Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Schertz during CMS and state inspections, most recent first.
A resident with dementia, DM, lymphedema, and multiple pressure-related wounds had physician orders for wound care to the great toes every shift, heels on specific days, and sacrum every shift and PRN. Review of the March TAR showed multiple dates where these ordered treatments were not documented. The ADON and Regional RN identified two LVNs as responsible for the wound care and acknowledged they could not explain the missing entries, while staff interviews indicated that wound care was reportedly performed on several of the undocumented dates but not charted. A photo of the sacral area and a text message from an LVN were cited as proof that care was provided, yet the facility’s documentation policy requiring all services to be recorded was not followed.
Unsafe Kitchen Sanitation and Food Handling: The facility failed to keep kitchen equipment and food handling practices sanitary and to maintain safe food temperatures. A convection oven had built-up residue and had not been deep cleaned for about 2 weeks, cookies were left uncovered on a prep table, plate covers were stacked while still wet, and lunch items on regular and puree trays were served below the stated safe temperature range. The kitchen hand-washing sink was also not functioning, and staff were observed washing hands at another sink.
Improper garbage disposal and an unclean dumpster area were observed at the facility. Staff used one dumpster for trash, but food items were found on the ground near it, and the DM stated this could attract insects and rodents and potentially lead to infestation in resident areas. The facility sanitation policy required refuse to be properly contained and garbage disposal areas to be maintained to prevent pests.
PASRR Level I screenings were inaccurate for 3 residents because mental illness diagnoses were not identified on the forms. One resident had schizoaffective disorder, anxiety, and schizophrenia with severe cognitive impairment; another had major depressive disorder with psychotic features and bipolar disorder; and a third had PTSD and depression. The MDS Coordinator stated these diagnoses should have been added to the PASRR screens, and the Administrator stated the MDS Coordinator was responsible for PASRR accuracy.
Incomplete Care Plans for Multiple Residents: The facility failed to include key care needs in several residents’ care plans. A resident with mental health diagnoses and severe cognitive impairment had no care plan for those needs, another resident’s colostomy-related behavior was not care planned despite staff reports, two residents’ smoking supervision needs were omitted even though smoking assessments identified them as safe smokers, and a resident’s wound care and gastrostomy-related care were not reflected in the care plan. The DON and MDS staff acknowledged the missing care plan elements.
Respiratory care was not provided consistently for two residents. One resident with COPD, acute respiratory failure with hypoxia, and severe cognitive impairment was observed using oxygen even though no physician order for oxygen was found, and the concentrator settings were observed at different levels during the survey. Another resident with sleep apnea had a CPAP mask left uncovered on the nightstand when not in use. In addition, two portable oxygen cylinders were observed on the floor in a resident room instead of being secured or stored in the designated oxygen storage area.
Expired meds and supplies were found in two med carts, including sterile water, an ostomy lubricant, iron supplement, and calcium carbonate. An insulin pen for one resident was used after the discard-after-opening date, and another resident with DM had missed doses of sliding-scale insulin when the order disappeared from the eMAR. The DON stated the expired items should have been removed, and staff acknowledged the insulin pen was used past its labeled discard date.
Infection control practices were not followed during wound care, catheter care, and incontinent care for four residents. An ADON provided wound care to a resident on EBP without a gown and the EBP door sign was missing; an LPN/CNA provided indwelling catheter care to another resident on EBP without a gown despite an EBP sign on the door; and two CNAs performed incontinent care while touching clean briefs with dirty gloves, with one also failing to use proper perineal care technique for an uncircumcised male resident.
Incomplete annual competency training documentation was found for MA G, MA I, CNA J, and CNA K. Their personnel files showed the yearly competency skill set training was not completed or could not be verified because the check off lists lacked the trainer's name and completion date. HR stated the DON and ADON provided the training, but there was no documentation to prove these staff completed the required CNA competency topics, and the DON could not confirm that these four staff were trained.
Failure to Provide Privacy During G-Tube Medication Administration: A nurse administered medication via a resident’s G-tube while the roommate was present, without pulling the curtain or closing the window blinds. The roommate saw the entire medication administration. The resident had dementia, severe cognitive impairment, and a feeding tube, and the DON stated this was a violation of the resident’s right to privacy.
Failure to Obtain Consent for PRN Risperidone: A resident with epilepsy, restlessness and agitation, and schizoaffective disorder had severe cognitive impairment and was ordered PRN risperiDONE for agitation. The MAR showed the medication was given, but the DON confirmed there was no consent in the chart for the antipsychotic and that consent should have been obtained from the responsible party before the medication was started.
A facility failed to keep call lights within reach for two residents with severe cognitive impairment and extensive assistance needs. Both were observed in bed with their call lights placed on a dresser near the foot of the bed, and each resident stated they could not reach or find the call light. One resident was later heard yelling for help and pain relief while staff were unable to hear her. Staff later stated the call lights had been forgotten after care, and the DON and Administrator confirmed call lights are the residents’ means to communicate with staff.
A resident with epilepsy, schizoaffective disorder, and severe cognitive impairment had a PRN risperiDONE order for restlessness and agitation that had no stop date and exceeded the 14-day limit for PRN psychotropic medications. The DON confirmed the order should have been limited to 14 days, and the facility policy stated PRN psychotropic orders are limited to 14 days.
MDS assessments for two residents did not accurately reflect anxiety diagnoses. One resident had anxiety and schizoaffective disorder, bipolar type, with severe cognitive impairment and a care plan that omitted the mental health history; the other resident had anxiety, a normal BIMS score, and a care plan noting Buspirone use, but the MDS still did not code anxiety. The MDS Coordinator and DON stated the assessments should accurately reflect resident status so care areas are captured and needed care and services are provided.
PASARR Services Not Incorporated Into Care Plan: A resident with anxiety, depression, schizoaffective disorder, bipolar type, and schizophrenia had a care plan that addressed psychotropic meds and mood problems, but it did not show PASARR positive status or habilitative services. A quarterly meeting with the local authority documented that the resident chose to continue habilitative services, and the MDS Coordinator stated the care plan did not include a focused area for those PASARR-identified services.
Failure to Complete Baseline Care Plans for Two Residents The facility failed to complete baseline care plans within 48 hours of admission for two residents. One resident had diagnoses including atrial fibrillation, HTN, and hyperlipidemia, spoke Spanish, had moderate cognitive impairment, required assistance with ADLs, and was observed with decaying teeth; the other resident had multiple neuropsychiatric and pain-related diagnoses and intact cognition. Record review showed neither resident had a baseline care plan completed, and staff interviews reflected uncertainty about responsibility for completing the plans.
A resident dependent on staff for transfers was moved from a wheelchair to a bed using a mechanical lift without the wheelchair being locked, without the lift brakes being applied, and with the lift base narrowed during the transfer. In a separate issue, the facility did not complete quarterly smoking assessments for another resident who continued to smoke, and the resident’s care plan did not include smoking-related care.
Incontinent care was not provided per policy for two residents. A female resident with severe cognitive impairment was cleaned without the CNA opening the labia area, and an uncircumcised male resident was cleaned without the CNA pulling back the foreskin and with multiple passes of one wipe. The DON confirmed both care techniques were incorrect, and the facility policy required separating the labia for females and pulling back the foreskin for uncircumcised males using a new wipe each stroke.
A resident with depression and schizoaffective disorder bipolar type remained on fluoxetine 50 mg daily even after the pharmacist recommended a GDR and the physician entered an order to reduce the dose to 40 mg daily. The MAR showed the resident continued receiving 10 mg plus 40 mg to equal 50 mg daily, and the DON confirmed the dose had not been changed despite the consultant recommendation and new MD order.
A resident with Alzheimer’s disease and severe cognitive impairment received Trazodone for depression, but the MAR/physician order listed the indication as Alzheimer’s disease instead of depression. The DON confirmed the medication was being used for depression and stated the indication entered by nursing was incorrect.
Medication storage and labeling were not maintained for two residents. One resident with DM1 had an insulin pen in a nursing cart with no open date, even though the label said to discard after 28 days, and staff stated the date should have been written on it. Another resident with severe cognitive impairment had an antifungal ointment left unattended on a nightstand, and staff stated all medications, including those brought from home, should be stored in locked carts.
Failure to Obtain Ordered Dentures: A resident with anxiety, DM, and no cognitive impairment was left waiting months for dentures. The care plan did not address his edentulous status or referral for dentures, and the facility changed dental providers multiple times. The most recent dental provider completed the exam and moldings but did not submit the order to make the dentures, and the SW and DON did not follow up to ensure the dentures were produced and delivered.
A resident meal service did not follow the posted menu when spinach listed for lunch was replaced with mixed vegetables. The DM posted a general notice that substitutions could occur, but did not identify the specific substitution, did not notify the Dietician of the menu change, and stated the spinach removal had been discussed only with the resident council rather than all residents.
A facility lacked a policy for foods brought by family or visitors, and surveyors found unlabeled, undated items in two residents’ personal refrigerators. One resident with malnutrition, a stage 3 pressure ulcer, and G-tube status had a small cup of food with no label or date, while another resident with MS, dementia, and TBI had multiple undated Jello, pudding, and juice items in a refrigerator with no temperature log. Staff and leadership stated the refrigerators were not being monitored and that no policy existed for personal refrigerators.
Missing QAPI Training for Staff: Review of personnel files showed that an unlicensed staff member and an LVN had not completed required QAPI training. HR confirmed the missing training and was unable to provide the facility policy on QAPI training by the end of the survey.
A resident with intact cognition, obesity, hypertensive heart disease, and muscle wasting used bilateral 1/4 bed rails as an enabler for bed mobility and positioning while requiring mechanical transfers with two staff. The care plan and physician orders authorized the rails and required quarterly nursing assessments to ensure safe, least-restrictive use, but no bed rail assessments were completed for two consecutive quarters. During observation, both rails were found in the up position and jammed, unable to be lowered by a CNA, and neither the CNA, an LVN, nor the DON were aware of the malfunction until the survey, despite a facility policy requiring proper installation, use per manufacturer instructions, and ongoing evaluation of bed rail safety.
A resident with TBI, mood disorder, anxiety, cognitive impairment, and left-sided hemiplegia/hemiparesis was verbally and physically abused by an RN during early-morning care. According to an LVN and a CNA, the RN loudly cursed at the resident in a public area, called her a "fucking whore" and "slut" for being shirtless, aggressively wheeled her back to her room, forcefully removed her clothing from a contracted arm despite the resident stating it hurt, and shoved her wheelchair into the room hard enough to slam into the bed. Another resident reported hearing the RN call someone a whore and a slut. Although the LVN stated she checked the resident for injuries and found none, this was not documented, and no investigation report was completed at the time, despite a facility policy requiring identification and investigation of all possible abuse incidents.
