Avir At Sherman
Inspection history, citations, penalties and survey trends for this long-term care facility in Sherman, Texas.
- Location
- 1000 Sara Swammy Dr, Sherman, Texas 75090
- CMS Provider Number
- 676120
- Inspections on file
- 35
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Avir At Sherman during CMS and state inspections, most recent first.
A CNA failed to follow hand hygiene and glove-change protocols while providing incontinence care to a cognitively impaired male resident who required substantial assistance with toileting and personal hygiene. After cleaning the resident’s perineal area and removing a urine-soaked brief, the CNA applied a clean brief without changing gloves or performing hand hygiene, then assisted with dressing and wheelchair transfer. The CNA also removed gloves, immediately donned new gloves without hand hygiene, and made the resident’s bed and handled soiled linens before finally sanitizing hands upon exiting the room. Both the CNA and ADON acknowledged that this practice did not follow facility policy, which requires hand hygiene before and after resident contact, when moving from dirty to clean tasks, and immediately after glove removal.
Staff failed to follow the facility’s medication administration policy by prefilling routine and controlled medications for multiple residents and storing them in medication cart drawers instead of preparing them at the time of administration. One MA used prefilled cups labeled with residents’ names, later comparing the contents to blister packs and the eMAR, and even added a missed cranberry tablet to an already prefilled cup before giving it. The same MA also administered a prefilled cup containing several drugs, including controlled substances such as Ativan and hydrocodone/APAP, after a resident’s scheduled dose time had passed. Another MA pre-pulled tramadol and hydrocodone/APAP for three residents at once to save time, acknowledging that controlled meds should be pulled and signed out one resident at a time at the time of administration. Leadership confirmed that prefilling medications, including narcotics, was contrary to facility policy, which requires verification of the rights of medication administration at the time doses are given.
A resident with dementia, metabolic encephalopathy, and protein-calorie malnutrition was discharged to another LTC facility without a required discharge summary in the electronic medical record. Although an LVN documented the transfer and that belongings and meds were sent, no discharge summary recapping the stay and final status was completed. The Regional Nurse Consultant indicated such summaries were expected within 72 hours of discharge, while the social worker, who arranged transfer to a secured unit with responsible party agreement, reported not knowing who was responsible for the summary. The DON stated nursing was responsible for initiating the discharge summary and that a recent change in the electronic record system contributed to staff uncertainty. The administrator and facility policy both specified that a comprehensive discharge summary, including diagnoses, medical history, course of illness, test results, functional and nutritional status, ADL ability, and medication therapy, must be completed and provided to the resident and receiving facility.
A resident with multiple complex medical conditions experienced a change in mental status that was identified by a family member, leading to a hospital transfer. Facility staff did not notify the attending physician of this significant change or the transfer, as required by policy. Interviews and record reviews confirmed that the responsible nurse failed to follow the notification protocol.
A resident with multiple complex diagnoses and a positive PASRR Level II determination did not have the required NFSS form for specialized therapy services submitted within the mandated timeframe. The delay occurred during a transition from a second party provider to internal management of PASRR documentation, resulting in late submission of necessary paperwork, though therapy services continued without interruption.
The facility did not maintain clean and sanitary shower rooms, with visible residues and stains left unaddressed due to inconsistent cleaning practices and lack of proper supplies. Multiple residents reported frequent shortages of clean washcloths and towels, sometimes using pillowcases or large towels for bathing, and experienced delays in bed linen changes. Staff interviews confirmed ongoing linen shortages and inconsistent adherence to cleaning and linen change protocols, resulting in unsanitary conditions and increased risk of infection for residents.
Three residents' care plans did not reflect their specific needs and preferences, including requests for only female staff for personal care, an exception for one male CNA, and documentation of severe hearing, vision, and communication impairments. Staff awareness of these needs was inconsistent, and the omissions led to repeated misunderstandings and unmet preferences.
Surveyors found that the facility's medication error rate exceeded 5% after two residents did not receive their prescribed medications as ordered. One resident was given the wrong dosage of Vitamin B-12 and missed a dose of duloxetine, while another did not receive folic acid. In both cases, medication aides signed the records as if the medications had been administered, contrary to facility policy.
Several residents with complex medical needs reported that meals were frequently cold, bland, and unappetizing, with specific complaints about tough, dry fried chicken and overcooked vegetables. Surveyors observed that food delivered to rooms was often lukewarm and unpalatable, and group interviews confirmed ongoing dissatisfaction with food quality and temperature. Staff and records acknowledged repeated complaints, and the facility lacked a specific policy on food palatability.
Surveyors identified deficiencies in food storage and hand hygiene practices in the kitchen, including improperly sealed, unlabeled, and undated food items in the freezer, and a Dietary Aide handling food and drink items without proper handwashing or glove use after touching clothing and personal items. These actions were inconsistent with facility policy and professional standards.
