occurred when an agency CNA, unfamiliar with the residents and the facility, fed the resident the wrong meal tray. The incident unfolded when the agency CNA, who had not received proper orientation for the hall she was assigned to, mistakenly fed the resident a meal intended for her roommate. The error was discovered when another CNA noticed the resident showing signs of distress, such as vomiting and a flushed face. The charge nurse was alerted, and immediate action was taken to address the choking, including performing the Heimlich maneuver and calling for medical assistance. The resident's oxygen levels were monitored, and a chest x-ray was ordered, which later showed no signs of aspiration. Interviews with staff revealed that the agency CNA was not familiar with the facility's residents and had not been oriented to the specific hall where the incident occurred. The facility's policy required licensed nursing staff to check meal trays for accuracy, but this procedure was not effectively followed, leading to the mix-up. The incident highlighted a breakdown in communication and procedural adherence, particularly concerning the distribution of meals and the orientation of agency staff.
Removal Plan
- Resident #1 will receive the appropriate physician ordered diet for all meals.
- Resident #1 has had a chest x-ray. The results reveal no negative outcome to her lungs.
- Resident #1's physician who is also the medical director has been notified both of the incident and the IJ status at the facility.
- A facility audit took place to ensure that all residents requiring modified texture diets for meals will receive their meals in the appropriate texture.
- DON and the dietary consultant audited all residents who require their diet to be served in an altered texture for meals to ensure that their meal tickets reflect the residents individual needs regarding texture with food in accordance with physician's diet orders.
- The dietary department designee will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate.
- The nurse in the dining room will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate.
- The nurse on the hall will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate.
- The DON will monitor meals to ensure staff compliance with ensuring that all meals/trays have the appropriate texture that matches the meal ticket and the physician ordered diet.
- Residents meal texture statuses will be audited upon admission, change of condition, appropriate MDS cycles and or anytime necessary.
- All trays will be compared to the actual plated meal for the resident by a licensed staff member prior to being served to the resident. The printed meal ticket will be compared to the tray/plate for accuracy.
- The Assistant Director of Nursing provided education to all staff regarding residents requiring specially textured meals to ensure those residents will receive the appropriately textured meal at all times.
- Licensed staff will be assigned by the DON to ensure that all trays/plates are correct prior to being served to the residents. Diet orders will match correctly to what is being served to the residents.
- The Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding residents requiring specially textured diets for meals.
- The regional clinical consultant will be responsible for ensuring that staff receive the inservice/training regarding residents requiring specially textured food for meals.
- The residents dietary food texture status will be communicated to facility staff directly by the DON and ADON. This process will be accomplished through photo copy and or written communication.
- The DON or their designee will be responsible for ensuring that the residents who require specially textured diets receive their food with the appropriate texture according to the physician's ordered diet.
- During the daily stand up process all recommendations and orders will be audited by the clinical team in consultation with the dietary supervisor to ensure compliance and follow up for all residents with orders and recommendations.
- The clinical consultant will review orders and recommendations as a tool for oversight to ensure compliance.
- Staff have been re-educated to identify the resident's diet by room number and bed designation of A or B.
- 100% Staff education compliance for those who may serve food to a resident will be completed.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which resulted in deficiencies in addressing their specific medical and nursing needs. Resident #50, a female with severe dementia and other conditions, was found to have bed rails on her bed without any corresponding care plan or physician orders. The Director of Nursing (DON) stated that the facility did not consider the mobility bar as a bed rail and acknowledged the lack of a care plan for it. Resident #74, a male with severe cognitive impairment and multiple medical conditions, had a catheter that was not reflected in his care plan. Observations revealed the catheter was improperly positioned, touching the floor, and not in a dignity bag. The care plan inaccurately described the resident as incontinent without mentioning the catheter, indicating a lack of proper documentation and planning for his needs. Similarly, Resident #138, a male with severe cognitive impairment and other health issues, had a catheter that was not documented in his care plan or physician orders. The DON admitted that the catheter was placed during a hospital stay and should have been documented upon the resident's return. The facility's policy requires comprehensive care plans to be developed and kept current, but this was not adhered to, leading to inadequate care planning for these residents.
Failure to Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to ensure the correct installation, use, and maintenance of bed rails for three residents. These residents were not assessed for the risk of entrapment from bed rails before installation, and there was no signed informed consent from their responsible parties. Resident #16, a female with a history of myocardial infarction and other conditions, was observed with side rails on her bed despite her care plan not reflecting their use. Similarly, Resident #50, diagnosed with severe dementia and other conditions, had bed rails that were not documented in her care plan. Resident #138, a male with severe cognitive impairment and other medical issues, also had bed rails that were not care planned or assessed for safety. Interviews with facility staff revealed a lack of awareness and documentation regarding the use of bed rails. The maintenance supervisor indicated that he did not keep track of which residents had bed rails and relied on the DON for guidance. The DON stated that the facility did not have bed rails, only grab bars, and that they did not consider these devices as bed rails. The MDS Regional Consultant mentioned that the rails were not considered restraints and thus were not reflected on the MDS. The Administrator acknowledged the absence of a policy for bed rails, as they did not view the assistive devices as bed rails.
