Avir At Texarkana
Inspection history, citations, penalties and survey trends for this long-term care facility in Texarkana, Texas.
- Location
- 4925 Elizabeth St, Texarkana, Texas 75503
- CMS Provider Number
- 676069
- Inspections on file
- 32
- Latest survey
- March 6, 2026
- Citations (last 12 mo.)
- 6 (2 serious)
Citation history
Health deficiencies cited at Avir At Texarkana during CMS and state inspections, most recent first.
A resident with chronic back and neck pain, cognitively intact and on scheduled Hydrocodone-Acetaminophen TID, went without multiple ordered doses when the medication was repeatedly documented as unavailable or "on order" on the MAR. Staff, including CMAs and an LVN, were aware the drug was not in the building and that the resident was distraught and reporting uncontrolled, excruciating pain, but there was no timely or documented notification to the MD or NP, no effective follow-up with the pharmacy, and no alternative pain management offered. Pharmacy records showed minimal documented requests from the facility, while the ADON and charge nurse acknowledged knowing about missed doses yet not documenting calls or reassessments. As a result, the resident experienced days without his prescribed pain medication and significant uncontrolled pain, constituting a failure to manage pain according to professional standards.
Two residents did not receive critical ordered medications when the facility failed to ensure timely acquisition, follow‑up, and administration of an anticonvulsant and a scheduled opioid analgesic. One resident with epilepsy missed multiple doses of Topamax 25 mg PO TID over several days when the drug was not available in the building, staff did not secure it from the pharmacy, pyxis, or a local source, and the MD/NP were not consistently or clearly notified despite MAR entries showing non‑administration. Another resident with chronic pain missed numerous doses of hydrocodone‑acetaminophen 10‑325 mg PO TID, with MAR notes repeatedly indicating the medication was “on order” or “waiting on arrival,” but there was no documented contact with the MD, NP, or pharmacy to resolve the lack of supply, and the resident reported severe uncontrolled pain during this period. Staff interviews revealed confusion over who was responsible for contacting the pharmacy, lack of documentation of calls and notifications, and absence of a reliable system for ordering and receiving medications after a corporate pharmacy change, leading to prolonged medication unavailability for both residents.
A resident with advanced Alzheimer's and multiple comorbidities experienced repeated falls, bruising, and behavioral changes while on hospice care. Facility staff failed to notify the resident's representative and hospice agency of these incidents and related medication changes, despite facility policy requiring such notifications. Documentation and interviews confirmed that notifications were often delayed or omitted, and staff reported confusion about when to document and communicate these events.
A nurse failed to document a fall incident involving a resident with multiple health conditions, did not notify the resident's family or physician, and did not complete an incident report as required by facility policy. The nurse stated she was told by the DON not to document the event, leading to incomplete medical records and lack of proper notification.
Staff members with facial hair were observed serving and preparing food without required hairnets or facial coverings, despite facility policy and staff acknowledgment of the need for these precautions to prevent food contamination. The deficiency was noted during kitchen observations and confirmed through staff interviews.
A deficiency occurred when only one CNA was present in a memory care unit, leaving residents unsupervised while the CNA assisted another individual. During this period, two residents with cognitive and behavioral impairments engaged in an altercation in the dining area. Staff interviews confirmed that the unit typically required two staff members due to the residents' needs, but this standard was not met at the time of the incident.
Two residents with severe cognitive impairment and behavioral issues were involved in a physical altercation, where one pulled the other's ear and was bitten in response. Staff were aware of ongoing behavioral conflicts between the two, and although interventions were in place, the incident still occurred, resulting in a minor injury.
A memory care unit was left unsupervised for at least six minutes when a CNA took a bathroom break, leaving residents with cognitive impairments and a history of falls at risk. A resident was found with blood around her mouth, another engaged in unsafe behavior, and a third was at risk of falling. Staff interviews revealed that it was common for the unit to be left unattended during breaks, despite the facility's policy emphasizing the need for supervision.
The facility failed to maintain food safety and sanitation standards in the kitchen, with issues such as carbon build-up on cooking equipment, improper facial hair coverage by staff, and inadequate food labeling and storage practices. These deficiencies could lead to food contamination and potential health risks for residents.
