Avir At San Antonio
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 50 Briggs Ave., San Antonio, Texas 78224
- CMS Provider Number
- 455713
- Inspections on file
- 35
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 29 (1 serious)
Citation history
Health deficiencies cited at Avir At San Antonio during CMS and state inspections, most recent first.
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.
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.
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.
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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A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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