A resident with TBI, mood disorder, anxiety, cognitive deficits, and hemiplegia/hemiparesis was allegedly subjected to verbal and physical abuse by an RN, who used profane, degrading language about the resident’s exposed breasts and forcefully pushed the resident in a wheelchair into her room, as witnessed by an LVN and a CNA. The LVN documented only the resident’s combative behavior and clothing issues, did not document a post-incident injury check, and did not immediately report the abuse to the administrator or authorities as required by facility policy and federal regulations. No investigation report was initiated at the time, and the administrator learned of the incident only days later, despite corroborating accounts from multiple staff and another resident who heard the RN yelling derogatory terms. Surveyors determined this delay in reporting and failure to promptly investigate constituted noncompliance at the Immediate Jeopardy level.
Surveyors found a medication cart on one hall left unlocked and unattended by an LVN, contrary to facility policy requiring locked storage of medications. During a narcotic count, an RN and LVN identified a discrepancy between the narcotic count sheet and the actual number of hydrocodone/acetaminophen tablets for a resident; the MAR showed a recent PRN dose, but the narcotic log had not been signed out for that administration, and the LVN stated he had forgotten to document it. The surveyor also observed another resident’s hydrocodone/acetaminophen blister pack with a broken seal over one pill; the RN and LVN initially attempted to discard a pill from a different resident’s blister pack of an unknown medication before correcting themselves and discarding the correct pill from the damaged pack.
A resident with severe cognitive impairment and multiple neurological and psychiatric diagnoses had conflicting documentation regarding code status, with the admission record, care plan, and active orders listing Full Code while a signed DNR form and hospice interdisciplinary notes identified DNR. The DON reported placing DNR information in the file and stated that either she or the MDS nurse would update the care plan, but the code status was not changed. The social worker believed the MDS nurse would update the care plan when a DNR was written, and the MDS nurse stated that no one had communicated the code status change and that care plan meetings had not been held prior to his assuming the role. This lack of communication and failure to revise the care plan and orders resulted in an inaccurate code status being maintained in the resident’s record.
A resident with severe cognitive impairment and multiple neurological and psychiatric diagnoses had an OOH-DNR form signed by the responsible party and filed under miscellaneous documents, while the admission record, face sheet, care plan, EMR summary page, and active physician orders all continued to list the resident as Full Code. A hospice interdisciplinary group report identified the resident as DNR, but this was not translated into updated physician orders or core clinical documentation. Interviews with the SW, DON, and MDS nurse revealed that responsibilities for updating code status were unclear and that communication about the change in code status did not occur, resulting in inconsistent and incomplete documentation of the resident’s wishes.
A resident with a history of mood and schizoaffective disorders became involved in a verbal altercation with another resident who had dementia and impulse disorders after refusing to share personal coffee creamer. The resident reported the incident as a grievance to an LVN, but no grievance report was generated, and the facility's grievance log remained blank for the month. This failure to document and address the grievance was contrary to facility policy and residents' rights.
Two residents with cognitive and behavioral health diagnoses engaged in a verbal altercation involving an attempt to take personal property, resulting in shouting and emotional distress. An LVN intervened and documented the incident but failed to report the allegation of verbal abuse and exploitation to facility leadership and authorities as required by policy.
A resident returned from the hospital with a fractured arm and physician orders for a stabilization sling, but the care plan was not updated to include this intervention. Although staff assisted the resident with the sling as ordered, the care plan lacked documentation of the new care needs, contrary to facility policy requiring comprehensive, person-centered care plans.
Surveyors observed improper storage of oxygen tubing for a resident with chronic lung and heart conditions, with tubing left uncovered and on the floor, as well as two CNAs failing to perform hand hygiene between distributing meal trays to different residents. Staff interviews and facility policy reviews confirmed that these actions did not meet infection control standards.
Staff failed to consistently knock and announce themselves before entering the rooms of two cognitively intact female residents, with one CNA entering without any announcement and another entering while simultaneously saying "knock knock." Interviews with staff confirmed that facility policy requires knocking and announcing before entry to maintain resident privacy and dignity, but these procedures were not followed.
A resident with COPD and coronary artery disease, requiring continuous oxygen therapy, was found with their oxygen tubing disconnected from the oxygen machine despite the machine being on and set to deliver oxygen. The resident believed the oxygen was running, and the charge nurse confirmed the tubing was not properly connected. The care plan included oxygen interventions but lacked a specific focus area for COPD, and the facility did not provide a respiratory care policy when requested.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions, as observed in the care planning documentation.
A resident with severe cognitive impairment and high fall risk did not have access to a working call light system, as confirmed by the DON during testing. The care plan lacked interventions for a call system, and there was no maintenance log or work order for repair. The Administrator, responsible for maintenance, acknowledged the absence of routine checks and the need for manual resets on the aging call system, contrary to facility policy requiring functional call systems at all times.
The facility did not ensure accurate nutritional status monitoring for residents, as evidenced by missing height documentation, overdue scale calibration, and inaccurate meal intake records. Additionally, significant weight loss in two residents was not reported to the registered dietitian or physician, and a required nutritional evaluation was not completed. These failures affected all residents reviewed for nutrition and resulted in inadequate monitoring and assessment of their nutritional needs.
A resident with multiple health conditions was identified as being at risk for malnutrition, and their care plan required a Mini Nutritional Evaluation and possible dietician consultation. The assessment was started but not completed, and the RD was not informed of the need for the evaluation, resulting in the care plan interventions not being fully implemented.
Two residents with cognitive impairments did not have care plans accessible in the current electronic medical record system due to incomplete transfer of records during a system change. Staff relied on requesting information from the MDS Coordinator, but there was no specific training on this process, resulting in incomplete documentation as required by facility policy.
The facility failed to provide adequate supervision and security, resulting in several residents testing positive for amphetamines. Residents were observed smoking unsupervised, and the back door was not secured, allowing access to the outside area. This lack of supervision enabled substance use among residents, as confirmed by drug tests.
The facility failed to obtain informed consent for psychotropic medications for three residents, leading to deficiencies in their care. A resident with schizophrenia was given paliperidone without a signed consent form. Another resident with dementia and depression received medications like trazodone and paroxetine without proper consent, as the family member listed was unaware of the medications. A third resident with schizoaffective disorder was prescribed Seroquel and ABH gel without a physically signed consent form, despite facility policy requiring written consent.
A resident with multiple health conditions and limited mobility was left without access to a call light after returning from dialysis, causing her to be in pain and unable to call for help. The van driver who assisted her did not place the call light within reach, and the facility's policy requires call lights to be accessible to residents. The DON and Administrator acknowledged the oversight, noting the importance of call light accessibility.
A facility failed to report drug use and abuse allegations involving four residents who tested positive for amphetamines. Despite staff observations of suspicious behavior and unsupervised smoking, the facility did not report the findings to the state, believing it was unnecessary due to voluntary drug use. This oversight could contribute to further abuse and neglect among residents.
The facility failed to provide adequate respiratory care for two residents requiring oxygen therapy. A resident with a history of acute respiratory failure and COPD did not have an oxygen sign posted on his door despite having an oxygen tank and concentrator in his room. Another resident with acute respiratory failure and heart failure lacked appropriate signage, had no active physician order for oxygen, and had oxygen tubing on the floor, undated, and not properly maintained. The facility's policy required oxygen signs and proper dating of equipment, but these protocols were not followed.
A facility failed to coordinate hospice care and maintain required documentation for a resident receiving hospice services. The resident, with multiple health conditions, lacked necessary hospice forms in their records, including the Individual Election/Cancellation/Update and Physician's Certificate of Terminal Illness. The facility's administrator acknowledged the absence of these forms and the lack of assigned responsibility for ensuring proper documentation.
The facility failed to develop comprehensive care plans for seven residents, omitting specific instructions for bed-to-chair transfers despite varying assistance needs. Interviews revealed reliance on resident profiles for transfer information, but the omission in care plans posed a risk of incorrect transfers and potential injuries.
A resident's privacy was compromised during peri-care when CNAs failed to fully close privacy curtains, leaving the resident exposed while a roommate was present. The resident, with multiple medical conditions and moderate cognitive impairment, required assistance with ADLs. The facility's policy on dignity, which mandates privacy during personal care, was not followed.
Incomplete and Inaccurate Documentation of Wound Care in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident receiving wound care. The resident was an elderly male with dementia, surgical aftercare for the digestive system, HTN, muscle wasting, lymphedema, and DM, who was admitted with no cognitive impairment per BIMS and was totally dependent for transfer and mobility. His care plan included wound care for pressure ulcers, notifying the MD of changes, following treatment orders, use of a pressure-relief mattress, and nutritional supplements and proteins. Physician orders for March included wound care to the great toes bilaterally every shift, to the left and right heels on Tuesday/Thursday/Saturday, and to the sacrum every shift and PRN. Record review of the March Treatment Administration Record (TAR) showed multiple dates where ordered wound care was not documented. For the great toes, wound care was not documented on several specified dates; for the heels, wound care was not documented on two specified dates; and for the sacrum, wound care was not documented on multiple specified dates. The ADON stated that the resident had lymphedema with swelling and oozing to both legs and confirmed the wound care orders, including additional orders for both legs on specific days and PRN. The ADON identified LVN B and LVN C as the nurses responsible for the wound care and acknowledged she could not explain why the physician-ordered wound care was not documented on the TAR on the identified dates. Interviews with facility staff revealed that wound care was reportedly performed on some of the dates where no documentation existed. The Regional RN stated that the lack of documentation on one date corresponded with the resident being in the hospital for observation after a fall, and reported that LVN B told him wound care was done but not documented on another date. LVN A reported witnessing LVN C provide wound care on one of the undocumented dates but was unsure if it was charted. LVN B admitted applying a wound patch on one date but forgetting to document it. The ADON reported monitoring wound care on another undocumented date and having a photo of the sacrum as proof care was done, and a text message from LVN C stated she performed wound care on three of the undocumented dates. The DON stated that, to her knowledge, wound care was provided on several of the dates in question but not documented, despite the facility’s policy requiring that all services provided and changes in condition be documented in the medical record.
