Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Temple West during CMS and state inspections, most recent first.
Failure to Follow Food Service Hygiene Standards: The DM was observed in the kitchen without a hair restraint while performing duties, despite facility policy requiring hair restraints for all staff in the kitchen. During multiple meal service observations, several staff members, including the ADM, RNs, LPNs, and CNAs, failed to sanitize their hands before serving drinks and food to residents. Interviews confirmed staff were trained on hand hygiene and food safety, and facility policy required proper handwashing and hair restraints during food handling.
A resident with significant physical disabilities and a care plan requiring assistance out of bed and into a wheelchair for meals was repeatedly left in bed until the afternoon, resulting in missed meals and prolonged periods in soiled briefs. Staff interviews and video evidence confirmed that some aides refused to provide care due to perceptions of the resident being 'difficult,' leading to ongoing neglect, missed meals, and significant weight loss.
A resident with significant physical limitations and a care plan requiring early assistance out of bed was repeatedly left in bed for most of the day, causing her to miss meals and remain in soiled linens. Staff interviews and documentation revealed that some CNAs refused to provide care due to personal conflicts, and facility leadership did not enforce care assignments, resulting in ongoing neglect and significant weight loss for the resident.
A resident with intact cognition reported that a former male staff member entered her room and made a suggestive, vulgar comment without physical contact. The administrator, who also served as the Abuse Coordinator, did not report the allegation to the State Survey Agency within the required timeframe, citing the resident's request not to report. The facility's policy mandates immediate reporting of such allegations, but this was not followed.
A resident with multiple health conditions did not receive TED hose as ordered due to a failure to schedule the order in the facility's system. The oversight meant the order did not appear on the TAR, and staff interviews confirmed the responsibility for scheduling was with the admitting nurses. The ADON noted the potential health risks of not following the order.
The facility failed to maintain a clean and safe environment for three residents, resulting in foul odors, unclean overbed tables, and soiled linens. Despite the presence of bags of soiled briefs and loose baseboards, residents expressed no concerns. Interviews with staff revealed that cleaning expectations were not met, leading to unsanitary conditions.
The facility failed to maintain proper hygiene and grooming for residents unable to perform ADLs. A resident with intact cognition was found with facial hair, causing embarrassment and isolation. Two residents with cognitive impairments had unclean nails with fecal matter, and another resident had mycotic nails. Staff acknowledged the potential health risks but did not provide necessary care as per facility policy.
The facility failed to maintain sanitation standards in the kitchen, as observed by uncovered food items, unclean equipment, and incomplete temperature and cleaning logs. Staff interviews confirmed that expected sanitation practices, such as cleaning thermometers and covering food, were not followed, posing a risk of foodborne illness to residents.
The facility failed to maintain an effective pest control program, resulting in flies and crickets in the kitchen and dining room. Residents were observed using personal fly swatters and covering drinks to manage the flies. Despite having a contract with a pest control company, the issue persisted, and the facility lacked a formal pest control policy.
A resident with quadriplegia and no cognitive impairment was frequently given showers late at night, contrary to his preferences. Despite expressing dissatisfaction, the facility did not document or offer alternative shower times, assuming the late schedule was due to the resident's routine of leaving and returning to the facility late. This resulted in a failure to honor the resident's right to self-determination and a dignified existence.
The facility failed to complete PASARR Level I screenings correctly for two residents, leading to a lack of necessary Level II assessments for those with mental illnesses. One resident was diagnosed with PTSD and anxiety disorder after admission, but her screenings did not reflect these conditions. Another resident was admitted with bipolar disorder and major depressive disorder, yet his screenings were also incorrect. Staff interviews revealed a lack of understanding and compliance with PASARR requirements.
A facility failed to include a resident's ADLs in their comprehensive care plan, which is essential for meeting the resident's medical, nursing, and psychosocial needs. The resident, with moderate cognitive impairment and multiple health conditions, required assistance with personal hygiene and supervision with other activities. Staff interviews highlighted the risk of inappropriate care due to the lack of documented ADLs, with the MDS Coordinator responsible for ensuring accurate care plans.