A malfunctioning call light system in the 200 Hall Memory Care Unit resulted in a loud, continuous alarm that persisted over several days, causing discomfort for residents and staff. Despite awareness of the issue, the facility was unable to silence the alarm due to wiring problems, and repair efforts were delayed. Interviews with staff revealed that the problem had been ongoing, and the maintenance request log did not document any repair requests.
The facility failed to ensure safe mechanical lift transfers for two residents, with staff not following proper procedures for spreading lift legs, posing a risk of accidents. Additionally, a resident's smoking materials were not secured as per facility policy, creating potential hazards.
A resident was unable to call for staff assistance due to a malfunctioning call light system, which was not promptly repaired. The resident had to wait for staff to enter her room, leading to unmet needs. The facility's policy on maintaining a functioning call light system was not adequately followed.
A resident with multiple health issues was found with a call light device on the floor, out of reach, while in bed. The resident was unaware the device was functional, as it had not been communicated to him. The facility failed to ensure the call light was accessible, posing a risk to the resident's ability to request assistance.
A resident's wheelchair had a malfunctioning right brake, which was not properly addressed by the facility. Despite being informed of the issue, the facility continued to use the wheelchair, posing a risk of falls. The resident had a history of falls and mobility issues, and the facility's policy on equipment maintenance was not followed.
A facility failed to protect a resident from verbal abuse when a CNA raised her voice and used inappropriate language. The incident was witnessed by another staff member, who reported it through a note. The resident, with a history of cognitive impairment, denied the abuse, but the DON noted the resident might not accurately report the incident.
A resident with cognitive impairment was verbally abused by a CNA, and the incident was not reported to the Administrator within the required 2-hour timeframe. The Activity Director and Business Office Manager failed to follow the facility's policy, leaving the resident at risk. The Administrator only became aware of the incident the following day through an anonymous note.
Failure to Provide Ordered Pain Medication and Notify Provider of Uncontrolled Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate, and consistent pain management to a cognitively intact male resident with chronic pain who was admitted with diagnoses including age-related physical disability, hypertension, schizophrenia, and major depressive disorder. His MDS showed he was able to make himself understood, understood others, and was on scheduled pain medication. He had a physician’s order for Hydrocodone-Acetaminophen 10-325 mg by mouth three times daily, and his care plan directed staff to give pain medication and evaluate his pain so that he would remain free from pain. Despite these orders, the Medication Administration Record (MAR) for two consecutive months showed multiple scheduled doses at 7:00 AM, 12:00 PM, and 5:00 PM documented as not administered, with reasons such as “other/see progress note,” and repeated administration notes stating the hydrocodone was “waiting on arrival,” “on order,” or “N/A.” During the period when the medication was unavailable, there was no documentation in the resident’s progress notes that the physician, nurse practitioner, or pharmacy had been notified that the resident was out of his ordered hydrocodone. A Triplicate Request form for the hydrocodone contained an undated, unsigned handwritten note indicating a new triplicate was required because the facility had changed pharmacies, but there was no corresponding documentation of timely follow-up or communication with the prescriber. The resident reported that he had gone without his pain medication for about five days, that he was told his pain medication was not in the building, and that he was not informed why he could not have it. He described excruciating back and neck pain, inability to sleep or rest, numbness in his hands and fingers, and rated his pain as greater than 10 on a 1–10 scale. He stated he was not offered any other pain medication and that non-pharmacologic measures such as repositioning and pillow adjustment were offered but refused because he wanted his prescribed pain medication. Multiple staff interviews revealed awareness that the resident’s hydrocodone was not available and that doses were being missed, but there was a lack of effective action and documentation to resolve the issue. An anonymous staff member and a medication aide stated they had informed charge nurses and the ADON that the resident’s pain medication was unavailable and that the resident was frustrated and distraught due to uncontrolled pain, yet the nurse practitioner reported she was never notified of the missed doses or change in the resident’s condition until weeks later. The ADON acknowledged knowing the resident had missed doses, stated she had called and faxed the pharmacy and contacted the nurse practitioner about triplicates, but admitted she had not documented any of these efforts or any notification to the physician or nurse practitioner about the missed medications. The charge nurse (LVN) on duty during part of the period admitted she knew the resident did not have his ordered hydrocodone, did not reassess his pain, did not offer alternative pain-relieving medications, and could not recall notifying the nurse practitioner. Pharmacy records showed only one facility request for hydrocodone and a subsequent supply, with no further logged activity until much later, indicating a lack of documented follow-up from the facility. These combined inactions and communication failures led to the resident going without his ordered scheduled pain medication and experiencing uncontrolled, excruciating pain with behavioral changes, while the facility failed to manage his pain consistent with professional standards of practice.