Unsafe Kitchen Sanitation and Food Handling
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During observation, built-up black residue was seen on the bottom of the convection oven, and the Director of Maintenance stated the oven had not been cleaned for about 2 weeks and had caked-on burnt food on the bottom and steel trays. The Director of Maintenance also stated that food being baked could be contaminated if crumbs fell on it. Cook P was observed with four baking sheets of chocolate chip cookies sitting uncovered on the prep table. She stated she had removed them from the convection oven less than 5 minutes earlier and said she should have covered them right away so they would not be contaminated by debris, but she had become busy washing dishes. In another observation, about 5 stacks of plate covers were stacked before they were dry, and the Director of Quality Assurance stated there was still water in between them and they should have been allowed to air dry before stacking. The facility also failed to maintain safe food temperatures for lunch served from the 200-hall cart. The Director of Maintenance took temperatures of the regular and puree diet trays and recorded items including pork chop with gravy, whipped sweet potatoes, and mixed vegetables at temperatures below the stated safe range. The Director later stated the pork should have reached 145 degrees and that the food served outside the safe range could result in the spread of foodborne illness. The kitchen hand-washing sink was also observed without running water on two occasions, and staff were seen washing hands at a sink by the stove. The Director of Maintenance stated the sink had not been working for about 2 weeks and that the sink normally used by dietary staff for handwashing was used for rinsing dishes.
Improper Garbage Disposal and Unsanitary Dumpster Area
Penalty
Summary
The facility failed to ensure staff disposed of garbage and refuse properly in 1 of 1 dumpster reviewed for trash disposal. During observation and interview, the dumpster located outside about 100 yards from the facility had about 2 servings of sweet potatoes on the ground a few feet from it, and the grounds around the dumpster were not clean and free from food items. The DM stated all staff used the one dumpster to dispose of trash, identified the food as sweet potatoes, and stated it could attract insects and rodents. The DM also stated the facility, including resident rooms, could become infested with insects and rodents, and that insects and rodents could carry diseases and infect residents. Review of the facility's sanitation policy stated garbage and refuse containers are to be properly covered and areas used for garbage disposal are to be free from odors and waste fats and maintained to prevent pests.
PASRR Level I screenings failed to identify mental illness diagnoses
Penalty
Summary
The facility failed to accurately complete PASRR Level I screenings for 3 of 8 residents reviewed for PASRR services by not identifying mental illness diagnoses on the screening forms. Resident #3’s record showed diagnoses including anxiety and schizoaffective disorder, bipolar type, and a quarterly MDS also listed schizophrenia. Her BIMS score was 3 of 15, reflecting severe cognitive impairment, and her care plan did not include her history of mental illness. During observation, she was in bed, answered only yes-or-no questions, and was unable to answer open-ended questions about her health condition. Resident #4’s record showed diagnoses including major depressive disorder, single episode, severe with psychotic features, and bipolar disorder, current episode depressed. His quarterly MDS documented bipolar disorder and depression, his BIMS score was 14, and his care plan included depression. However, his PASRR screening marked “No” for mental illness in section C0100. Resident #23’s record showed diagnoses including PTSD and depression, his quarterly MDS documented depression and PTSD, his BIMS score was 9, and his care plan focused on risk for depression. His PASRR screening also marked “No” for mental illness in section C0100. The MDS Coordinator stated that diagnoses reflecting mental illness should be added to PASRR Level I screenings and that a diagnosis of dementia would not negate an evaluation. He stated Resident #3’s schizoaffective disorder was not added, Resident #4’s major depressive disorder should have been added, and Resident #23’s PTSD should have been added. The Administrator stated the MDS Coordinator was responsible for ensuring PASRR accuracy. The facility policy and the Texas HHS PASRR Level I guidance both identified mental illness diagnoses such as schizophrenia, bipolar disorder, and major depressive disorder as examples that should be considered during screening.
Incomplete Care Plans for Mental Health, Ostomy Behavior, Smoking, and Wound/G-Tube Care
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for multiple residents, and the records and interviews showed that key care needs were not reflected in the plans. For Resident #3, the chart showed diagnoses including anxiety, depression, and schizoaffective disorder, bipolar type, along with severe cognitive impairment and communication problems, but the care plan did not include her history of mental illness or the care and services related to those conditions. The MDS Coordinator and DON both stated the care plan should reflect the resident’s care needs and services identified in the assessment, and that without this information staff would not know what care to provide. For Resident #20, the quarterly MDS documented an ostomy, and another resident reported that he removed his colostomy bag and threw it on the floor, leaving feces in the room and causing a bad odor. The care plan dated 2/1/26 did not include this behavior, and progress notes from 1/1/26 through 2/27/26 did not document it either. An LVN stated other nursing staff had reported the behavior, and the DON stated that if true it should have been included so staff would know how to address it. The facility also did not care plan smoking for Resident #23 and Resident #19, even though both smoking assessments identified them as safe smokers requiring supervision during smoking at all times, with cigarettes and lighters stored by the facility. Resident #23 was observed smoking with supervision in the designated smoking area, and the DON stated smoking should be care planned so staff would know whether the resident was a safe smoker and whether assistive items were needed. For Resident #18, the record showed orders for wound care to multiple foot and ankle areas and for gastrostomy-related care, but the comprehensive care plan did not include wound care or tube feeding-related care. The MDS Coordinator, ADON, and DON each acknowledged that the wound and gastrostomy-related care should have been reflected in the care plan and that the omission could affect the resident’s care.
Respiratory Care and Oxygen Storage Deficiencies
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents and in one room where oxygen cylinders were stored. Two portable oxygen cylinders were observed on the floor by a resident’s bed and dresser in a room, rather than being secured in a stand or stored in the designated oxygen storage room. An LVN stated the cylinders should not be on the floor because they could be knocked over, and the DON stated oxygen cylinders should be secured in a caddie or stand and stored in the oxygen storage room when not in use. Resident #48 had diagnoses including COPD, acute respiratory failure with hypoxia, and anoxic brain damage, and had severe cognitive impairment with a BIMS score of 03. Although the resident’s MDS coded oxygen therapy and the care plan directed oxygen administration as prescribed or per standing order, the physician order summary did not show an oxygen order. The resident was observed using oxygen on multiple occasions, including with the cannula under the chin while connected to a concentrator set at 4 liters per minute, and later with the cannula being placed on the face while the concentrator remained connected. On another observation, the resident was wearing oxygen in the common area and the concentrator was set below 2 liters per minute, approximately 1 liter per minute, with the maintenance light red until staff adjusted the setting. Resident #43 had diagnoses including atherosclerotic heart disease, sleep apnea, and diabetes mellitus, and the MDS identified non-invasive mechanical ventilator use for CPAP therapy. The resident’s care plan addressed CPAP therapy for sleep apnea. During observation, the resident’s CPAP mask was uncovered and connected to the machine on the nightstand. The resident stated she used CPAP every night, and an LVN stated the mask should have been covered with a plastic bag when not in use to prevent possible infection. The DON also stated the mask should have been covered in a plastic bag when not used.
Expired Medications and Missed Insulin Administration
Penalty
Summary
Pharmaceutical services were not provided to meet the needs of residents because expired medications and supplies were found in two medication carts. On the B-hall nursing cart, surveyors observed three 250 mL bottles of sterile water that had expired on 02/09/2026 and one spray bottle of safe simple-odor eliminate clear lubricant for ostomy pouch that had expired on 09/02/2025. On the A-hall nursing cart, surveyors observed one bottle of Geri care Iron supplement liquid ferrous sulfate 220 mg/5 mL that had expired on 07/2025 and one bottle of calcium carbonate 500 mg that had expired on 01/2026. Staff interviewed about the findings stated the expired items should have been removed from the carts per facility policy, and the DON stated expired medications should be removed because using them might not reach therapeutic effects. Resident #61, a 69-year-old female with metabolic encephalopathy, diabetes mellitus, and dementia, had an order for insulin glargine (Lantus/Basaglar) 10 units subcutaneously in the morning. Her insulin pen was observed in the A-hall nursing cart with an open date of 01/23/2026 and a label stating to discard 28 days after opening. The pen was still used on 02/25/2026 even though the 28th day after opening was 02/20/2026. The LVN stated the pen should have been discarded on 02/20/2026 and acknowledged using it on 02/25/2026 was her mistake. Resident #30, a 79-year-old female with fracture of the left lower leg, type 2 diabetes mellitus, and dementia, had orders for Basaglar 25 units at bedtime and insulin lispro per sliding scale at bedtime. The MAR showed the resident received the long-acting insulin as ordered, but there was no documented evidence that the short-acting insulin was given on 02/17/2026, 02/18/2026, 02/19/2026, and 02/20/2026. The DON stated the pharmacy staff deleted the short-acting insulin order from the system by accident, the order was restored on 02/21/2026, and the resident then resumed receiving the insulin. The DON and the nurse practitioner both stated the resident did not have any negative effect during the days the short-acting insulin was not given.
Infection Control Lapses During Wound, Catheter, and Incontinent Care
Penalty
Summary
The facility failed to establish and maintain infection control practices during wound care, catheter care, and incontinent care for four residents. Resident #71 was admitted with diagnoses including postoperative digestive system aftercare, hypertension, and lymphedema, had intact cognition, required substantial assistance with transfers, and had unhealed pressure ulcers/injuries. The resident’s care plan and physician orders included wound care, and the resident was supposed to be on Enhanced Barrier Precautions (EBP) because of wounds. During wound care, the ADON washed hands, donned gloves, and performed the treatment without wearing a gown, and there was no EBP sign on the resident’s door. The ADON stated she forgot the gown, and the DON stated the resident was supposed to have EBP and that the sign had not been placed on the door. Resident #7 had diagnoses including cerebral infarction, neuromuscular bladder dysfunction, and UTI, with moderate cognitive impairment and an indwelling urinary catheter. The resident’s care plan and physician order required EBP, including gown and gloves during high-contact care such as catheter care. During observation, CNA-L washed hands and provided indwelling urinary catheter care without putting on a gown, even though an EBP sign was posted on the door stating to use gown and gloves during high-contact resident care activities such as catheter care. CNA-L stated she forgot to wear a gown, and the DON stated the CNA should have worn one during catheter care. Resident #5 had diagnoses including epilepsy, restlessness and agitation, and schizoaffective disorder, with severe cognitive impairment and bowel and bladder incontinence. During incontinent care, CNA-O cleaned the resident’s groin and genital area, then removed the soiled brief and placed a clean brief under the resident without changing from old, dirty gloves to clean gloves. CNA-O stated she should have changed gloves before placing the clean brief. Resident #56 had diagnoses including orthopedic aftercare, fracture of the right femur neck, and infection following a deep incisional surgical site procedure, with severe cognitive impairment and bowel and bladder incontinence. During incontinent care, CNA-J cleaned the resident’s groin and penis area, did not pull back the foreskin, used multiple passes with one wipe, and then placed a clean brief under the resident without changing gloves. CNA-J stated she was nervous and should have changed gloves and used a new wipe with each stroke; the DON also stated the CNA should have changed gloves and used a new wipe with each stroke.