Multiple lapses in infection control were observed, including a nurse failing to use required PPE during IV medication administration for a resident on Enhanced Barrier Precautions, improper disinfection of glucometers between residents, a medication aide not performing hand hygiene and mishandling medications after they were dropped, and a CNA not performing hand hygiene after resident contact. These actions did not follow established infection control protocols and placed residents at risk for infection and cross-contamination.
A resident with diabetes, malnutrition, anemia, and lactose intolerance did not receive a therapeutic diet as ordered by her physician. The facility did not offer a diabetic diet and failed to clarify or communicate the physician's order, resulting in the resident receiving regular meals that did not meet her medical needs. Dietary and nursing staff were not properly notified, and the dietician did not assess the resident's dietary requirements in a timely manner.
Nursing staff did not consistently document or assess a resident’s vital signs, dialysis access site, or mental status after the resident returned from dialysis, despite facility policy requiring such monitoring. Pre-dialysis assessments were generally completed, but post-dialysis sections of communication records were left incomplete, and staff interviews revealed a lack of awareness about the requirement for post-dialysis assessment and documentation.
A resident with multiple psychiatric diagnoses, including PTSD and schizoaffective disorder, did not receive ongoing psychiatric services as required. Despite being prescribed several psychotropic medications and having a care plan that called for regular mental health follow-up, the resident missed scheduled psychiatric appointments for several months, and facility staff were unaware of the lapse. The lack of clear responsibility and follow-up led to the resident not receiving necessary behavioral health services.
A nurse failed to properly prime a Humalog insulin pen before administering insulin to a resident with Type 2 diabetes, resulting in the potential for inaccurate dosing. The nurse was unaware of the correct priming procedure, and the facility's medication administration policy did not address insulin pen use.
A resident with multiple medical conditions and limited hand function was found with an over-the-counter topical analgesic at her bedside, without a physician order or documentation of self-administration ability. Staff were aware of the medication's presence but did not ensure its removal or secure storage, contrary to facility policy requiring all medications to be stored by authorized personnel.
A resident who was dependent on staff for ADLs and had a history of heart attack, contractures, and hemiplegia was found with long, dirty fingernails. Staff interviews confirmed that nail care responsibilities were not met according to facility policy, resulting in inadequate grooming and personal hygiene for the resident.
A LVN failed to disinfect a blood pressure cuff between use on two residents with significant medical conditions, contrary to facility policy requiring cleaning of non-critical equipment between residents. The incident was observed during a medication pass and confirmed by both the LVN and DON.
The facility failed to maintain personal hygiene for two residents, leading to long and dirty fingernails. One resident, with multiple health issues including diabetes, had not received nail care for over a month, despite it being part of her care plan. Another resident, requiring extensive assistance, was found with discolored and dirty nails. Staff interviews revealed a lack of adherence to the facility's policy on regular nail care, posing potential infection risks.
The facility failed to properly store and date food items in its kitchen, with observations noting missing expiration dates on various food packages. Additionally, a staff member was observed with improperly restrained hair while handling utensils, violating the facility's sanitation policy. These deficiencies were confirmed by the Dietary Manager and a kitchen staff member, highlighting lapses in adherence to food safety standards.
The facility failed to label and monitor insulin pens for expiration dates on a medication cart, affecting two residents with diabetes. Observations revealed that the insulin pens had expired open dates, contrary to the facility's medication storage policy. Interviews with staff confirmed the oversight in checking expiration dates, which could lead to diminished medication effectiveness.
A resident with severe cognitive impairment received incontinence care from CNAs, during which one CNA failed to perform hand hygiene after removing dirty gloves and before donning clean ones. This action violated the facility's infection control policy, which mandates hand washing after glove removal to prevent infection spread.
The facility failed to provide timely incontinence care for four residents, leading to inadequate personal hygiene and potential health risks. Residents reported long wait times for call light responses and inconsistent care, with staff interviews revealing discrepancies in expected response times.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper hand hygiene practices during incontinence care for one resident. The resident was an older male with seizure disorder/epilepsy, hypertension, and depression, with a BIMS score of 07 indicating severely impaired cognition, and required substantial/maximal one-person physical assistance with toilet use and personal hygiene. During an observed episode of incontinence care, the CNA entered the bathroom in response to the call light, found the resident standing next to the toilet with pants and brief down, washed her hands, and donned clean gloves. She then cleaned the resident’s buttocks and the tip of his penis using wipes and removed a urine-soaked brief. After completing the cleaning of the resident’s perineal area, the CNA obtained and applied a clean brief without changing gloves or performing hand hygiene. She then assisted the resident in pulling up his pants, returning to the wheelchair, washing his hands, and exiting the bathroom. The CNA removed her gloves, exited the bathroom, immediately donned new gloves from a box near the exit door without performing hand hygiene, and proceeded to make the resident’s bed and handle dirty linens and trash before finally removing gloves and sanitizing her hands upon leaving the room. In interviews, the CNA acknowledged she was supposed to wash hands before and after care, and to change gloves and perform hand hygiene before applying a clean brief, stating she did not do so because she was nervous. The ADON confirmed that facility expectations and policy required hand hygiene and glove changes when moving from dirty to clean tasks, and record review of the hand hygiene policy specified hand hygiene before and after resident contact, before moving from a soiled to a clean body site on the same resident, and immediately after glove removal.