Failure to Obtain and Administer Ordered Anticonvulsant and Pain Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for residents, specifically seizure and pain medications. One cognitively intact male resident with epilepsy had an active order for Topamax 25 mg PO three times daily for seizure prevention. His February MAR showed multiple doses not administered beginning on 02/10/2026, with entries marked as “other/see progress note,” and documentation that the medication was not available. The resident’s care plan required seizure medications to be given as ordered and for staff to monitor effectiveness and side effects, but the ordered Topamax was not on hand from 02/10/2026–02/15/2026, and the facility did not obtain the drug from the pharmacy, pyxis, or a local pharmacy during that period. Staff interviews revealed inconsistent and incomplete follow‑up on the missing Topamax. Medication aides reported notifying charge nurses and the ADON that the resident was out of Topamax and that the medication had not arrived after being ordered, but some nurses did not follow through with the pharmacy. The ADON stated she had called and faxed the pharmacy multiple times and believed the Nurse Practitioner had been informed that the resident had missed multiple doses, but she acknowledged she did not document any of these contacts or the missed doses. The Nurse Practitioner, however, stated she had no knowledge that the resident was without Topamax prior to 02/15/2026 and only learned on that date that the resident had missed five days of doses. The physician also reported he was not notified that the resident had missed Topamax doses, had seizure‑like episodes, or had been transported to the hospital, and pharmacy records showed no refill activity between 01/26/2026 and 02/15/2026 despite the facility’s claims of repeated contacts. A second cognitively intact male resident with chronic pain and an order for scheduled hydrocodone‑acetaminophen 10‑325 mg PO three times daily also experienced prolonged unavailability of his medication. His MAR and administration notes from late January through early February documented repeated missed doses with notations such as “waiting on arrival,” “on order,” and “N/A,” indicating the drug was not in the building. Progress notes for this period did not show that the physician, NP, or pharmacy were notified that the resident was out of hydrocodone. A triplicate request form for the hydrocodone dated 01/05/2026 contained an undated, unsigned handwritten note stating a new triplicate was required because the pharmacy had changed, but there was no evidence of follow‑up to secure the medication. The resident reported he went without his pain medication for about five days, experienced excruciating back and neck pain with numbness in his hands and fingers, could not sleep, and became agitated and irritable, while staff only offered non‑pharmacologic measures such as repositioning and pillow adjustment. Across both cases, staff accounts showed confusion and disagreement about responsibilities for ordering, tracking, and following up on medications. Medication aides stated they were not allowed to call the pharmacy and relied on nurses, while at least one LVN stated MAs had the same access she did and should handle their own follow‑up. The ADON reported there was no clear system in place for ordering and receiving medications after a corporate pharmacy change, and that staff often did not know which pharmacy number to call. The Corporate Regional Nurse acknowledged that the facility had experienced problems after the corporate pharmacy change and that an acute review later identified missed medications due to unavailability, but maintained that the facility had notified the NP and followed up with the pharmacy. The survey identified that the facility failed to ensure timely acquisition and administration of ordered medications, failed to consistently notify the physician/NP when medications were unavailable, and failed to document and escalate these issues, resulting in missed anticonvulsant and pain medications for two residents.