Incomplete Annual Competency Training Documentation
Penalty
Summary
The facility failed to ensure an effective training program was implemented and maintained for all existing staff for 4 of 8 staff whose records were reviewed for training: MA G, MA I, CNA J, and CNA K. Review of personnel files showed these staff, all hired on 3/1/25, had not completed their yearly competency skill set training. Their competency check off lists also did not include the trainer's name, and the completion date for training was left blank. Review of the CNA Orientation/Competency Checklist showed required training topics including system access, facility email, Teams, SharePoint, policies and procedures, LMS Relias, meetings, rounds, intake procedures, oral intake measurements, feeding and nourishment tasks, documentation, bedmaking, infection control, admission/discharge processes, ADL assistance, transfer techniques, hygiene, toileting, mobility assistance, observation documentation, reporting changes in resident status, and general duties. During interview, HR staff stated MA G and MA I were also CNAs and were required to complete the same competency training as CNAs, but the competency records did not show the trainer's name or date completed. The HR staff stated the DON and ADON trained staff, but she could not prove MA G, MA I, CNA J, and CNA K completed their yearly competency skill set training. The DON stated she and the ADON had competency training for multiple nursing staff during February 2026 but could not remember who they trained and could not attest that these four staff completed the competency skill set training.
Failure to Provide Privacy During G-Tube Medication Administration
Penalty
Summary
The facility failed to treat a resident with respect and dignity and to provide care in a manner and environment that maintained or enhanced quality of life when a nurse administered medication via the resident’s gastrostomy tube without providing privacy. Resident #3 was an 87-year-old female with dementia, gastrostomy tube status, and cerebral infarction. Her quarterly MDS showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, and her care plan noted tube feeding related to dysphasia and memory loss related to dementia. During observation, LVN-M entered the resident’s room and began administering one medication through the gastrostomy tube while the roommate was present in the room watching TV. The nurse did not pull the curtain or close the window blinds, and the roommate saw the medication administration. The resident was unable to be interviewed. LVN-M stated she should have used the curtain and closed the blind, and said she forgot to provide privacy because she was very nervous. The DON stated the nurse should have used the curtain and closed the window blind and that this was a violation of the resident’s right to privacy.
Failure to Obtain Consent for PRN Risperidone
Penalty
Summary
The facility failed to ensure that Resident #5 was informed of and participated in her treatment, including advance information about the risks and benefits of proposed care and treatment alternatives, because informed consent was not obtained for Risperdal (risperidone). Resident #5 was a female admitted with diagnoses of epilepsy, restlessness and agitation, and schizoaffective disorder. Her admission MDS reflected a BIMS score of 3 out of 15, indicating severe cognitive impairment, and she was assessed as having psychiatric/mood disorder and being on an antipsychotic medication. Her care plan addressed psychotropic medication use and directed staff to administer psychotropic medications as ordered and monitor for side effects and effectiveness every shift. The physician ordered risperiDONE 0.5 mg by mouth every 24 hours as needed for restlessness and agitation, and the MAR showed the resident received a dose on 02/12/2026 at 7:20 PM. During interview, the DON stated there was no consent in the resident's medical record for risperidone and that the facility should have obtained consent from the resident's responsible party before starting the psychotropic medication. The DON also stated she did not know why the nurses did not obtain the consent and identified the charge nurse as responsible for getting it.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure the call light was within reach for two residents, both of whom had significant cognitive impairment and required substantial assistance with multiple activities of daily living. One resident had diagnoses including mild intellectual disabilities, chronic pain syndrome, chest pain, cerebral palsy, and lack of coordination, with a BIMS score of 7 and substantial/maximal assistance needed for toileting hygiene, dressing, transfers, and bathing-related tasks. The other resident had diagnoses including Alzheimer’s disease, generalized anxiety, polyneuropathy, and joint pain, with a BIMS score of 5 and substantial/maximal assistance or supervision/touching assistance needed for toileting hygiene, dressing, personal hygiene, and transfers. During observation, both residents were found in bed with the bed in the lowest position and the head of bed elevated, while their call lights were placed on the dresser near the foot of the bed rather than within reach. One resident stated she did not think her call light worked and looked around her bed unable to find it. The other resident stated she had her call light, then felt around the bed and said she could not reach it or find it. The resident also pointed to her cellphone and stated she did not think it would call the facility. Later, one resident was heard yelling for assistance and for the nurse because of leg pain while staff at the end of the hallway could not hear her. A LVN entered the room, adjusted the bed, and offered pain medication, then left to get the medication without noticing the call light on the dresser. A CNA later placed the call light on the resident’s lap and also placed the other resident’s call light on her stomach, stating the call light should be placed near the resident. Another CNA stated both residents had been showered and that the call lights were forgotten. The DON and Administrator stated the call light should always be within reach and was how residents communicated with staff, and the facility policy stated each resident is provided with a means to call staff directly for assistance from the bed, toileting/bathing facilities, and the floor.
PRN Antipsychotic Order Exceeded 14-Day Limit
Penalty
Summary
The facility failed to ensure that a PRN order for risperiDONE, an antipsychotic medication, was limited to 14 days for one resident. Resident #5 was admitted with diagnoses including epilepsy, restlessness and agitation, and schizoaffective disorder. Her admission MDS reflected severe cognitive impairment with a BIMS score of 3 out of 15, and she was assessed as having psychiatric/mood disorder and being on an antipsychotic medication. Her care plan addressed use of psychotropic medications and directed staff to administer them as ordered and monitor for side effects and effectiveness every shift. Record review showed that Resident #5 had an order for risperiDONE 0.5 mg by mouth every 24 hours as needed for restlessness and agitation, started on 02/09/2026, with no stop date listed. The MAR showed she received risperiDONE on 02/12/2026 at 7:20 PM. During interview, the DON confirmed the PRN risperiDONE order should have been written for only 14 days and stated she did not know why it was written beyond that period. The facility policy titled Psychotropic Medication Use Policy stated that PRN orders for psychotropic medication are limited to 14 days.
MDS Assessments Did Not Reflect Anxiety Diagnoses
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for two residents whose records were reviewed. One resident was admitted with diagnoses including anxiety and schizoaffective disorder, bipolar type, but the quarterly MDS did not code an anxiety disorder. That resident’s BIMS score was 3 of 15, reflecting severe cognitive impairment. The care plan did not include the resident’s history of mental illness, including depression, anxiety, and schizoaffective disorder, bipolar type, and the record also noted impaired cognitive function related to dementia and a communication problem. During observation, the resident was lying in bed, answered yes-or-no questions, did not answer open-ended questions, and was unable to provide specific answers about health conditions. A second resident was admitted with a diagnosis including anxiety, but the quarterly MDS also did not reflect an anxiety disorder. That resident’s BIMS score was 15 of 15, indicating no cognitive impairment. The care plan noted the resident used anti-anxiety medication, Buspirone, with an intervention to administer anti-anxiety medication as ordered by the physician. During observation and interview, the resident was lying in bed, engaged in conversation, and discussed dissatisfaction with services and food, but did not answer other questions related to health condition. The MDS Coordinator stated the assessment should accurately reflect resident status so care areas can be transferred to the care plan and nursing staff know the resident’s care areas. The DON stated both residents’ MDS assessments did not reflect a diagnosis of anxiety disorder and that assessments should accurately reflect resident status to ensure needed care and services.
PASARR Services Not Reflected in Care Plan
Penalty
Summary
The facility failed to coordinate assessments with the PASARR program and did not incorporate the recommendations from the PASARR Level II determination and evaluation report into the care plan for Resident #42. Resident #42 was admitted with diagnoses including anxiety, depression, schizoaffective disorder, bipolar type, and mood disorder due to a known physiological condition with depressive features. His quarterly MDS documented depression and schizophrenia, and his BIMS score was 15 of 15, indicating no cognitive impairment. His care plan dated 12/10/25 addressed psychotropic medication use and a mood problem, with interventions to administer medications as ordered, but it did not indicate that he was PASARR positive or that he was receiving habilitative services. A quarterly meeting between the local authority, the resident, and facility staff documented that Resident #42's service plan was updated and that he chose to continue habilitative services. During observation and interview, Resident #42 was lying in bed and engaged in conversation, but attempts to ask him about PASRR services were unsuccessful. The MDS Coordinator stated that the care plan did not include a focused area related to PASARR habilitative services identified in the PASARR service plan for coordination of care, and acknowledged that the care plan should reflect the resident's care needs and services identified by the local authority.
Failure to Complete Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #4 and Resident #70. The facility record review showed that neither resident had a baseline care plan completed at all. Facility policy stated that a baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within 48 hours of admission and includes instructions needed to provide effective, person-centered care that meets professional standards of quality care. Resident #70's face sheet showed admission with diagnoses including unspecified atrial fibrillation, essential hypertension, and hyperlipidemia. Her 5-day MDS indicated she was Hispanic/Latino, had a BIMS score of 9 out of 15, had adequate hearing, and required partial to moderate assistance for most ADLs. Observation found her lying in bed with a water jug on the bedside table, speaking Spanish, and appearing not to hear questions clearly. Her upper and lower teeth were observed to be decaying and dark brown. During interviews, staff stated she was a new admission and that baseline care planning had not been completed; the DON also stated she had noted the decaying teeth and planned to add her for dental services, but had not spoken with social work about a dental referral. Resident #4's record showed diagnoses including other spondylosis with radiculopathy, bipolar disorder, senile degeneration of brain, chronic pain syndrome, dysphagia, unspecified dementia, polyneuropathy, anxiety, and other listed conditions. His quarterly MDS showed a BIMS score of 14, indicating intact cognition. Observation found him sitting in a wheelchair watching television, and he stated staff took care of him and shaved him when he let them. Interviews with the MDS Coordinator and Administrator showed differing understandings of responsibility for care planning, with the MDS Coordinator stating baseline care plans were done by RNs on admission and the DON or ADON initiated them, while the Administrator stated care plans were the responsibility of the MDS Coordinator and Social Worker. Both residents lacked completed baseline care plans in the electronic record.