Prefilling of Routine and Controlled Medications in Violation of Medication Administration Policy
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services and to follow its own medication administration policy, including procedures to assure accurate administration of drugs and biologicals, for six residents observed during a medication pass. Medication Aide (MA) A was observed using prefilled medication cups stored in the top drawer of the medication cart, each labeled with a resident’s name and containing multiple pills that had been pulled before the scheduled administration time. For one resident, MA A retrieved a plastic cup already filled with several pills, then had to go to another medication cart to obtain the resident’s blister packs and compare the contents of the cup with the electronic medication administration record (eMAR) and the blister packs before administering the medications. In another instance, MA A was observed transporting two medication carts to a different hall to administer a second resident’s medications. The top drawer of one cart contained multiple prefilled medication cups labeled with different residents’ names. MA A selected the cup labeled for the second resident, then compared the pills in the cup with the blister packs and the eMAR and discovered that a cranberry tablet had been omitted. She then opened the cart, retrieved a cranberry tablet from a bottle, and added it to the prefilled cup containing other previously pulled medications such as amiodarone, Plavix, Eliquis, potassium chloride, vitamin C, and a multivitamin before administering them. Later, MA A pulled another prefilled cup labeled for a third resident whose medications were scheduled for 7 a.m. but had been delayed at the resident’s request. She compared the contents with the blister packs and eMAR, which showed that the cup already contained multiple medications, including controlled substances (Ativan and hydrocodone/acetaminophen), as well as other drugs such as carbidopa-levodopa, Wellbutrin XL, Lasix, primidone, and Flomax, and then administered them. During interview, MA A acknowledged knowing that she was not supposed to prefill medications and that she was required to follow the rights of medication administration (right resident, right medication, right dosage, right time, and right route). She stated she had been having difficulty completing medication passes within prescribed times because residents’ routine medications were scheduled at different times and she had to move between multiple carts and halls, so she took a shortcut by prefilling medications and consolidating them into one cart. She also stated she had requested that nurses correct administration times but that this had not been done due to staff changes, and she recognized that prefilling medications posed risks such as medications being spilled or the wrong resident’s medications being given. A separate deficiency was identified with MA B, who was observed at another medication cart with three prefilled medication cups in the top drawer, each labeled with a different resident’s name and containing controlled medications scheduled to be given with morning medications. MA B unlocked the narcotic lock box, pulled the blister packs, and compared them with the eMAR and the pills in the cups, confirming that the cups contained tramadol for two residents and hydrocodone/acetaminophen for a third resident. MA B stated she had pulled all of the narcotics at once around 8:45 a.m. for a 9:00 a.m. medication pass to save time, despite knowing that she was supposed to pull and sign out controlled medications one resident at a time at the time of administration. She acknowledged that prefilling and leaving medications in the cart could result in medications being mixed up, spilled, or given to the wrong resident. The Assistant Director of Nursing (ADON) stated that staff were not allowed to prefill medications for multiple residents and were required to prepare medications at the time of administration. The ADON explained that prefilling and storing multiple residents’ medications in the cart created the possibility that medications could be spilled, mixed up, or taken for the wrong resident, and that narcotics and controlled medications were to be signed out and administered at the same time. The Director of Nursing (DON) confirmed that prefilling medications was not consistent with facility policy, which required staff to compare medications with the eMAR at the time of administration to ensure the right dose, medication, resident, route, and time, and noted that some medications required parameters to be checked prior to administration that could be overlooked if medications were prefilled. The facility’s written policy on administering medications specified that medications are to be administered in a safe and timely manner as prescribed, that the individual administering medications must verify resident identity, and that the medication label must be checked three times to verify the right resident, medication, dosage, time, and route before administration.