Failure to Notify Resident's Representative and Hospice of Significant Changes
Penalty
Summary
The facility failed to notify a resident's representative (RP) and hospice agency of multiple significant changes in the resident's condition, including falls, bruising, behavioral changes, and medication changes. Documentation revealed that the resident, who had a history of cerebral infarction, hemiplegia, Alzheimer's disease, repeated falls, and was receiving hospice services, experienced several incidents such as sliding or rolling out of bed, developing new bruises, and exhibiting increased agitation and behavioral changes. Despite these events, there was no documentation that the RP or hospice agency were notified in a timely manner, as required by facility policy and professional standards. Nursing notes and interviews indicated that staff, including RNs and LVNs, often failed to document or communicate these incidents to the appropriate parties. In several instances, falls and new bruising were observed and assessed by nursing staff, but notifications to the RP and hospice agency were either delayed or not made at all. Medication changes ordered by the hospice physician in response to the resident's behavioral changes were also not communicated to the RP. Staff interviews revealed confusion regarding documentation and notification procedures, with some staff reporting that they were told by previous management not to document certain incidents if the resident was care planned for such events. The lack of notification was confirmed through interviews with the resident's RP and hospice representatives, who stated they were not informed of several falls, behavioral changes, or medication adjustments. The facility's own policies required prompt notification of the resident's physician, RP, and hospice agency in the event of accidents, incidents, injuries, or significant changes in condition. The failure to follow these policies resulted in the RP and hospice agency being unaware of important changes in the resident's status, as evidenced by the RP only learning of some incidents through hospice or after reviewing the resident's chart.
Failure to Document and Report Resident Fall
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented in accordance with accepted professional standards. Specifically, a nurse (LVN) did not document an incident in which a resident was found on the floor by a hospice aide during the early morning hours. The nurse did not record the fall in the resident's medical record, did not notify the resident's responsible party, and did not complete an incident report as required by facility policy. The nurse stated that she was instructed by the Director of Nursing (DON) not to complete an incident report or document the event, despite being aware of the facility's procedures for reporting and documenting falls. The resident involved had a complex medical history, including diagnoses of cerebral infarction, hemiplegia, hemiparesis, mood and anxiety disorders, Alzheimer's disease, weakness, lack of coordination, repeated falls, and abnormal albumin levels. The resident was receiving hospice services, was at risk for falls, and required substantial assistance with activities of daily living. On the morning of the incident, the hospice aide found the resident on the floor, attempted to seek help, and eventually located the nurse to assist in moving the resident. The nurse assessed the resident and found no injuries but did not document the incident or notify the family as required. Interviews with facility staff and review of facility policy confirmed that the nurse was expected to document the fall, notify the physician and family, and complete an incident report within 24 hours. The nurse admitted to not fulfilling these responsibilities, citing instructions from the DON. The administrator acknowledged confusion among staff regarding reporting and documentation expectations, particularly due to conflicting instructions from the previous DON. The facility's policy clearly outlined the steps to be taken following a fall, including documentation and notification requirements, which were not followed in this case.
Failure to Enforce Hair Restraint and Facial Covering Use in Food Service Areas
Penalty
Summary
The facility failed to ensure that food service staff adhered to professional standards for food safety by not requiring the use of appropriate hair restraints and facial coverings in the kitchen. Observations revealed that Dishwasher A, who had facial hair above his upper lip and on his chin, was not wearing a facial covering while serving food and washing dishes. Additionally, Dishwasher A was not wearing a hairnet or facial covering while in the dishwashing area, despite having been educated on the requirement to wear these items when serving food. Another staff member, [NAME] B, was observed preparing food without a facial covering to cover his facial hair. Both staff members acknowledged the importance of wearing hairnets and facial coverings to prevent hair from contaminating residents' food, but failed to comply with these requirements during the observed periods. Interviews with various staff, including the Assistant Dietary Manager and Interim Administrator, confirmed that all individuals entering the kitchen, including the dishwashing area, were expected to wear hairnets and facial coverings if they had facial hair. The facility's policy, revised in November 2022, also required food and nutrition services staff to wear hair restraints to prevent hair from contacting food. The lack of a current Dietary Manager and recent staffing changes were noted, but staff were aware of the facility's expectations regarding food safety practices. No specific residents were identified as being directly affected in the report.