Unsafe Mechanical Lift Transfer and Missed Smoking Assessment
Penalty
Summary
Nursing staff failed to ensure safe use of a mechanical lift during a transfer of a resident who was dependent on staff for chair/bed-to-chair transfers. During an observation, CNA E and MA F transferred the resident from a wheelchair to a bed using a mechanical lift, but the wheelchair was not locked before the lift was used. MA F operated the lift without applying the brakes, narrowed the base of the lift while the resident was suspended in the air, and then lowered the resident onto the bed. CNA E assisted with the transfer and guided the resident during the process. The resident involved had diagnoses including transient ischemic attack, morbid obesity, and muscle wasting and atrophy of both upper arms. Her annual MDS showed a BIMS score of 15 out of 15 and indicated she was dependent on nursing staff for transfers. The care plan identified a risk for self-care deficit, but it did not address transfers or how many staff should assist during a transfer. During interview, CNA E stated the wheelchair should have been locked to prevent it from rolling, and MA F stated the lift base should have been widened for stability and locked when lifting and lowering the resident. The facility also failed to conduct quarterly smoking assessments for another resident who was smoking at the facility. The resident’s record showed a smoking assessment dated 08/21/2025 stating she was safe to smoke with supervision and that cigarettes and lighters would be stored by the facility, but no further smoking assessments were found through 02/27/2026. The resident’s comprehensive care plan did not include a smoking care plan. The DON stated the resident had been smoking since admission and acknowledged that smoking assessments should have been completed quarterly, consistent with the facility’s smoking policy.
Incontinent Care Not Provided Per Policy for Two Residents
Penalty
Summary
The facility failed to ensure appropriate incontinent care was provided to two residents who were incontinent of bowel and bladder. Resident #5, a female with severe cognitive impairment, epilepsy, restlessness and agitation, and schizoaffective disorder, was assessed as always incontinent of bowel and bladder and had a care plan directing staff to clean the peri-area with each incontinence episode. During observation, CNA-O opened the resident’s dirty brief and cleaned the groin and genital area without opening the resident’s labia area before cleaning the buttocks. CNA-O stated she did not open the labia area, and later stated she should have done so. The DON also stated the labia area should have been opened to prevent possible infection. Resident #56, a 38-year-old male with severe cognitive impairment, required substantial/maximal assistance with transfers and was always incontinent of bowel and bladder. During observation, CNA-J provided incontinent care to the resident, who was uncircumcised, but did not pull back the foreskin before cleaning the penis and used multiple passes of one wipe. CNA-J stated she did not pull back the foreskin and used multiple passes because she was very nervous, and stated she should have pulled back the foreskin and used a new wipe with each stroke. The DON stated the foreskin should have been pulled back and a new wipe should have been used with each stroke. The facility policy on perineal care required separating the labia for females and, for uncircumcised males, gently pulling back the foreskin and wiping from the urethral opening outward with a new wipe each stroke.
Failure to Implement Fluoxetine Gradual Dose Reduction
Penalty
Summary
The facility failed to act on a pharmacist’s drug regimen review recommendation for Resident #42, who had diagnoses including depression and schizoaffective disorder bipolar type and a BIMS score of 15/15. The resident’s care plan identified use of fluoxetine as an antidepressant medication, and the physician orders in February 2026 showed fluoxetine 10 mg and fluoxetine 40 mg given together to equal 50 mg daily. A pharmacy consultant recommendation dated 1/25/26 called for a gradual dose reduction of fluoxetine, and the physician agreed by issuing a new order to discontinue the 50 mg daily dose and start 40 mg daily on 2/5/26. However, review of the February 2026 MAR showed the resident continued to receive fluoxetine 10 mg and 40 mg to equal 50 mg daily from 2/1/26 through 2/27/26. The DON acknowledged that the resident was still receiving 50 mg daily and stated it was important to follow the pharmacist recommendations and physician orders.
Incorrect Indication Entered for Trazodone Order
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary drugs because nursing staff did not document an appropriate indication for Trazodone. Resident #5 had diagnoses including Alzheimer’s disease and a BIMS score of 0 of 15, reflecting severe cognitive impairment. Her consent dated 7/31/25 authorized Trazodone 150 mg at bedtime for depression, and her February 2026 physician orders showed Trazodone 150 mg at bedtime with the indication entered as Alzheimer’s disease, unspecified. Record review showed the resident had previously been receiving Trazodone 100 mg at bedtime related to major depressive disorder, recurrent, unspecified, with that order discontinued on 2/18/26 and replaced by the 150 mg order. During interview, the DON stated the resident was taking Trazodone for depression and not for Alzheimer’s disease, and acknowledged the indication in the order was incorrect. The DON also stated the nurse who received the order was responsible for entering it correctly and that she and the DON reviewed orders every morning for accuracy, but she did not remember reviewing this resident’s orders.
Medication Storage and Labeling Deficiency
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored in secured locations for two residents reviewed. Resident #58, a female with schizoaffective disorder, type 1 diabetes mellitus, and hypertension, had an order for insulin glargine-yfgn 10 units subcutaneously at bedtime. On observation, her insulin pen was found inside the A-hall nursing cart with no open date written on it, even though the pen label stated to discard after 28 days. The LVN stated that without an open date, nurses would not know when to discard the insulin pen, and the DON stated the open date should have been written on the pen because using old insulin might affect therapeutic effects. Resident #53, a male with chronic embolism and thrombosis of vein, diabetes mellitus, and hypertension, had severe cognitive impairment and was dependent for transfers and toileting. On observation, one tube of antifungal ointment cream was left unattended on his nightstand while he was sleeping. The LVN stated the resident did not have an order for the antifungal ointment and that the resident's family might have brought it from home, and also stated any medication should have been stored in the locked carts to prevent other residents from using it. The DON stated that any medication, including medications brought from home, should have been stored in the locked carts.
Failure to Obtain Ordered Dentures
Penalty
Summary
The facility failed to provide or obtain routine dental services for Resident #42, who was admitted with diagnoses including anxiety disorder and type 2 diabetes mellitus and had a BIMS score of 15 of 15. The resident’s care plan did not address that he was edentulous or include a plan to refer him to a dentist for dentures. During observation and interview, the resident stated he had been waiting for his dentures for months, did not want a mechanical soft diet, and wanted to be able to chew his food and shave properly. The social worker stated the facility changed dental providers about three times, and the most recent provider completed the exam and moldings for dentures but did not submit the order to have them made. The social worker also stated she had not called any community dentist after a local dentist would not accept the resident’s insurance and had not followed back up to ensure the dentures were being produced. The DON stated the provider had said the order to make the dentures fell between the cracks and that the provider would resubmit the order and mail the dentures, but the DON had not reached out to confirm they were made and sent.
Menu Substitution Not Communicated to Residents
Penalty
Summary
The facility failed to follow the posted menu for lunch on 2/26/26. The week-at-a-glance monthly menu for Fall/Winter 2025-26 showed that lunch was to include sliced pork with gravy, whipped sweet potato, seasoned spinach, honey kissed roll, margarine, and fruit cobbler. During observation at 12:15 PM, residents were served sliced pork with gravy, whipped sweet potato, mixed vegetables, honey kissed roll, margarine, and fruit cobbler instead of the spinach listed on the menu. The dining room had a posted sign showing the lunch meal per the menu, and a smaller sign stated there may be substitutions. During interview, the DM stated she posted a general notice that substitutions could occur but did not post that mixed vegetables were being substituted for seasoned spinach. The DM also stated she met with the resident council at scheduled meetings and that residents asked her to remove spinach from the menu, but she did not discuss it with all residents and did not notify the facility Dietician of the menu changes. The DM further stated she realized not all residents voted on what food items to remove and that some residents might not want the same items removed or the substitutions.
Unlabeled and Undated Food in Resident Refrigerators
Penalty
Summary
The facility failed to have a policy regarding the use and storage of foods brought to residents by family and other visitors, and surveyors found unlabeled and undated food items in residents’ personal refrigerators. Resident #18, an older male with protein-calorie malnutrition, a stage 3 buttock pressure ulcer, and gastrostomy status, was observed sleeping in his room with a personal refrigerator that contained a small plastic cup of food with no date and no label. An LVN stated the item was not dated or labeled and said the night nurses were supposed to check the refrigerator daily. Resident #61, who had diagnoses including multiple sclerosis, dementia, and a traumatic brain injury sequela, had a BIMS score of 15 and required varying levels of assistance with care. Her care plan included interventions related to knowledge deficit and nutrition. During observation, her personal refrigerator contained ice buildup, a thermometer, six small cups of Jello and pudding from the kitchen that were not dated, and four glasses of apple juice that were not dated. The resident stated she ate the items later if she did not like the kitchen food and said staff did not check her refrigerator or its temperature. On a later observation, the refrigerator still contained four dessert cups, three with beads of clear liquid inside the lids and no dates. An LVN stated food items should have dates to help ensure freshness and said staff did not go through resident refrigerators. The DON stated the facility did not monitor residents’ personal refrigerators and did not believe there was a policy for them. The Administrator also stated there was no policy regarding personal refrigerators and who was responsible for them, while the RNC stated the facility was responsible for monitoring them and checking expiration dates, but acknowledged there was no policy regarding personal refrigerators.
Missing QAPI Training for Staff
Penalty
Summary
Mandatory training on the facility’s QAPI program was not completed for all staff. Review of personnel files showed that MA G, an unlicensed staff member, and LVN H, a licensed staff member, had not completed QAPI training. During interview, the HR staff stated she had been in her position for a few months and was responsible for ensuring all employees completed required training. She confirmed that MA G and LVN H had not completed QAPI training and was unable to provide the facility policy on completing QAPI training by the end of the survey.