A resident with impaired vision and multiple health issues was observed smoking without the required supervision and smoking apron, contrary to the facility's policy. The resident's care plan and smoking safety screen indicated the need for these precautions, which were not followed, potentially placing the resident at risk.
The facility failed to provide proper respiratory care for two residents, leading to potential infection risks. A resident with a tracheostomy had dirty oxygen concentrator filters and improper tracheostomy care, lacking aseptic technique. Another resident's oxygen concentrator filter was also dirty. Facility policies on tracheostomy care and infection prevention were not followed, posing risks of respiratory infections.
A facility failed to provide trauma-informed care for a resident with PTSD, as her care plan did not include an assessment or documentation of her PTSD triggers. Despite the resident's ability to communicate her needs, the care plan lacked specific interventions to address her triggers, such as unexpected room entries and loud conversations. Interviews with staff revealed a lack of awareness and documentation regarding these triggers, highlighting a gap in the facility's procedures for addressing the needs of trauma survivors.
A resident in a persistent vegetative state received improper tracheostomy care from an RN, who failed to use aseptic techniques and proper hand hygiene. The RN did not wash hands before donning gloves, used an inappropriate wipe to clean the overbed table, and performed suctioning through a mucus-filled tracheostomy mask. These actions were against the facility's policies, potentially risking infection.
Failure to Follow Food Service Hygiene Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen and dining room. During kitchen observations, the DM was observed on 12/16/25 at 9:14 AM and again on 12/17/2025 at 1:35 PM without a hair restraint while in the kitchen, including while testing the dishwasher temperature and while obtaining policy and logbooks. The DM stated that employees were expected to follow the company-wide sanitation policy and acknowledged that hair restraints were needed because hair could contaminate food. The [NAME] and the ADM also stated that everyone entering the kitchen was required to wear a hair net that completely covers the hair on their heads. During dining room meal service observations, staff failed to perform hand sanitation before serving drinks and food to residents. On 12/16/25 at 11:29 AM, 4 staff members (CNA A, CNA B, LVN D, RN C) did not sanitize their hands before beginning drink and food service to 11 residents. On 12/17/2025 at 11:39 AM, 3 staff members (RN C, LVN D, CNA F) again failed to sanitize their hands before beginning drink and food service to 13 residents. On 12/18/25 at 7:30 AM, 5 staff members (ADM, LVN D, CNA H, CNA G, RN C) failed to sanitize their hands before beginning drink and food service to 11 residents. Interviews showed that staff and leadership were aware of the hand hygiene expectations. The DM stated that all staff were expected to sanitize hands before food service and between serving each drink and plate, and that improper hand hygiene could cause food-borne illness. The [NAME] stated that everyone was supposed to practice hand hygiene and that staff were to wash hands anytime they touched their hair or body. CNA G, CNA H, LVN D, ADON, and ADM each stated that hand hygiene was part of their training and that staff were expected to sanitize hands before and between serving residents. Record review showed dietary orientation and competency checklists for 8 kitchen staff and in-service training on infection control and food safety completed 12/01/2025, along with facility policies requiring hair restraints and handwashing for food handling.