Failure to Complete Required Discharge Summary for Discharged Resident
Penalty
Summary
The facility failed to complete a required discharge summary, including a recapitulation of the resident’s stay and final status at discharge, for one resident who was permanently discharged. The resident was an elderly female with dementia, metabolic encephalopathy, and unspecified protein-calorie malnutrition who had been admitted and later discharged to another nursing home/LTC facility with a secured unit. The discharge MDS indicated a discharge with return not anticipated, and a nurse’s progress note documented that the resident was transferred to a new facility with personal belongings and medications sent. However, review of the electronic medical record showed that no discharge summary was present for this resident. Interviews revealed confusion and lack of clarity among staff regarding responsibility for completing the discharge summary. The Regional Nurse Consultant stated that a discharge summary with a recapitulation of the resident’s stay was expected within 72 hours of discharge and was part of the overall discharge process initiated at admission. The Social Worker reported arranging the transfer after being instructed by the Administrator and DON to find a secured placement due to exit-seeking behavior and confirmed agreement from the responsible party, but stated she did not know who was responsible for the discharge summary and had not been instructed on this. The DON stated that nursing was responsible for initiating the discharge summary in the electronic record, including medications sent, care received, and medical history, and acknowledged that the facility had recently changed electronic record systems and staff were still learning the process. The Administrator stated the discharge summary should be completed the day of or the day after discharge and be part of the electronic health record, and the facility’s policy required a discharge summary that included a description of the resident’s diagnoses, medical history, course of illness, test results, functional status, ADL ability, nutritional status, and medication therapy, with a copy provided to the resident and receiving facility and filed in the medical record.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's mental status, as required by facility policy. The resident, an elderly female with a complex medical history including acute kidney failure, chronic kidney disease, recent stroke, C-Diff infection, UTI, and metabolic encephalopathy, was admitted to the facility and experienced a change in mental status during her stay. Staff interviews and record reviews revealed that the resident was only at the facility for three days before being sent to the hospital at the request of her family, who noticed the change in her condition. On the day of the incident, the resident was observed by staff to be alert and oriented, but the change in mental status was not immediately recognized by the staff, many of whom had limited prior experience with the resident. The family member identified the change and requested hospital transfer. The nurse responsible for the resident at the time did not notify the attending physician of the change in condition or the transfer, as confirmed by interviews with facility leadership and the physician. The facility's policy required immediate notification of the physician in the event of a significant change in condition or hospital transfer, but this was not followed. Interviews with the resident's physicians and facility staff confirmed that the physician was not informed of the change in mental status or the hospital transfer. Both the Assistant Director of Nursing and the Administrator acknowledged that the nurse failed to follow the notification policy. The deficiency was identified through interviews, record reviews, and confirmation from the involved parties that the required physician notification did not occur.
Failure to Timely Submit PASRR NFSS Form for Specialized Therapy Services
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II determination and evaluation report for one resident who was reviewed for PASRR assessments. Specifically, the facility did not submit the Nursing Facility Specialized Services (NFSS) form request for therapy services by the required deadline. The resident in question was a female with multiple complex diagnoses, including cerebral palsy, speech and language deficits, muscle weakness, lack of coordination, chronic obstructive pulmonary disease, vision impairments, schizoaffective disorder, bipolar disorder, paraplegia, gout, and cerebrovascular disease. She was identified as PASRR positive for developmental disability and required specialized therapy services as indicated by the service coordinator. Record review showed that the resident's care plan and PASRR Comprehensive Service Plan documented the need for ongoing specialized occupational, physical, and speech therapy services. The facility had an interdisciplinary team meeting where these services were agreed upon, and the NFSS form was required to be submitted within 20 days of the meeting. However, due to a transition in facility ownership and a change from a second party provider to internal management of PASRR documentation, the NFSS form was not submitted within the required timeframe. The delay was attributed to the previous provider's failure to submit the documentation during the transition period. Interviews with facility staff confirmed that the missed deadline was not initially recognized by current staff and was only brought to their attention after notification from a PASRR representative. Despite the missed deadline, the resident continued to receive therapy services without interruption, and there was no documentation of services being declined or interrupted as a result of the deficiency. The facility's PASRR policy requires compliance with all federal and state regulations, including timely submission of required forms.
Failure to Maintain Clean Shower Rooms and Provide Adequate Linens
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents, specifically in the maintenance of shower rooms and the provision of clean linens. Observations revealed that two of five shower rooms had visible orange, pink, black, and brown residues along grout lines, walls, and floors, with one area appearing to have a stain resembling feces. Housekeeping staff acknowledged that showers were not cleaned to the expected standard, citing a lack of proper cleaning supplies such as scrubbers and inconsistent cleaning practices. The Housekeeping Supervisor admitted she had not noticed the extent of the residue until it was pointed out, and staff interviews revealed confusion over cleaning responsibilities, with some CNAs stating that aides, not housekeepers, typically cleaned the shower rooms. Multiple residents reported a lack of clean washcloths and towels for bathing, with some resorting to using pillowcases or large towels in place of washcloths. Interviews with residents and a confidential group of twelve residents confirmed ongoing issues with linen shortages, particularly washcloths, and inconsistent bed linen changes after showers. Staff interviews corroborated these shortages, with laundry and housekeeping staff noting that supplies would often run out and that orders for new linens were placed only every two weeks. Observations of linen carts and storage areas confirmed the lack of clean washcloths and towels available for resident use. One resident was observed to have a stained fitted sheet on her bed for at least two consecutive days, with staff acknowledging that sheets should be changed on shower days or when soiled. Interviews with CNAs, LVNs, and the DON revealed inconsistent practices regarding the frequency of linen changes and further confirmed periodic shortages of clean linens and towels. The facility's policy required a safe, clean, and homelike environment, but the policy was not provided upon request by surveyors. The failures in cleaning and linen provision placed residents at risk of exposure to infectious diseases and unsanitary conditions, as directly stated in the report.