Failure to Perform Required Bed Rail Safety Assessments and Maintenance
Penalty
Summary
The deficiency involves the facility’s failure to follow its own bed safety and bed rail policy and the resident’s care plan requirements for assessment and monitoring of bed rails. The facility was required to assess residents for safety risks related to bed rails, review risks and benefits with the resident or representative, obtain informed consent, and ensure proper installation and maintenance of bed rails. For one resident, the facility did not complete the required quarterly bed rail safety assessments as outlined in the comprehensive care plan, which specified that nurses would review bed rails quarterly to minimize risks and ensure the device was least restrictive. The resident involved was an adult female with diagnoses including hypertensive heart disease, obesity, and muscle wasting and atrophy. Her Quarterly MDS showed intact cognition with a BIMS score of 15/15, no functional limitation in range of motion of upper and lower extremities, and dependence on staff for chair-to-bed and toilet transfers, requiring mechanical transfers with two persons. The care plan and physician orders documented the use of bilateral one-quarter bed rails to promote independence with bed mobility and positioning, and a bed rail assessment completed in May 2025 indicated that side rails/assist bars were appropriate and served as an enabler to promote independence. However, there were no subsequent bed rail assessments completed for the second and third quarters of 2025. During observation, surveyors noted that the resident’s bed had bilateral one-quarter bed rails in the up position, and a CNA was unable to lower either rail because they were jammed. The CNA and an LVN both stated they were unaware that the bed rails could not be lowered and reported that the resident had not complained about the rails. The DON acknowledged that the bed rails should have been able to be lowered without difficulty for safety, confirmed that quarterly bed rail assessments were not completed as required, and stated that because these assessments were not done, the facility did not know the bed rails were not functioning correctly. The facility’s written policy required that bed rails be properly installed and used according to manufacturer’s instructions and that residents be evaluated for bed rail use if alternatives did not meet their needs, but these processes were not carried out as required for this resident.
Verbal and Physical Abuse of a Resident by RN and Failure to Investigate Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse by a registered nurse. The resident was an adult female with a history of diffuse traumatic brain injury, mood disorder due to a physiological condition, anxiety disorder, unsteadiness on feet, cognitive communication deficit, insomnia, conversion disorder with seizures, speech and language disorder following cerebral infarction, cerebral infarction, and left-sided hemiplegia/hemiparesis. Her discharge MDS showed moderately impaired cognition with a BIMS score of 10. Her care plan noted a history of reporting that care had not been provided when it had, claiming staff tossed her down hallways without evidence of injury, and throwing herself out of bed while stating someone else had thrown her. On the morning of 10/4/25 at approximately 5:20 a.m., an LVN heard a CNA calling from the resident’s room, reporting that the resident was kicking and punching her and asking the LVN to witness the behaviors. The LVN documented in a nursing note that the resident was hitting and kicking the CNA, that staff assisted and changed the resident into clean clothes, and that the resident came out of her room naked with her breasts exposed after taking off her clean shirt. The LVN’s later written statement described that when the RN arrived, the resident came out of her room shirtless with her breasts exposed, and the RN shouted, in the presence of the CNA, “What is this a fucking whore house, out here for everybody to see your tits,” then wheeled the resident back to her room. Inside the room, according to the LVN’s statement, the RN pulled the resident’s shirt off aggressively and continued verbal abuse, calling the resident a “fucking whore” and stating this was a place of business, not a whore house. The RN reportedly acknowledged to the LVN and CNA that she “went a little overboard” and that she knew it was verbal abuse. The LVN’s statement further described that after the three staff went outside briefly, they saw through a window that the resident again had her shirt off with her breasts exposed. The RN extinguished her cigarette, stated she was “done,” and went back inside, followed by the LVN. The RN then pushed the resident in her wheelchair very fast and aggressively, leaned to the resident’s ear, and called her a “fucking whore” and “slut,” adding that this was why her husband left her there because he did not want a whore. The RN then, at full force, pushed the resident into her room and released the wheelchair, causing it to roll into the room and slam into the bed, which the LVN heard as a loud thud along with the resident’s scream. The LVN reported that the RN ripped the shirt off the resident’s contracted arm, causing the resident to say, “stop that hurts you bitch,” and then aggressively and forcefully removed the sweater and put on another shirt while continuing to call the resident a slut and whore, before leaving and slamming the door. The LVN stated she checked the resident for injuries and found none but did not document this assessment. A subsequent skin assessment on 10/7/25 documented no new or unusual markings or bruises. Another CNA corroborated that the resident was combative and agitated that morning and that she saw the RN get aggressive by pushing the resident into her room, calling her a slut, and shutting the door. Another resident reported being awakened by the RN yelling and hearing the RN call someone a whore and a slut, and later being told by the RN that she had been talking to the resident because she was naked. The facility did not complete an investigation report for the 10/4/25 incident at the time it occurred, despite having a written abuse, neglect, and exploitation prevention policy requiring identification and investigation of all possible incidents of abuse and protection of residents from abuse by anyone.
Removal Plan
- Report the incident to HHSC.
- Start an in-service for all staff on abuse and neglect.
- Complete a head-to-toe assessment by nursing for Resident #1.
- Notify the responsible party of Resident #1 of the incident.
- Conduct resident safety interviews.
- Terminate RN A.
- Have Resident #1 evaluated by a mental health professional.
Failure to Immediately Report and Investigate Alleged Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of verbal and physical abuse of a resident by a registered nurse to the abuse coordinator and appropriate authorities, as required by regulation and facility policy. A female resident with a history of traumatic brain injury, mood disorder, anxiety disorder, cognitive communication deficit, cerebral infarction with resulting hemiplegia/hemiparesis, and moderately impaired cognition (BIMS score of 10) was the subject of the alleged abuse. Her care plan noted a history of making false accusations and claiming care had not been provided, but the incident in question was directly witnessed and described in detail by staff. The facility’s policy on Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating required that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source be reported immediately to the administrator and other officials, with “immediately” defined as within two hours for allegations involving abuse or resulting in serious bodily injury. On the early morning in question, an LVN documented that she was at the nurses’ station when a CNA called from the resident’s room, stating the resident was kicking and punching her and asking the LVN to witness the behaviors. The LVN’s written statement described that when the RN arrived, the resident attempted to remove her shirt, came out of her room shirtless with her breasts exposed, and the RN loudly used profane and degrading language, referring to the environment as a “whore house” and commenting on the resident’s exposed breasts. The LVN stated that the RN wheeled the resident back to her room, aggressively pulled off the resident’s shirt, and continued verbally abusing her with repeated profanities and derogatory terms. Later, after the RN and staff briefly went outside, they saw the resident again without her shirt; the LVN reported that the RN reacted by forcefully pushing the resident in her wheelchair very fast into her room, leaning into the resident’s ear and calling her further profane and degrading names, then pushing the wheelchair into the room at full force so that it slammed into the bed, followed by aggressively removing the resident’s clothing and continuing the verbal abuse. The LVN stated she checked the resident for injuries after the incident and found none, but she did not document this assessment in the record. The nursing progress note entered by the LVN that morning only described the resident as hitting and kicking the CNA, being changed into clean clothes, coming out of the room naked with breasts showing, being instructed to keep clothes on, and being clothed at that time; it did not document the RN’s alleged verbal or physical abuse. No facility investigation report was completed for this incident at the time, and the incident was not immediately reported to the administrator or authorities. The LVN later stated she knew from training that she was supposed to report the incident immediately but delayed, initially attempting to follow chain of command by contacting the DON and believing the incident occurred on a different date. The administrator confirmed he was not informed until several days later, at which time the alleged perpetrator acknowledged telling the resident she was “acting like a whore” and pushing the resident into her room without controlling the wheelchair. Another CNA corroborated that the RN was aggressive, pushed the resident into her room, called her a slut, and shut the door, and a neighboring resident reported hearing the RN yelling and calling someone a whore and a slut. The delay in reporting and lack of immediate investigation and documentation led surveyors to identify noncompliance at the Immediate Jeopardy level from the date of the incident until several days later.
Removal Plan
- Incident reported to HHSC.
- 3613-A report sent to HHSC with the investigation findings.
- Inservice over abuse and neglect started for all staff.
- Head to toe assessment completed by nursing for Resident #1.
- Responsible party of Resident #1 notified of incident.
- Resident safe interviews conducted.
- RN A terminated.
- Resident #1 evaluated by a mental health professional.
Unlocked Med Cart and Improper Narcotic Handling and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were stored and controlled in accordance with its own policies and accepted professional standards. During an observation, the B hall medication cart was found positioned on the side of the nursing station facing the hallway and left unlocked, while the assigned LVN was seated at the nurses’ station and not in view of the cart. The LVN acknowledged that the cart was unlocked and stated it should not be left in that condition. The facility’s written policy required that compartments containing medications and biologicals, including carts, be locked when not in use and not left unattended if open or otherwise available to others. The surveyor’s review of records for one resident showed an active order for hydrocodone/acetaminophen 7.5-325 mg, to be given every six hours as needed for pain, with the last administration documented on the MAR as occurring that afternoon. When the LVN and an RN later counted the narcotic medications in the B hall cart, the narcotic count sheet for this resident’s hydrocodone/acetaminophen indicated 17 tablets remaining, but the blister package contained only 16 tablets. The narcotic log showed the LVN had last signed out the medication the previous day, even though the LVN stated he had administered a dose that day and had forgotten to document it on the narcotic sheet. The LVN stated that the narcotic log needed to be completed at the time of dispensing to show who had given the medication. During the same narcotic count, the surveyor observed another resident’s blister pack of hydrocodone/acetaminophen 5-325 mg with a broken seal over one of the pills, although the pill remained in the package. The RN asked the LVN if tape could be placed over the package, and the LVN responded that the pill should be discarded. Both then decided to discard the pill. The RN initially dispensed a pill from a different resident’s blister pack of an unknown medication to discard, and the surveyor pointed out that the patient and medication did not match the observed blister pack. The RN and LVN then located and discarded the correct pill from the broken blister pack. The LVN later stated that any blister packs with a hole and the medication still inside should be discarded because they could have been tampered with or might not be the correct medication. The facility’s policies required controlled substances to be securely stored, properly documented, and any broken blister packs to be wasted with two staff as witnesses.
Failure to Update Care Plan and Orders to Reflect Resident DNR Status
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident’s code status. The resident, an elderly female with severe cognitive impairment (BIMS score of 4) and diagnoses including unspecified dementia, depression, epilepsy, paranoid schizophrenia, and Alzheimer’s disease, was admitted with documentation in the admission record and care plan indicating a Full Code status. Her active physician orders also listed her as Full Code. However, the electronic medical record contained a DNR form signed by her responsible party, and hospice documentation from an interdisciplinary group meeting listed her code status as DNR. Interviews and record review showed that the change in code status to DNR was not communicated or incorporated into the resident’s care plan or active orders. The DON reported downloading DNR information into the resident’s file and keeping hard copies, and stated that either she or the MDS nurse would enter the code status into the care plan, but she did not know why this resident’s code status was not updated. The social worker stated that code status would be addressed in care plan meetings and believed the MDS nurse would update the care plan when a DNR was written. The MDS nurse stated that no one had communicated the code status change to him, suggested hospice may not have written a DNR order or informed the charge nurse, and noted he had been in the position for only two months and that no care plan meetings had been held prior to his tenure. As a result, the resident’s care plan and active orders continued to reflect Full Code despite existing DNR documentation.