Failure to Protect Resident from Neglect and Missed Care
Penalty
Summary
The facility failed to ensure that a resident was protected from psychosocial abuse and neglect, as evidenced by repeated failures to assist her out of bed at a reasonable time, resulting in her missing breakfast and lunch and remaining in a soiled brief for extended periods. The resident, who had diagnoses including rheumatoid arthritis, dysphagia, acquired deformity of the neck, and adult failure to thrive, was dependent on staff for transfers and required to be in her wheelchair to feed herself due to physical limitations. Her care plan specifically directed staff to get her out of bed between 6:00 AM and 7:30 AM daily and to ensure she was up for all meals, but this was not consistently followed. Multiple observations, interviews, and record reviews revealed that the resident was often left in bed until the afternoon, missing meals and personal care. Video evidence and staff interviews confirmed that on several occasions, she was not assisted out of bed until after 1:00 PM, and her call light was left unanswered for hours while she remained in soiled conditions. Staff acknowledged that some aides refused to enter her room due to perceptions of her being a 'difficult' resident, and this led to her care needs being neglected. The resident herself reported feeling hungry, neglected, and tired of being left in her own waste, and her family members corroborated these accounts, stating that the neglect was ongoing and not limited to isolated incidents. Documentation showed a significant weight loss over several months, and staff interviews confirmed that the resident's care plan was not being followed after an initial period of compliance. Staff also admitted to avoiding her room and not providing timely assistance, with some stating they would not go in due to previous accusations made by the resident. The administration was aware that staff were refusing to care for her and that she was missing meals and personal care, but failed to ensure consistent adherence to her care plan and basic care standards.
Removal Plan
- Facility team members were in serviced on Abuse/Neglect for all team members including new hires, PRN, vacation, Agency and Leave of Absence. Education will be provided through verbal in servicing and post-test will be given to ensure retention of education. DON/ADON were provided training on Abuse/Neglect by RDO/RDCS.
- Skin assessment was completed on Resident #1. Skilled Wound Care Physician will conduct an onsite visit.
- Interviewable residents were interviewed by IDT team to inquire if residents had any concerns with any basic care not being met.
- Weight loss summary report was reviewed for all significant weight losses for those residents who are not able to be interviewed to validate that residents who need assistance with meals did not sustain weight loss due to lack of required assistance with meal service and review meal intake documentation.
- Clinical team was in serviced on importance of Q2 hour rounding on residents requiring assistance to ensure their needs are being met.
- One on one education completed with CNA C regarding assisting residents or finding assistance to provide care for residents in need. All staff assigned to resident hall were in serviced that they cannot refuse to go into resident room as assigned. Administrator trained by Regional Director of Operations.
- Daily rounding will be conducted by the IDT team for all assigned residents to address any concerns and identify any issues for those residents unable to communicate.
- Ad HOC QAPI meeting with MD conducted to discuss the plan of correction for compliance.
Failure to Prevent Neglect and Ensure Timely Care for Resident
Penalty
Summary
The facility failed to administer care in a manner that enabled effective and efficient use of its resources to maintain the highest practicable well-being of a resident. The administrator did not ensure that staff refrained from willful abuse and neglect, as evidenced by staff not assisting a resident out of bed at a reasonable time, causing her to miss breakfast and lunch on a regular basis. The resident was consistently left in bed for most of the day, despite care plans and interdisciplinary team agreements specifying she should be up in her wheelchair between 6:00 AM and 7:30 AM daily to eat meals and reduce her risk for aspiration pneumonia. The resident, an elderly female with rheumatoid arthritis, dysphagia, acquired neck deformity, and adult failure to thrive, was dependent on staff for transfers and required to be in her wheelchair to feed herself due to physical limitations. Multiple records, including care plans, progress notes, and video evidence, showed repeated instances where she was not assisted out of bed until the afternoon, resulting in missed meals and prolonged periods in soiled linens. Staff interviews confirmed that some aides refused to enter her room due to personal conflicts or perceptions of her being a difficult resident, and this refusal was tolerated by facility leadership. The resident experienced significant weight loss over several months, and both she and her family reported feelings of neglect and lack of dignity. Observations and interviews with staff, the resident, and her family revealed a pattern of neglect, with staff failing to follow the care plan and not providing timely assistance. Staff acknowledged that the resident was often not gotten up before breakfast, and some admitted to avoiding her room. Leadership interviews indicated awareness of the issue, with the administrator and others noting that staff were allowed to refuse care assignments. The facility's own policies required prevention and identification of neglect, but these were not followed, resulting in the resident missing meals, remaining in bed for extended periods, and experiencing psychosocial and physical harm.