Failure to Accurately Reflect Resident Preferences and Needs in Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive care plans accurately reflected the needs and preferences of three residents, as identified through observation, interviews, and record review. One resident, a cognitively intact female with multiple diagnoses including diabetes, malnutrition, depression, and metabolic encephalopathy, expressed a clear preference for only female staff to provide her personal and incontinent care. Despite communicating this preference to several staff members, her care plan did not document this need, and some staff were unaware of her wishes, resulting in her being pressured to accept care from male staff during a weekend. Another resident, a female with severe cognitive impairment and a diagnosis of dementia and depression, preferred only female aides except for one specific male CNA. Both the resident and her family had to repeatedly inform staff of this preference when male aides were assigned to her, as it was not reflected in her care plan. While some staff were aware of her wishes through verbal communication, others were not, and the care plan did not specify her preference or the exception for the one male CNA. A third resident, a male with severe hearing impairment, moderately impaired vision, and aphasia following a stroke, had no documentation in his care plan regarding his communication or sensory deficits. Staff interviews revealed inconsistent awareness of his needs, with some staff noting his hearing and vision issues and others unsure. The responsible party also confirmed the resident's significant impairments, but these were not addressed in the care plan, leaving staff without clear guidance on how to communicate with or care for him.
Medication Error Rate Exceeds 5% Due to Incorrect Dosage and Omitted Medications
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 7.89% based on three errors out of 38 observed opportunities. These errors involved two residents and two medication aides during medication administration. The errors included administering the incorrect dosage of a prescribed medication and omitting required medications during scheduled medication passes. One incident involved a cognitively intact female resident with a history of coronary artery disease, heart failure, depression, and muscle weakness. The medication aide administered 1000 mcg of Vitamin B-12 instead of the prescribed 100 mcg and failed to administer duloxetine 60 mg as ordered. The medication administration record was inaccurately signed to indicate that the medications were given as ordered, and a late administration note was entered, but the correct medications were not provided at the scheduled time. The aide later acknowledged misreading the dosage and missing the duloxetine during the medication pass. Another incident involved a cognitively intact female resident with heart failure and anemia. The medication aide failed to administer the resident's prescribed folic acid 1 mg during the morning medication pass, although the medication administration record was signed as if it had been given. The aide later confirmed the omission. Facility policy requires medications to be administered and documented as ordered by the physician, with verification of the medication and dosage prior to administration, but these procedures were not followed in the cited instances.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to provide palatable, attractive, and appropriately tempered food and drink for residents during a lunch meal, as observed and reported by both residents and surveyors. Multiple residents, including those with diabetes, malnutrition, anemia, heart failure, and kidney disease, reported that the food was often cold, bland, and unappetizing. Specific complaints included fried chicken that was too tough and dry to eat, mashed potatoes that were not edible, and vegetables that were overcooked or bland. Residents stated that they frequently had to supplement their meals with food brought in from outside due to dissatisfaction with the facility's offerings. Observations during meal service revealed that food trays delivered to residents' rooms were often lukewarm by the time they arrived, with the last tray being delivered significantly after dining room service had concluded. Surveyors who tested a tray found the fried chicken to be dry and difficult to chew, the broccoli bland and mushy, and the cheese sauce lacking flavor. Residents in the dining room finished eating well before those in their rooms received their meals, and group interviews confirmed that food temperature and palatability were ongoing issues despite previous attempts to address them. Interviews with staff and review of facility records indicated that complaints about food quality, temperature, and timeliness had been ongoing, with residents and staff both acknowledging the problems. The facility had attempted to address these concerns by purchasing warming trays and encouraging residents to request alternative meals, but residents continued to report dissatisfaction. The facility did not have a specific policy on food palatability, relying instead on general standards and recipes provided by an external source.