Failure to Accurately Update and Align Code Status Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records regarding a resident’s code status in accordance with accepted professional standards. A female resident with diagnoses including unspecified dementia, depression, epilepsy, paranoid schizophrenia, and Alzheimer’s disease was admitted with documentation on her admission record, face sheet, care plan, electronic medical record opening page, and active physician orders all indicating a code status of Full Code. Her most recent MDS showed a BIMS score of 4, indicating severe cognitive impairment. Despite this, an out-of-hospital DNR (OOH-DNR) form signed by her responsible party was filed only under Miscellaneous documents in the electronic medical record, and the resident’s code status was not updated in the care plan, admission record, or active orders. Further record review showed that a hospice interdisciplinary group meeting report listed the resident’s code status as DNR, but this information was not reflected in the facility’s primary clinical documentation or physician orders. In interviews, the Social Worker stated that code status would be addressed in care plan meetings and that she believed the MDS Nurse would update the care plan when a DNR was written. The DON reported that she downloaded DNR information into the resident’s file and kept hard copies, and that either she or the MDS Nurse would enter the code status into the care plan, but she did not know why this resident’s code status was not updated or why physician’s orders were not obtained. The MDS Nurse stated that no one had communicated that the resident’s code status had changed and suggested that hospice either did not write a DNR order or did not provide the information to the charge nurse to update the orders.
Failure to Document and Address Resident Grievance Following Verbal Altercation
Penalty
Summary
The facility failed to ensure that residents could voice grievances without discrimination or reprisal, as required by policy. On the morning of 8/14/2025, a resident with a history of mood disorder and schizoaffective disorder became involved in a verbal altercation with another resident who had dementia and impulse disorders. The incident began when the first resident refused to share his personal coffee creamer with the second resident, leading to a shouting match with exchanged insults. The situation escalated to the point that other residents in the dining room were emotionally disturbed. Following the altercation, the first resident was visibly upset and reported his complaint about the other resident's behavior to LVN A, expressing that he felt his grievance was not being taken seriously. Despite the resident's clear attempt to voice a grievance, LVN A did not generate a grievance report as required by facility policy, although she did document the incident in the nursing progress notes and reported it to the RN supervisor. The facility's grievance log for the month was found to be blank, indicating that no grievances were documented, including this incident. Interviews with staff and review of facility policy confirmed that all grievances, whether oral or written, should be documented and reported to leadership for investigation and resolution. The DON was unaware of the grievance and stated that both LVN A and the RN supervisor were responsible for ensuring grievances were documented and reported to the grievance coordinator. The failure to document and address the resident's grievance represented a violation of the residents' rights and facility policy.
Failure to Timely Report Alleged Abuse and Exploitation Between Residents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source and misappropriation of resident property—were reported immediately, as required by regulation. On the morning of 8/14/2025, a verbal altercation occurred between two residents in the dining room, during which one resident attempted to take another resident's personal coffee creamer, leading to a shouting match with cursing insults exchanged. The incident was witnessed by LVN A, who intervened and redirected the residents but did not report the allegation of verbal abuse and exploitation to the Administrator or follow the facility's established reporting procedures. A review of the residents' records revealed that both individuals involved had significant mental health and cognitive diagnoses. One resident had a history of mood disorder and schizoaffective disorder, with a care plan noting a potential for verbal aggression and a BIMS score indicating moderate cognitive impairment. The other resident had dementia, anxiety, and impulse disorders, with a care plan also noting a potential for verbal aggression and a BIMS score indicating cognitive intactness. Despite these risk factors and the escalation of the incident, the required immediate reporting to facility leadership and state authorities did not occur. Interviews confirmed that LVN A documented the incident in the nursing progress notes and reported it to the RN supervisor but did not escalate the report to the DON or Administrator as required. The DON later confirmed that she had not received any report of the incident and reiterated that staff had been trained to report all allegations of abuse, neglect, or exploitation. A review of the facility's policy confirmed the requirement for immediate reporting of such incidents to the Administrator and appropriate authorities, which was not followed in this case.
Failure to Update Care Plan for Resident's Arm Sling Post-Hospitalization
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who returned from hospitalization with a left arm fracture. Despite physician orders requiring the resident to wear a stabilization arm sling, the care plan did not include any focus, goals, or interventions related to the use of the sling. Record reviews confirmed that the care plan was not updated to reflect the new care needs following the resident's return from the hospital. Observations showed the resident using a soft cast and sling, and interviews with nursing staff and the DON confirmed that the care plan lacked documentation for the prescribed sling, even though staff were aware of and assisted with the sling as ordered. The resident had a history of hemiplegia and required assistance with activities of daily living. The omission in the care plan was identified through review of medical records, staff interviews, and direct observation. The facility's own policy required that care plans be comprehensive and person-centered, including measurable objectives and interventions based on thorough assessment, but this was not followed in the case of the resident's new need for arm stabilization.
Failure to Maintain Infection Control: Improper Oxygen Tubing Storage and Hand Hygiene Lapses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving three residents. For one resident requiring continuous oxygen therapy due to chronic obstructive pulmonary disease and coronary artery disease, the oxygen tubing was observed uncovered and lying on the floor, both at the oxygen machine and portable tank. The tubing was not stored in a protective bag as required, and staff confirmed that such storage was necessary to prevent contamination. The resident was unaware that the tubing was not connected to the machine, and staff acknowledged the tubing was contaminated and needed replacement. Additionally, two certified nursing assistants (CNAs) were observed distributing meal trays to residents without performing hand hygiene between residents. One CNA provided a meal tray and set up the meal for a resident, then immediately proceeded to the next resident's room and handled another meal tray without sanitizing their hands. The second CNA followed a similar process, setting up a meal tray for a resident and then moving to another room without hand hygiene. Both CNAs acknowledged during interviews that hand sanitization was required between residents to prevent infection, and the facility's policy confirmed this expectation. The facility's own infection control policies, including those on standard precautions and hand hygiene, were not followed in these instances. The policies require hand hygiene before and after resident contact and proper handling and storage of resident-care equipment to prevent contamination. These failures were directly observed and confirmed by staff interviews and record reviews, demonstrating a breakdown in adherence to established infection control protocols.
Failure to Ensure Resident Privacy and Dignity During Room Entry
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence, self-determination, and communication by not ensuring staff consistently knocked and announced themselves before entering residents' rooms. Specifically, a CNA entered a female resident's room without knocking or announcing, interrupting an interview with a State Surveyor, and proceeded to set up the resident's meal tray before leaving. The resident, who had an intact cognitive status as indicated by a BIMS score of 14 out of 15, confirmed that she did not hear the CNA knock or announce their presence. In another instance, a different CNA entered another female resident's room while simultaneously saying "knock knock" as they walked in, rather than before entering. This resident also had an intact cognitive status, with a BIMS score of 15 out of 15. Interviews with staff, including CNAs, LVN, ADON, DON, and the Administrator, revealed that the facility's policy requires staff to knock and announce themselves before entering residents' rooms to maintain privacy and dignity. However, the observed actions did not align with this policy, as staff either failed to knock or did so while entering, rather than prior to entry. The facility's written policy on residents' rights also emphasizes the importance of privacy, dignity, and respect, which was not upheld in these instances.
Failure to Ensure Proper Oxygen Administration for Resident Requiring Respiratory Care
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and coronary artery disease, who required continuous oxygen therapy, was observed wearing an oxygen nasal cannula that was not connected to the oxygen machine. The oxygen machine was on and set to deliver two liters per minute, but the tubing was disconnected at the machine end, resulting in the resident not receiving the prescribed oxygen. The resident, who had moderate cognitive impairment, stated he wore the oxygen all the time and believed it was running, though he did not feel short of breath at the time of observation. The charge nurse confirmed that the oxygen tubing was not connected to the machine and acknowledged the risks associated with improper oxygen setup. The resident's care plan included interventions for oxygen therapy, but there was no documented focus area specifically for COPD. Additionally, when the facility's respiratory care policy was requested, it was not provided before the survey exit.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized planning to meet the resident's assessed needs.
Failure to Provide Functional Call Light System for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, high fall risk, and significant physical limitations did not have access to a functional call light system in her room. The resident, who was dependent on staff for transfers and had a history of falls, was observed to lack a working call light, which was confirmed through direct testing by the Director of Nursing (DON). The call light failed to activate at the room wall panel, hallway indicator, or nurse's station, while the roommate's call light was functional. The resident's care plan did not include interventions for a call system, and her fall risk assessment indicated a high risk. Interviews revealed that there was no work order for repair of the call light, no maintenance log for checking call light functionality, and no maintenance staff employed at the time. The Administrator, who was responsible for maintenance, acknowledged the lack of routine checks and explained that the call system was older and sometimes required manual resetting. The facility's policy required that each resident have a functional call system at all times, and alternative communication means should be documented in the care plan if the resident could not use the standard system. The deficiency was identified through observations, interviews, and record review.
Failure to Maintain Accurate Nutritional Status and Documentation
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, including usual or desirable body weight, for all residents reviewed for nutrition status. Specifically, there was a lack of documented heights for all 58 residents, which prevented accurate calculation of BMI and assessment of nutritional needs. Multiple dietary consultant reports noted missing heights and recommended obtaining them, but these were not entered into the current electronic medical record system due to data transfer issues from the previous system. The registered dietitian confirmed that the absence of height data hindered his ability to track low BMIs and provide appropriate interventions. The facility also failed to maintain proper calibration and inspection of the scale used for weighing residents. The last inspection was overdue, and the scale had not been calibrated as required by the manufacturer's maintenance schedule. Staff interviews revealed that the scale's calibration was not up to date, and there was confusion about the accuracy of weights being recorded. Additionally, meal intake percentages were inaccurately documented in advance in the electronic medical record for several residents, with some meals being charted before they were actually consumed. Observations showed discrepancies between the documented intake and what residents actually ate, and staff interviews confirmed that some CNAs were entering meal percentages prematurely or inaccurately. Furthermore, the facility did not notify the registered dietitian or physician when significant weight loss occurred in two residents. There was also a failure to complete a Mini Nutritional Evaluation for a resident as required by her care plan. These actions and inactions, including inaccurate weight and intake documentation, lack of timely communication with clinical staff, and missing nutritional assessments, contributed to the deficiency in maintaining residents' nutritional status.