Removal Plan
- Regional Director of Operations in serviced Administrator on Abuse/Neglect.
- Regional Director of Operations and Director of Clinical Services will attend EMR meetings to ensure any resident issues identified have appropriate interventions.
- Administrator in-serviced all team members on compliance 24-hour hot line where team members can report any concerns and or if administration is not taking corrective action or putting interventions in place to ensure residents are being cared for by staff appropriately.
- Compliance hotline notifications will be posted by time clock and breakrooms.
- Administrator trained by Regional Director of Operations.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of abuse involving a resident was reported immediately to the State Survey Agency as required. A female resident with intact cognition, who was her own responsible party and had multiple medical diagnoses including acute respiratory failure, congestive heart failure, and COPD, reported to the administrator that a male who previously worked at the facility entered her room at approximately 2:00 AM and made a suggestive, vulgar comment. The resident stated that she was not touched and did not feel unsafe, and requested that the incident not be reported to authorities or her family. Despite the facility's policy requiring immediate reporting of all abuse allegations to the appropriate agencies within two hours, the administrator, who also served as the Abuse Coordinator, did not report the incident as he was honoring the resident's request. The social worker, after being informed of the allegation, advised the administrator that it should be reported, but the administrator still did not report the incident in a timely manner. The facility's policy clearly outlines the steps and timeframe for reporting such allegations, which were not followed in this case.
Failure to Schedule TED Hose Order for Resident
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not schedule an order to apply TED hose to the resident's lower extremities during their stay. The resident, a male with end-stage renal disease, type II diabetes, morbid obesity, gout, thrombosis, and dependence on renal dialysis, was admitted and discharged within a week. Despite a physician's order to apply TED hose daily, this order was not scheduled, and thus did not appear on the Treatment Administration Record (TAR). Interviews with facility staff revealed that the responsibility for scheduling physician orders fell to the admitting nurses, but this order was overlooked. The Assistant Director of Nursing (ADON) acknowledged the importance of scheduling orders to ensure they are followed and noted that the failure to do so could risk the resident's health by increasing the likelihood of edema or blood clots. The facility's policy on medication orders did not address the scheduling of physician orders, and an in-service conducted prior to the incident emphasized the need to complete all queued orders upon admission.
Facility Fails to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for three residents, as observed during a survey. The deficiencies included foul odors in the rooms of two residents, bags of soiled briefs left in the restroom, and a pair of pants with a soiled brief on the restroom floor. Additionally, one resident's overbed table was found to be unclean, with food debris and a sticky dried liquid substance present. The baseboard in the restroom was also noted to be loose and falling onto the floor, posing a potential fall hazard. Resident #5, a female with a history of dementia, chronic kidney disease, diabetes, and other health issues, was found to have a room with a foul odor and bed linens with dried feces and brown stains. Despite these conditions, the resident expressed no concerns about her care. Resident #25, who has hemiparesis and other medical conditions, was dependent on staff for all toileting needs. Her room also had a foul odor, and her overbed table was unclean. Both residents' restrooms had bags of soiled briefs and loose baseboards. Resident #39, a male with dementia and other health issues, was found to have a room with a foul odor and bed linens stained with urine and covered in flies and gnats. Interviews with housekeeping staff and the Director of Nursing (DON) revealed that there were expectations for maintaining cleanliness, but these were not met. The facility's cleaning guidelines were not adequately followed, leading to unsanitary and potentially unsafe conditions for the residents.