Deficient Food Storage and Hand Hygiene Practices in Kitchen
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding food storage and handling practices. During an inspection of the kitchen freezer, several food items, including corn dogs, biscuits, and dinner rolls, were found in open plastic bags that were not sealed, labeled, or dated. The Dietary Manager confirmed that these items should have been properly sealed and labeled, and acknowledged that the lack of labeling and sealing could lead to freezer burn and cross-contamination if the food was consumed. Additionally, during lunch service, a Dietary Aide was observed carrying trays of water and tea in a manner that allowed the cups to touch his clothing. The aide placed the trays on a serving table, wiped his hands on his shirt and pants, and then put on gloves without washing his hands. He subsequently handled food and drink items with gloved hands after touching his clothing and personal items, and disposed of dirty gloves on a food service table. The aide admitted he should have washed his hands before donning gloves and should not have touched his clothing or personal items while wearing gloves. Review of facility policies and the FDA Food Code confirmed that all food items removed from original packaging must be labeled and dated, and that proper hand hygiene, including washing hands before putting on gloves and after touching potentially contaminated surfaces, is required. The observed actions were inconsistent with these standards and policies, as confirmed by interviews with the Dietary Manager and the Dietary Aide.
Multiple Lapses in Infection Control Practices
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 four residents. One incident involved a nurse administering intravenous antibiotics to a resident with a venous access device who was on Enhanced Barrier Precautions (EBP). The nurse performed hand hygiene and donned gloves but failed to wear a gown as required by EBP protocols, despite signage indicating the need for such precautions. The nurse later acknowledged confusion about the required personal protective equipment (PPE) for different situations, even though he had received training. Additional deficiencies were observed in the disinfection of glucometers used for fingerstick blood sugar testing on two residents. Nurses wiped the glucometers with germicidal wipes but did not allow the devices to air dry for the required contact time before returning them to the medication cart, potentially leading to cross-contamination. One nurse was unaware of the need to let the device air dry, and the facility did not have a specific policy for glucometer disinfection, relying instead on manufacturer instructions. Further lapses included a medication aide carrying eye drops and nasal spray into a resident's room, placing them on the bed and resident's chair, and failing to perform hand hygiene before administering the medications. The aide also failed to discard the medications after they were dropped on the floor, instead returning them to the medication cart. In another instance, a CNA did not perform hand hygiene after transferring a resident to a wheelchair and before leaving the room, contrary to facility policy. These actions were confirmed through staff interviews and record reviews, demonstrating a pattern of non-compliance with established infection control protocols.
Failure to Provide Physician-Ordered Therapeutic Diet for Diabetic Resident
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including diabetes, malnutrition, anemia, and lactose intolerance, was not provided with a therapeutic diet as ordered by the physician. The physician's order specified a diabetic diet with a 1500ml fluid restriction and lactose intolerance, but the facility did not have a diabetic diet and instead offered a Low Concentrated Sweets (LCS) diet for diabetic residents. The resident's care plan and medical nutrition therapy assessment reflected the need for a diabetic diet, but her meal ticket listed a regular diet, and her lunch tray included items not consistent with a diabetic or lactose-intolerant diet, such as a dinner roll, fried chicken, pineapples in juice, and packets of sugar. Interviews revealed that the dietary and nursing staff were not properly notified or did not clarify the physician's order for a diabetic diet, as the facility did not offer this specific diet. The dietary manager was unaware of the resident's need for a diabetic diet until after the resident reported receiving inappropriate meals. The process for communicating new or changed diet orders involved nursing staff filling out a dietary form and handing it to the dietary manager, but this process failed in this instance, resulting in the resident not receiving the prescribed diet. Further, the dietician responsible for reviewing new admissions did not assess the resident's dietary needs within the expected timeframe, and the facility's policy required nursing to clarify any diet orders not matching the facility's available diets before forwarding them to dietary services. The lack of timely clarification and communication led to the resident receiving meals inconsistent with her medical needs and physician's orders.
Failure to Document and Assess Post-Dialysis Care
Penalty
Summary
Facility nursing staff failed to ensure that a resident requiring dialysis received care consistent with professional standards of practice. Specifically, on multiple occasions, staff did not document or assess the resident’s vital signs, dialysis access site, or mental status after the resident returned from dialysis treatments. This lack of post-dialysis assessment and documentation was noted on three separate dates, despite the facility’s policy requiring such monitoring. The resident involved was an older adult with diagnoses including anemia, kidney disease, heart failure, and diabetes, and was cognitively intact. She received dialysis twice weekly. While pre-dialysis assessments and documentation were generally completed, the post-dialysis sections of the communication records were left incomplete by facility nurses, even though the dialysis center staff completed their own sections. There were also no progress notes reflecting pre- or post-dialysis assessments by nursing staff during the relevant period. Interviews with staff revealed a lack of awareness regarding the requirement to complete post-dialysis assessments and documentation. The DON was unaware that these sections were not being completed, and one LVN stated she did not know she was supposed to check the resident’s vitals upon return from dialysis. The facility’s policy clearly outlined the need for monitoring blood pressure, pulse, and access site after dialysis, but these steps were not consistently followed.