Failure to Complete Nutritional Assessment per Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive, person-centered care plan for a resident with multiple diagnoses, including muscle weakness, atrophy, lack of coordination, and cognitive communication deficit. The resident's care plan identified a risk for malnutrition and included specific interventions such as completing a Mini Nutritional Evaluation and consulting a dietician based on the results. However, the Mini Nutritional Assessment for the resident was started but not completed, and the Registered Dietician (RD) was unaware that the evaluation was required. The care plan interventions were not fully carried out as intended. Interviews revealed a lack of communication and follow-through regarding the nutritional assessment. The RD stated he was not informed that a Mini Nutrition Evaluation was needed, and the Regional Nurse Consultant indicated that care plans should trigger the RD to complete necessary assessments. Facility policy required the care plan to describe services to maintain the resident's well-being, but this was not achieved due to the incomplete assessment and lack of coordination among staff.
Care Plans Not Accessible in Electronic Medical Records
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records in accordance with accepted professional standards for two residents. Specifically, care plans for these residents were not accessible in their current active electronic medical records. One resident, a female with muscle weakness, atrophy, lack of coordination, and cognitive communication deficit, had a moderate cognitive impairment as indicated by a BIMS score of 10 out of 15. Another resident, a female with hypertension, atrial fibrillation, and osteoarthritis of the hip, had a severe cognitive impairment with a BIMS score of 7 out of 15. Despite their needs, neither resident had a care plan available in the current electronic system. Interviews with facility staff revealed that the transition from the former electronic medical record system to the current one (PCC) resulted in incomplete transfer of care plans. The MDS Coordinator acknowledged that not all care plans had been entered into the new system and that staff were instructed to request care plans or MDS assessments from her if needed. However, there was no specific training for staff to know they could contact the MDS nurse or administration at any time for this information. The facility's policy required comprehensive assessments to be maintained in the resident's active record, but this was not followed for the affected residents.
Inadequate Supervision and Security Leads to Substance Use Among Residents
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for several residents, leading to a situation where multiple residents tested positive for amphetamines. Residents were observed smoking unsupervised, and the facility did not adequately secure the back door, allowing residents to access the outside area without supervision. This lack of supervision and security allowed residents to engage in substance use, as evidenced by positive drug tests for amphetamines among several residents. Resident #36, who had a history of schizoaffective disorder and substance use, was found to be acting erratically and admitted to consuming alcohol and smoking outside designated times. Despite being advised against such behavior due to her medical condition and medication regimen, she was observed unsupervised on the back patio with other residents. This behavior was linked to her interactions with other residents who were also involved in substance use, as confirmed by drug tests. The facility's failure to lock the back door and supervise residents adequately led to a situation where residents could access the community and engage in unsupervised activities, including substance use. Staff reported concerns about the unlocked doors and the presence of visitors who might be supplying drugs, but these concerns were not addressed by management. The facility's policies on smoking and substance use were not effectively enforced, contributing to the deficiency.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for three residents, leading to deficiencies in their care. Resident #9, a male with a history of schizophrenia and other mental health conditions, was administered paliperidone without a signed consent form. Although a form was partially completed by healthcare professionals, the section for the resident or their representative's signature was left blank, indicating a lack of proper consent. Resident #25, a female with dementia and depression, was given medications such as trazodone, paroxetine, and buspirone without proper consent. The facility had a consent form with a typed name of a family member, but this individual was unaware of the medications and had not been consulted. Interviews revealed that the resident did not know what medications she was taking, and the family member, who was believed to be the representative, had not been involved in the consent process. Resident #30, a female with schizoaffective disorder and other health issues, was prescribed Seroquel and ABH gel without a physically signed consent form. The facility documented telephone consent from a responsible party, but the forms lacked physical signatures. The facility's policy required written consent for psychotropic medications, which was not adhered to in these cases, leading to the administration of medications without proper informed consent.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodation of their needs, specifically regarding the placement of the call light. The resident, an elderly female with a history of fractures, multiple trauma, atrial fibrillation, heart failure, and renal insufficiency, was observed in a wheelchair by her bedside, unable to reach her call light. Despite having a fully intact cognition, as indicated by a BIMS score of 15, the resident was dependent on others for transfers and had impairment on one side of her body. On the day of the incident, the resident returned from dialysis and was assisted to her room by a van driver who did not place the call light within her reach. Consequently, the resident was in pain and unable to call for help, relying on her roommate to press the call light for her. The Director of Nursing (DON) acknowledged that the van driver should have ensured the call light was accessible to the resident, although the driver is not responsible for transferring residents. The facility had only one working Hoyer lift, which did not affect the timely response for care, according to the DON. The facility's policy on answering call lights emphasizes the importance of ensuring the call light is within easy reach of residents confined to a bed or chair. The Administrator noted that the resident had a cell phone to contact him if needed, but affirmed that the call light should be within reach for all residents.
Failure to Report Drug Use and Abuse Allegations
Penalty
Summary
The facility failed to report alleged violations involving abuse and neglect, specifically related to drug use, to the state reporting agency within the required timeframe. Four residents tested positive for amphetamines during a facility investigation of possible drug use, but the facility did not report these findings to the state. This failure to report could contribute to further abuse and neglect among residents. Resident #9, a male with a history of alcohol or drug abuse, tested positive for amphetamines. His care plan included interventions for supervised smoking breaks due to a history of setting a fire. Resident #36, a female with schizoaffective disorder and a history of drug abuse, exhibited erratic behavior and admitted to taking a pill given by another resident. She was sent to the hospital and later tested positive for amphetamines. Resident #40, a male with a history of illicit drug use, was suspected of distributing drugs to other residents. He tested positive for MDMA, methamphetamine, and amphetamines. Resident #21, a male with a history of alcohol or drug abuse, also tested positive for amphetamines. Interviews with staff revealed concerns about residents accessing drugs and engaging in unsupervised smoking on the patio. Staff reported suspicious behavior and the presence of a visitor entering through an unlocked door. Despite these observations, the facility did not report the drug use to the state, as they believed it was not necessary due to the residents' voluntary drug use. The facility's policy on abuse prevention requires the investigation and reporting of any allegations of abuse within federal timeframes, which was not adhered to in this case.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents requiring oxygen therapy. Resident #29, a male with a history of acute respiratory failure, pulmonary embolism, and COPD, did not have an oxygen sign posted on his door despite having an oxygen tank and concentrator in his room. His care plan required oxygen therapy to maintain SPO2 at 90% or greater, with a physician's order for PRN oxygen via nasal cannula. However, during an observation, it was noted that no signage was present to indicate the use of oxygen. Similarly, Resident #163, a male with acute respiratory failure and heart failure, also lacked appropriate signage to indicate oxygen use. Additionally, there was no active physician order for oxygen, and the oxygen tubing was found on the floor, undated, and not properly maintained. The facility's policy required oxygen signs and proper dating of equipment, but these protocols were not followed. Interviews with staff revealed inconsistencies in the implementation of these procedures, contributing to the deficiency.
Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. Specifically, for one resident, the facility did not maintain the required hospice forms and documentation in the current hospice binders. This included the absence of Form 3071, Individual Election/Cancellation/Update, and Form 3074, Physician's Certificate of Terminal Illness. The lack of these documents could potentially place residents at risk of receiving inadequate end-of-life care due to insufficient documentation, coordination of care, and communication of resident needs. The resident in question was a female with multiple diagnoses, including opioid dependence, schizoaffective disorders, sarcoidosis, hypothyroidism, chronic pain syndrome, unspecified osteoarthritis, and sciatica. The facility's administrator admitted that the hospice company had not provided the required forms and that there was no assigned responsibility within the facility to ensure all necessary paperwork for hospice was present. This oversight was attributed to the resident being private pay for hospice and Medicaid pending, leading to a misunderstanding of the facility's obligations regarding documentation.
Failure to Develop Comprehensive Care Plans for Resident Transfers
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for seven residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental needs. This deficiency was identified during a review of the care plans and interviews with facility staff. The care plans lacked specific instructions on how to safely transfer residents from bed to chair, despite the residents' varying levels of assistance required for such transfers. Resident #1, a female with a history of severe traumatic brain injury and moderate cognitive impairment, required substantial assistance for transfers. However, her care plan did not include instructions for bed-to-chair transfers. Similarly, Resident #2, a male with congenital myasthenia and moderate cognitive impairment, required supervision for transfers, but his care plan also lacked specific transfer instructions. Other residents, including those with dementia, cerebral infarction, and congestive heart failure, were assessed as needing varying levels of assistance, from partial to maximal, yet their care plans did not address the necessary transfer procedures. Interviews with the MDS Coordinator and the regional nurse consultant revealed that the facility relied on resident profiles in the Point of Care system to inform staff about transfer needs. However, the MDS Coordinator acknowledged the omission of transfer instructions in the care plans, recognizing the potential risk of staff performing incorrect transfers, which could lead to injuries. The facility's policy on comprehensive person-centered care plans emphasized the need to describe services to maintain residents' well-being, highlighting the importance of including transfer instructions in the care plans.
Failure to Ensure Resident Privacy During Peri-Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during peri-care, as observed by surveyors. Two CNAs, while providing peri-care, did not fully close the privacy curtains, leaving the resident exposed to view from the sides of the bed. This incident occurred while the resident's roommate was present in the room, compromising the resident's privacy. The CNAs acknowledged the oversight, with one admitting she did not notice the roommate's presence and confirming that she should have closed the curtains completely. The resident involved had a history of multiple medical conditions, including rheumatoid lung disease, noninfective gastroenteritis, rheumatoid arthritis, type 2 diabetes mellitus, major depressive disorder, and a urinary tract infection. The resident was moderately cognitively impaired and required assistance with activities of daily living. The facility's policy on dignity emphasized the importance of maintaining resident privacy during personal care, which was not adhered to in this instance. Interviews with the RN and DON confirmed the expectation that privacy curtains should be fully closed during such care.
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What surveyors actually found near you
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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.
Illustrative
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Nursing homes near Schertz
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trucare Living Centers - Selma | 2.9 mi | ★★★★★ | 11 | 0 |
| Silver Tree Nursing And Rehabilitation Center | 3.1 mi | ★★★★★ | 25 | 1 |
| Advanced Rehabilitation & Healthcare Of Live Oak | 4.6 mi | ★★★★★ | 3 | 0 |
| Avir At Converse | 6.1 mi | ★★★★★ | 13 | 0 |
| The Army Residence Community Health Care Center | 7 mi | ★★★★★ | 0 | 0 |
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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.