Failure to Maintain Resident Hygiene and Grooming
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene. This deficiency was observed in four residents. Resident #5, a 73-year-old female with intact cognition but impaired vision, was found with facial hair approximately 1 inch long, which she was unaware of and embarrassed by. Despite requiring supervision for personal hygiene, the staff did not assist her in removing the facial hair, leading to her isolation due to embarrassment. Resident #6, with severe cognitive impairment, was observed with a blackish/brownish substance under her fingernails, accompanied by an odor of excreta. She required substantial assistance with ADLs, including personal hygiene, but her nails were not cleaned as needed. Similarly, Resident #7, with moderately impaired cognition, had a blackish substance under her fingernails, which she identified as feces from scratching her bottom. Despite requesting assistance, her nails were not cleaned because it was not her scheduled shower day. Resident #20, with severe cognitive impairment and dependent on staff for all ADLs, was found with mycotic fingernails and a dark substance under her nails. The staff, including the LVN and CNA, acknowledged the presence of dirt and potential bacteria under the residents' nails, which could lead to illness if ingested. The facility's policy required nail care to be performed on bath days and as needed, but this was not adhered to, resulting in poor hygiene and potential health risks for the residents.
Facility Fails to Maintain Sanitation Standards in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen. During an inspection, it was noted that a 55-gallon trash can in the kitchen prep area was without a lid, and utensil storage drawers contained food debris and bits of paper. Several food items, including scrambled eggs, sausage links, toast, pancakes, chicken strips, chicken nuggets, melted butter, and white gravy, were left uncovered on various surfaces. Additionally, the juice gun nozzle had a reddish-pink buildup, and the ice machine bucket contained standing water with food debris and a filmy substance. The ice machine door and seal were observed to have black and gray dirt and mold buildup. Another trash can near the hand hygiene sink in the dish room was also found without a cover. The facility also failed to ensure that temperature logs and cleaning logs were being completed. Observations revealed that a staff member did not clean the thermometer before taking food temperatures during the pureed production of butter beans, green beans, scalloped potatoes, sliced bread, and cornmeal crusted tilapia. Record reviews showed that the last documented cleaning of the ice machine was dated several months prior, and the weekly cleaning schedule had incomplete documentation for September. The daily cleaning schedule also had missing documentation for numerous tasks. Interviews with staff, including [NAME] K and the Dietary Manager (DM J), confirmed that the expected sanitation practices were not being followed. The staff acknowledged the proper procedure for taking food temperatures, which includes using an alcohol swab before and after each use, was not adhered to. The Dietary Manager expressed that it was their expectation for the kitchen to be clean, for all staff to complete cleaning lists, and for food items to be covered and stored properly. The Administrator also emphasized the importance of maintaining good sanitation to prevent foodborne illness among residents.
Pest Control Deficiency in Facility's Kitchen and Dining Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and crickets in the kitchen and dining room. Observations and resident interviews revealed numerous flies in the dining room, with residents covering their drinks and using personal fly swatters to manage the situation. Flies were observed landing on resident food, and dead crickets were found in the kitchen dish room. Additionally, the covered smoking patio area, which connects to the dining room, was found to have cats, bird feathers, and biological material attracting flies. Interviews with facility staff, including MD L and DM J, indicated that the facility had a contract with a pest control company for monthly treatments, but the issue with flies had not been effectively addressed. The facility had previously used bug lights to catch flying pests but no longer had them in place. The Administrator acknowledged the expectation for a pest-free environment and the potential negative outcomes of not achieving this. Despite daily monitoring of the building's exterior for pests, the facility lacked a formal pest control policy, as confirmed by the Administrator.
Failure to Respect Resident's Shower Preferences
Penalty
Summary
The facility failed to honor the resident's right to a dignified existence and self-determination by not accommodating Resident #17's preference for shower times. Resident #17, a male with quadriplegia and other significant medical conditions, was dependent on staff for activities of daily living, including showering. Despite having a BIMS score indicating no cognitive impairment, the resident's care plan did not reflect his preference for shower times, and he was frequently given showers late at night, which was not his preference. Interviews with Resident #17 revealed that he was often showered after 9:00 PM, which was not his choice, but rather a result of the staff's routine of showering other residents first. The resident expressed that while a late shower was better than no shower, he would prefer not to wait in his wheelchair until late at night for a shower. Staff members, including CNAs and the DON, believed that the late shower times were due to the resident's schedule of leaving the facility during the day and returning late at night, although there was no documentation to support this claim. The facility's administration, including the DON and ADM, acknowledged that showers were offered based on resident preferences but did not have a specific time for completion. They also noted that Resident #17's out-of-facility schedule was not routinely documented, leading to assumptions about his shower preferences. Despite the resident's expressed dissatisfaction with late-night showers, the facility did not offer or document alternative shower times, resulting in a failure to respect the resident's rights and preferences.