Failure to Ensure Ongoing Psychiatric Services for Resident with Mental Health Diagnoses
Penalty
Summary
A resident with a history of multiple psychiatric diagnoses, including anxiety, depression, schizoaffective disorder, and post-traumatic stress disorder, did not receive ongoing psychiatric services as required. The resident had previously attended psychiatric appointments outside the facility, with the last documented visit occurring several months prior to the survey. Despite being scheduled for regular follow-up every two months, there was no documentation or explanation for the missed appointments, and the resident confirmed he had not attended psychiatric services for an extended period and was unsure of the reason. Medical records indicated the resident was prescribed several psychotropic medications, including Latuda, Trazadone, Prozac, and buspirone, and his care plan identified him as being at risk for behavioral symptoms related to past trauma. The care plan included interventions such as allowing the resident to discuss emotions in a safe environment and consulting mental health services as needed. However, there was no evidence that the facility ensured the resident continued to receive psychiatric evaluations or medication management as outlined in his care plan and physician's notes. Interviews with facility staff revealed a lack of awareness and follow-up regarding the resident's missed psychiatric appointments. The DON was unaware that the resident had not been seen by psychiatric services, and the social worker was unfamiliar with the resident's outside psychiatric care. The process for tracking and scheduling follow-up appointments was unclear, and responsibility for ensuring ongoing psychiatric care was not consistently assigned or monitored, resulting in the resident not receiving necessary behavioral health services.
Failure to Follow Insulin Pen Priming Procedure
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to follow the manufacturer's instructions for priming a Humalog insulin pen prior to administering insulin to a resident with Type 2 diabetes. The LVN did not prime the pen with 2 units as required, but instead dialed in an extra unit and pushed out 1 unit before administering the prescribed dose. The LVN was unaware of the correct priming procedure, which is necessary to ensure the accurate delivery of insulin. The resident involved was a female with a diagnosis of Type 2 diabetes, who was prescribed Humalog insulin per a sliding scale. Observation confirmed that the LVN did not prime the pen according to manufacturer instructions, and interviews revealed a lack of knowledge regarding the correct procedure. Additionally, the facility's medication administration policy did not include specific procedures for the use of insulin pens.
Improper Storage of Over-the-Counter Medication at Bedside
Penalty
Summary
A deficiency occurred when a resident was found to have a tube of BioFreeze, an over-the-counter topical analgesic, at her bedside table, accessible without staff supervision. The resident, an elderly female with diagnoses including hypertension, dementia, and cervical disc myelopathy, had a BIMS score indicating intact cognition but also had hand contractures that limited her ability to self-administer medication. There was no documentation in her care plan regarding her ability to self-administer medications, and no physician order was present for the BioFreeze. Multiple staff members, including CNAs and nursing leadership, were aware or became aware of the medication's presence but did not ensure its removal or proper storage according to facility policy. Interviews revealed that staff assumed nursing was aware of the medication, and the ADON had previously instructed a CNA to remove it but did not verify its removal. The DON confirmed that all medications, including over-the-counter products, require a physician order and must be stored securely in the medication cart. Facility policy states that only authorized personnel may administer medications and that self-administration must be specifically authorized by a physician. Despite these policies, the medication remained accessible at the resident's bedside, contrary to established procedures.
Failure to Provide Nail Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was unable to perform these tasks independently. Specifically, on 04/16/2025, a male resident with a history of myocardial infarction, contractures of the left hand and shoulder, and hemiplegia/hemiparesis was observed to have fingernails approximately 0.5 inches in length with a dark substance underneath. The resident, who was cognitively intact but dependent on staff for showering, bathing, and toileting hygiene, stated that his nails were too long and that he did not like it. Interviews with staff revealed that certified nursing assistants (CNAs) and nurses were responsible for nail care, with the exception that only nurses could provide nail care for residents with diabetes. Staff acknowledged that the resident's nails were long, dirty, and needed to be trimmed and cleaned, and recognized the risk of infection associated with this deficiency. Review of the facility's policy confirmed that nail care procedures were in place, but these were not followed for this resident.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices when a licensed vocational nurse (LVN) did not disinfect a blood pressure cuff between use on two residents. During a morning medication pass, the LVN checked the blood pressure of one resident and then immediately used the same cuff on another resident without sanitizing it before or after each use. This was observed directly by surveyors and confirmed in interviews with the LVN, who acknowledged that reusable medical equipment should be sanitized between residents to prevent cross contamination, but stated she forgot due to being new to the facility. Both residents involved had significant medical histories, including coronary artery disease, hypertension, diabetes, stroke, heart failure, and dementia, with varying levels of cognitive impairment as indicated by their BIMS scores. The facility's own infection control policy required that non-critical resident-care items, such as blood pressure cuffs, be cleaned and disinfected between residents. The Director of Nursing confirmed awareness of the incident and reiterated the expectation that all medical equipment be sanitized between uses.