High Medication Error Rate in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 62.96% based on 17 errors out of 27 opportunities. This involved three residents who did not receive their medications on time or as prescribed. Resident #16, a female with a history of myocardial infarction, atrial fibrillation, and other conditions, did not receive her medications at the scheduled times. Observations noted that her medications, including aspirin and apixaban, were administered late. Resident #63, a female with atrial fibrillation and lymphedema, also experienced medication administration issues. Her bumetanide, a diuretic, was not administered as ordered due to a misinterpretation of the blood pressure parameters by the LVN. This error occurred despite the resident's blood pressure being within acceptable limits for administration. Additionally, her other medications were given significantly later than the prescribed times. Resident #79, a male with depression and hypertension, received an incorrect dosage of sertraline. The facility's policy allows for medication administration within a one-hour window before or after the scheduled time, but this was not adhered to. The LVN involved in these errors was not accustomed to the day shift and did not seek assistance from other staff, contributing to the high error rate.
Failure to Maintain Safe and Sanitary Laundry Room Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the laundry room, as observed during a survey. Specifically, the facility did not properly dispose of and maintain the lint accumulation in the dryers. During an observation, it was noted that two of the three dryers in use had a thick layer of lint, approximately one inch thick, on the lint traps and some lint at the bottom of the dryers. This accumulation of lint was not addressed in a timely manner, which could lead to an unsafe and unsanitary environment. Interviews with the laundry aide and the Laundry/Housekeeping Supervisor revealed that there was no log for tracking the cleaning of the lint traps, and the facility did not have a written policy for this task. The laundry aide admitted to not cleaning the lint traps after every two loads as required, due to being busy with other tasks. The supervisor confirmed the risk of fire if the lint traps were not cleaned regularly. The Administrator, upon inspection, found the lint traps clean and stated that the laundry aide had only done two loads and had cleaned the traps prior. However, the lack of a tracking log or policy was acknowledged.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete assessments for two residents, leading to potential inadequate care. Resident #138, a male with severe cognitive impairment and multiple diagnoses including a stage 4 pressure ulcer and acute kidney injury, had an indwelling catheter that was not documented in his care plan or indicated on his Minimum Data Set (MDS). The MDS inaccurately reflected that he was always incontinent of bowel and bladder without any appliances, despite staff providing care for his catheter. The MDS Regional Consultant acknowledged the oversight, attributing it to recent staffing changes among MDS nurses. Similarly, Resident #52, a female with acute systolic heart failure and end-stage renal disease, was not accurately assessed on her MDS, which failed to indicate her ongoing dialysis and oxygen therapy. Her care plan, however, did reflect these needs, including scheduled dialysis appointments and continuous oxygen therapy. The MDS Regional Consultant confirmed the inaccuracies in the MDS, emphasizing the importance of accurate documentation for staff to understand and meet the resident's care needs. The facility relied on the CMS RAI manual for regulatory compliance, but no specific policy on MDS was provided by the Administrator.
Failure to Coordinate PASRR Assessments for Residents
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for two residents, leading to deficiencies in their care. Resident #8, a female with diagnoses including dementia, recurrent depressive disorder, psychotic disorder with hallucinations, and paranoid schizophrenia, was admitted without an accurate PASRR Level 1 Screening. Her records indicated severe cognitive impairment and the use of multiple medications for mental health conditions, yet her PASRR screening did not reflect any evidence of mental illness or dementia. This oversight was acknowledged by a regional consultant who noted the need for additional documentation due to the resident's dementia diagnosis. Similarly, Resident #35, who was admitted with unspecified dementia and a psychotic disorder with delusions, also lacked an updated PASRR Level 1 Screening. Despite receiving antipsychotic medications and having a care plan addressing the risks associated with these medications, his PASRR screening from 2017 did not indicate any mental illness. The MDS Regional Consultant admitted that the screening was not updated following his diagnosis of psychosis, which could result in the resident missing out on necessary services. This failure to update the PASRR screenings could prevent residents from receiving needed assessments and specialized services.
Failure to Update Care Plans After Significant Changes
Penalty
Summary
The facility failed to update the care plans for two residents following significant changes in their conditions. Resident #68's care plan was not revised after a significant change Minimum Data Set (MDS) assessment indicated that the resident was dependent on staff for all Activities of Daily Living (ADL) care. Despite this assessment, the care plan did not reflect the resident's dependency on one or two staff members for ADL care. This oversight was confirmed during an interview with the MDS Regional Consultant, who acknowledged that the care plan did not accurately represent the resident's current needs. Similarly, Resident #71's care plan was not updated after the resident developed a venous ulcer on the left shin, which was not present at the time of the admission MDS assessment. The resident was receiving wound treatment for this condition, but the care plan was not revised to reflect this significant change. An interview with the LVN/MDS Regional Consultant revealed that the care plan should have been updated to provide an accurate picture of the resident's physical and medical condition, ensuring that nursing staff understood the care required. The failure to update the care plans could affect any resident and contribute to them not receiving the necessary care and services.