Failure to Complete PASARR Screenings Correctly
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASARR) Level I screenings were completed correctly, and residents with a mental illness were provided with a PASARR Level II assessment. This deficiency was identified for two residents, Resident #33 and Resident #32, who were reviewed for PASARR assessments. Resident #33 did not have a new PASARR Level I screening despite being diagnosed with a mental illness after admission. Similarly, Resident #32's PASARR Level I was not completed correctly, even though a mental illness was diagnosed upon admission. Resident #33, a female resident, was admitted with diagnoses including post-traumatic stress disorder (PTSD), anxiety disorder, and chronic pain syndrome. Despite these diagnoses, her PASARR Level I screenings conducted on multiple occasions indicated that she did not have a mental illness. Interviews with the resident revealed that she experienced anxiety and PTSD triggers, particularly when staff entered her room without knocking or when there were loud noises. The Assistant Director of Nurses and the MDS Coordinator acknowledged that a new PASARR Level I should have been completed following the new diagnosis of PTSD, which would have triggered a Level II assessment. Resident #32, a male resident, was admitted with multiple diagnoses, including bipolar disorder, major depressive disorder, and anxiety disorder. His PASARR Level I screenings also failed to reflect his mental illness, despite these diagnoses being present upon admission. The MDS Coordinator confirmed that a new PASARR Level I should have been completed, which would have led to a Level II assessment. The Director of Nurses and the facility Administrator expressed a lack of detailed knowledge about PASARR requirements, indicating a gap in the facility's compliance with ensuring residents receive necessary assessments and services.
Failure to Document ADLs in Resident's Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan did not include the resident's Activities of Daily Living (ADLs), which are crucial for ensuring appropriate physical care. The resident in question was an elderly female with diagnoses of polyosteoarthritis, anxiety disorder, and age-related cataracts, and had a moderately impaired cognition with a BIMS score of 9. The resident required assistance with personal hygiene, repositioning in bed, and dressing, and supervision with bathing, repositioning in bed, and transfers. Interviews with facility staff, including the Assistant Director of Nurses, MDS Coordinator, Director of Nurses, and a CNA, revealed that the omission of ADLs from the care plan could lead to inappropriate care being provided, as staff would not have clear guidance on the resident's needs. The MDS Coordinator acknowledged the responsibility to ensure all care plans were documented correctly, and the Director of Nurses indicated a need to review the protocol for care plans. The Administrator confirmed that all residents' ADLs were expected to be documented on the comprehensive care plan, and the failure to do so was attributed to the MDS Coordinator's oversight.
Failure to Supervise Resident Smoking
Penalty
Summary
The facility failed to ensure a safe environment for Resident #31, who was observed smoking without the required supervision and adaptive equipment, specifically a smoking apron. This deficiency was identified during an observation in the designated smoking area, where Resident #31 was found smoking without staff supervision and without wearing the smoking apron, despite the facility's policy requiring supervision and the use of a smoking apron for this resident. The resident's care plan and smoking safety screen both indicated the need for these precautions due to the resident's impaired vision and other health conditions. Resident #31, a male with a history of dementia, bipolar disorder, legal blindness, and other health issues, was deemed safe to smoke only with supervision and the use of a smoking apron. The facility's smoking policy mandates that all residents who smoke must be evaluated for their ability to do so safely, and any necessary precautions should be documented and followed. Interviews with the Director of Nursing (DON) and the Administrator revealed that their expectations were for staff to adhere to the recommendations from the smoking evaluations, which were not followed in this instance, potentially placing the resident at risk of harm.