Failure to Maintain Residents' Personal Hygiene
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #13, a female with multiple diagnoses including diabetes and moderate cognitive impairment, was observed with long and dirty fingernails. Despite her care plan indicating that nail care should be performed on bath days and as needed, interviews revealed that her nails had not been trimmed for over a month. Both CNAs and LVNs were responsible for nail care, but due to her diabetes, only nurses were allowed to perform this task. The LVN admitted to not offering nail care recently, acknowledging the risk of infection from inadequate nail care. Similarly, Resident #40, a male with moderate cognitive impairment and requiring extensive assistance, was found with discolored and dirty fingernails. His care plan also emphasized the importance of maintaining personal hygiene. Interviews with staff indicated that CNAs were responsible for nail care unless the resident had diabetes. The DON confirmed that nail care should be provided regularly, especially during shower times, and acknowledged the potential infection control issues arising from neglecting this aspect of care. The facility's policy on activities of daily living was not adhered to, resulting in these deficiencies.
Deficiencies in Food Storage and Hair Restraint Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, as observed during a survey. Specifically, food items in the refrigerator, freezer, and dry storage were not properly covered and dated. Observations revealed that a packet of hot dogs in the refrigerator, a packet of tortillas in the dry storage, and a packet of bread in the freezer lacked expiration dates. Additionally, a packet of cornflakes was left open without a use-by date. These lapses in food storage practices were confirmed through interviews with the Dietary Manager and a kitchen staff member, who acknowledged the importance of dating and covering food items to prevent food-borne illnesses. Furthermore, the facility did not ensure that kitchen staff used appropriate hair restraints. During a lunch meal service observation, a staff member was seen with improperly restrained hair while handling washed utensils in the kitchen prep area. The Dietary Manager confirmed that all kitchen staff are required to wear hair restraints as part of their uniform to prevent hair from contaminating food. The staff member admitted to having long, frizzy hair that was not fully secured, acknowledging the risk of hair contaminating food and the potential for food-borne illness. The facility's policies on food storage and employee sanitation, as well as the FDA Food Code, were not followed, contributing to these deficiencies.
Expired Insulin Pens Found on Medication Cart
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles, specifically regarding the expiration dates of insulin pens on the 200 hall nurses' medication cart. During an observation, it was found that insulin pens for two residents had expired open dates. One insulin pen for a female resident with type 2 diabetes mellitus and hyperlipidemia was opened beyond the 28-day discard period. Similarly, another insulin pen for a male resident with type 2 diabetes mellitus, elevated blood pressure, and hyperlipidemia was also found to be expired. Interviews with the LVN and the DON revealed that the insulin pens were not checked for expiration dates, and the purpose of open dates was acknowledged as being for expiration purposes. The facility's policy on medication storage requires that outdated medications be immediately removed and disposed of, which was not adhered to in this instance. The failure to monitor and discard expired insulin pens could result in diminished effectiveness of the medication for the residents involved.
Infection Control Lapse During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by the actions of CNA D during incontinence care for a resident. The resident, a female with severe cognitive impairment due to dementia, required extensive assistance with personal hygiene. During the care, CNA D did not perform hand hygiene after removing dirty gloves and before donning clean gloves, which is a critical step in preventing the spread of infection. This lapse occurred despite the facility's policy requiring hand washing after glove removal. The incident was observed during a care session where CNA D and another CNA were attending to the resident. After cleaning the resident's front pubic area and discarding the dirty gloves, CNA D failed to wash her hands before putting on new gloves to continue the care. This oversight was acknowledged by CNA D, who attributed it to nervousness, and was confirmed by the Director of Nursing, who reiterated the importance of hand hygiene in infection prevention. The facility's policy clearly states that hand washing is essential after glove removal, highlighting the deficiency in adherence to established infection control protocols.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received necessary services to maintain good personal hygiene. Specifically, the facility did not provide timely incontinence care every two hours or as needed for four out of five residents reviewed. This failure was observed through record reviews, interviews, and direct observations, indicating a pattern of neglect in providing essential care to residents who are incontinent and at risk for skin breakdown and other complications. Resident #1, a cognitively intact female with multiple diagnoses including blindness, ankylosing spondylitis, and chronic kidney disease, reported being left wet overnight and not receiving timely incontinence care. Her care records showed significant gaps in incontinence care, with long intervals between changes. Similar issues were reported by Resident #3, who also noted that her roommate did not receive timely care. Resident #4, who has Alzheimer's disease and other chronic conditions, reported that staff often did not respond to call lights, forcing her to change herself. Resident #5, who is on diuretic therapy, expressed concerns about long wait times for call light responses, especially during mealtimes. Interviews with staff members, including CNAs and RNs, revealed inconsistencies in the expected response times for call lights and incontinence care. While some staff stated that call lights should be answered within 5-10 minutes, others were unsure of specific timeframes. The facility's call light procedures emphasized the importance of prompt responses, yet the observed practices did not align with these guidelines. This discrepancy between policy and practice contributed to the inadequate care provided to the residents, as documented in their care records and personal accounts.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
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