Improper Use of Gait Belt and Lack of Supervision During Transfers
Penalty
Summary
The facility failed to ensure the proper use of assistance devices to prevent accidents for a resident with a history of falls. The resident, who was admitted with diagnoses including vascular dementia, chronic kidney disease, and congestive heart failure, was dependent on staff for transfers and used a manual wheelchair for mobility. The resident's care plan highlighted a history of falling and included interventions such as keeping the call light within reach and using a low bed with fall mats. During observations, it was noted that CNAs improperly used a gait belt by placing it over the resident's chest instead of the waist during a bed to wheelchair transfer. This incorrect application of the gait belt was due to the CNAs' inability to secure it around the resident's waist because of her breast. Additionally, an LVN transferred the resident from the wheelchair to the bed without using a gait belt, which compromised the resident's stability and safety during the transfer. Interviews with the CNAs and LVN revealed a lack of adherence to the facility's policy, which mandates the use of a gait belt around the waist for safe transfers. The DON and ADON confirmed that the gait belt should always be placed around the waistline to stabilize residents effectively. The facility's policy, dated 12/2017, outlines the correct procedure for using a gait belt to ensure resident safety during transfers.
Inadequate Catheter Care for Two Residents
Penalty
Summary
The facility failed to provide appropriate care for two residents with indwelling urinary catheters, leading to potential risks of urinary tract infections. Resident #74, a male with severe cognitive impairment and multiple diagnoses including urinary tract infection and hemiplegia, was observed with a catheter touching the floor, which was stepped on by a staff member. The resident's care plan did not mention the catheter, and the catheter care orders were not properly followed, as confirmed by interviews with the LVN and DON. Resident #138, also with severe cognitive impairment and multiple health issues, had a catheter without documented physician orders or inclusion in the care plan. The DON admitted that the catheter was placed during a hospital stay and returned with the resident, but the facility failed to enter the necessary orders into the electronic medical records. Despite the lack of documentation, the staff reportedly provided daily catheter care. The facility's policy on incontinent care was not adhered to, as evidenced by the lack of privacy and dignity in catheter management.
Inadequate Qualifications of Dietary Manager
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. The Dietary Manager (DM) did not possess the necessary certification, education, or qualifications to serve as the Director of Food and Nutrition Services. The DM's personnel file indicated a hire date of 10/02/23, but lacked evidence of certification as a dietary manager, food service manager, or similar national certification. Additionally, the DM did not have an associate's or higher degree in food service management or hospitality, nor had he completed a comprehensive course in food safety management. Although the DM had experience as an assistant DM in four other nursing facilities since 2014, this did not meet the required qualifications. The DM had only completed a short 4-hour course before taking the Texas Food Safety Manager Certification Examination, which he passed on 10/08/23. However, this certification alone did not meet the national standards for food service management and safety. Furthermore, the facility's Registered Dietitian (RD) was contracted and not a full-time employee, which may have contributed to the deficiency in the food and nutrition service. The lack of appropriate qualifications and certifications for the DM could potentially place residents at risk of foodborne illness and inadequate nutrition.
Deficient Coordination and Documentation of Hospice Care
Penalty
Summary
The facility failed to properly coordinate and document hospice care for two residents receiving hospice services, leading to deficiencies in their care. For one resident, the facility did not ensure that the most recent Physician Certification of Terminal Illness and the Hospice election form were completed and included in the hospice documents. The form 3071, which should have contained critical information such as terminal diagnoses and attending physician details, was incomplete. Additionally, the form 3074 for the physician certification of terminal illness was missing, which is necessary for recertification after six months. For another resident, the facility did not have the Physician Certification of Terminal Illness completed, nor was the most recent plan of care or hospice physician orders available at the facility. The resident's care plan indicated the need for hospice due to a terminal illness, but there was a lack of communication and documentation between the facility and the hospice agency. Interviews with facility staff revealed that they were aware of these documentation gaps and the need to contact the hospice company to rectify the situation. The absence of a hospice policy further compounded the issue, as it was not provided when requested.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. In the first incident, a resident's fall mat was observed to have multiple visible stains and spots, which were dark brown or black on a light gray mat. The resident, who had severe cognitive impairment and a history of climbing out of bed, was unable to be interviewed. The facility administrator was uncertain about the cleanliness of the mat, suggesting it might have been stained despite cleaning efforts or had something spilled on it. In the second incident, an LVN failed to perform hand hygiene between glove changes while administering a bolus tube feeding to another resident. The LVN admitted to not having her usual supplies and forgetting to use hand sanitizer, acknowledging the importance of hand hygiene in preventing infections. The facility's policies on infection control and enteral feeding emphasize the necessity of hand washing and the use of standard precautions, which were not followed in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legend Oaks Healthcare And Rehabilitation Center - | 0.8 mi | ★★★★★ | 17 | 0 |
| Mccullough Hall Nursing Center Inc | 1.6 mi | — | 0 | 0 |
| San Jose Nursing Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Hunters Pond Rehabilitation And Healthcare | 2.5 mi | ★★★★★ | 10 | 0 |
| San Antonio West Nursing And Rehabilitation | 3.6 mi | ★★★★★ | 40 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.