Failure to Maintain Aseptic Technique and Clean Respiratory Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for two residents, leading to potential risks of respiratory infections. Resident #38, a female in a persistent vegetative state with a tracheostomy, was observed to have her oxygen concentrator and compressor air intake filters covered in a gray substance, indicating they were not cleaned as required. Additionally, during tracheostomy care, RN I did not follow aseptic techniques, such as washing hands appropriately, using sterile gloves, or cleaning the trach mask and stoma, which could introduce bacteria and cause infections. Resident #20, a female with severe cognitive impairment and a tracheostomy, also had an oxygen concentrator with an air intake filter covered in a gray substance. The facility's policy required these filters to be cleaned weekly, but observations showed they remained dirty, posing a risk of respiratory infections. Interviews with LVN H and the DON confirmed the expectation for regular cleaning to prevent infections, which was not adhered to. The facility's policies on tracheostomy care and respiratory therapy infection prevention were not followed, as evidenced by the lack of aseptic technique and failure to maintain clean respiratory equipment. These deficiencies in care could lead to respiratory infections for residents dependent on respiratory support, highlighting a significant lapse in adhering to established care protocols.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with post-traumatic stress disorder (PTSD), anxiety disorder, dependence on renal dialysis, and chronic pain syndrome. The resident's comprehensive care plan did not include an assessment or documentation of potential PTSD triggers, which is crucial for preventing re-traumatization. Despite the resident's intact cognition and her ability to communicate her needs, the care plan lacked specific interventions to address her PTSD triggers, such as unexpected room entries and loud conversations, which she identified as anxiety-inducing. Interviews with the resident and facility staff revealed a lack of awareness and documentation regarding the resident's PTSD triggers. The MDS Coordinator acknowledged the importance of identifying and documenting these triggers in the care plan to prevent re-traumatization. The Director of Nurses and the Administrator confirmed that care plans should be individualized and include specific triggers for residents with PTSD. However, the facility did not provide a policy on care plan revisions, indicating a gap in their procedures for addressing the needs of trauma survivors.
Inadequate Infection Control During Tracheostomy Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the improper tracheostomy care provided to a resident. The resident, a female in a persistent vegetative state, was dependent on staff for all activities of daily living and required tracheostomy care. During an observation, RN I performed tracheostomy care without adhering to aseptic techniques, which included not washing hands before donning gloves, using an incontinent wipe instead of a germicidal wipe to clean the overbed table, and failing to clean the tracheostomy mask and stoma area. RN I's actions included using the same pair of gloves to gather supplies, handling the suction tubing, and performing suctioning through a mucus-filled tracheostomy mask. The RN did not wash her hands between glove changes and failed to clean the tracheostomy mask or stoma area before inserting a new inner cannula. These actions were contrary to the facility's policy on tracheostomy care, which requires aseptic techniques and proper hand hygiene to prevent infections. Interviews with RN I and the Director of Nursing (DON) confirmed the deviations from the facility's policies. RN I acknowledged the failure to use proper hand hygiene and aseptic techniques, which could introduce bacteria and cause infections. The DON stated that the facility's policy requires nurses to perform tracheostomy care using aseptic techniques and that failure to do so could lead to resident infections.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Temple
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Temple East | 0.2 mi | ★★★★★ | 3 | 0 |
| Morada Temple | 0.4 mi | ★★★★★ | 5 | 0 |
| Cornerstone Gardens Llp | 0.6 mi | ★★★★★ | 0 | 0 |
| Avir At Weston | 0.8 mi | ★★★★★ | 3 | 0 |
| Baylor Scott & White Continuing Care Hospital Skil | 0.9 mi | ★★★★★ | 1 | 0 |
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