Failure to Provide Adequate Supervision in Memory Care Unit Resulting in Resident Altercation
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for residents in one of its memory care units. On the date of the incident, only one CNA was present in the memory care unit while the other staff member was absent. During this time, the CNA was occupied in another resident's room assisting with morning care, leaving the remaining residents in the dining area unsupervised. As a result, two residents engaged in an altercation, during which they were observed swatting and slapping at each other's hands. The CNA intervened upon noticing the incident and separated the residents, after which a nurse assessed both individuals and found no injuries. One of the residents involved had a history of Alzheimer's disease, dementia, schizoaffective disorder, muscle weakness, impaired vision, and repeated falls. This resident was severely cognitively impaired, used a wheelchair for mobility, and was dependent on staff for most activities of daily living. The other resident had a history of cerebral infarction, schizophrenia, gait abnormalities, and lack of coordination, with moderate cognitive impairment and a documented history of physical behavioral symptoms directed toward others. Both residents were considered elopement risks and resided on the secured memory care unit due to their behavioral and safety needs. Interviews with staff, including the CNA, RN, DON, and interim administrator, confirmed that there was only one staff member present in the memory care unit at the time of the incident. Staff acknowledged that the unit typically required two staff members due to the residents' behavioral challenges and supervision needs. The facility's policy for the secured unit emphasized the importance of providing a safe and structured environment for residents at risk of elopement or harm due to cognitive impairment. However, on the day of the incident, the lack of adequate staffing and supervision directly led to the altercation between the two residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure that two residents were free from physical abuse when an altercation occurred between them. On the specified date, one resident, who had a history of severe cognitive impairment, mental health conditions, and episodes of aggression, entered the main dining area and pulled another resident's ear. The second resident, also with severe cognitive impairment and a diagnosis of Alzheimer's disease, responded by biting the first resident on the right wrist. Both residents had documented histories of behavioral issues, including aggression and non-cooperation with care, as noted in their care plans and assessments. Staff interviews revealed that the two residents were known to have frequent verbal and physical altercations, with some staff reporting that such behaviors occurred almost daily. However, other staff and the DON stated that it had not been reported that these altercations happened daily. On the day of the incident, staff immediately separated the residents and assessed them for injuries. The first resident sustained a small bruise to her right wrist, while the second resident had no injuries. The incident was documented, and the appropriate parties were notified as per facility policy. The facility's policies required staff to protect residents from abuse, including abuse from other residents, and to investigate and report all altercations. The care plans for both residents included interventions such as medication administration, behavioral monitoring, psychiatric consults, and separation of residents when necessary. Despite these measures, the altercation occurred, indicating a failure to prevent resident-to-resident abuse as required by facility policy and regulatory standards.
Inadequate Supervision in Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents in one of its memory care units. On a specific occasion, a Certified Nursing Assistant (CNA) left the memory care unit unattended for at least six minutes to take a bathroom break, as observed by a state surveyor. During this time, several residents with cognitive impairments and a history of falls were left without supervision, increasing their risk of injury. Resident #1, who has a history of cerebrovascular disease, Parkinson's disease, and cognitive impairments, was found with blood around her mouth, which was not present before the CNA left the unit. Resident #2, diagnosed with severe cognitive impairment and bipolar disorder, was observed engaging in potentially unsafe behavior by putting water onto a cloth item. Resident #3, with a history of falls and moderate cognitive impairment, was seen self-propelling in a wheelchair, holding her leg up, indicating a potential fall risk. Interviews with staff revealed that it was common for the memory care unit to be left unsupervised during staff breaks, as there was only one aide assigned per unit during certain shifts. Staff members, including CNAs and Licensed Vocational Nurses (LVNs), acknowledged the risks associated with leaving residents unsupervised, particularly given the residents' high fall risk and potential for aggressive behavior. The facility's policy emphasized the importance of supervision to prevent accidents, but the practice of leaving the unit unattended contradicted this policy.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as observed in the kitchen. There was a significant carbon build-up on two baking sheets and one skillet, indicating inadequate cleaning practices. Additionally, male kitchen staff, including the Dietary Manager, were observed not wearing proper facial hair covers, which could lead to contamination. The Dietary Manager admitted to not cleaning the pans sufficiently and acknowledged the potential risk of contamination from uncovered facial hair. Further observations revealed improper storage practices, such as a scoop being left inside a sugar bin, which could lead to contamination. The facility also failed to date and label food items in Freezer #1, Freezer #2, and Refrigerator #1. This included various unlabeled and undated food packages, which could result in the use of expired or incorrect food items. The Dietary Manager confirmed that it was everyone's responsibility to date and label foods, but ultimately his responsibility to ensure compliance. Interviews with the Dietary Manager and the Administrator highlighted a lack of adherence to facility policies and procedures regarding food safety and sanitation. The Administrator expressed expectations for clean cooking equipment and proper storage of scoops to prevent foodborne illnesses. The facility's policies, aligned with state and federal food codes, emphasize the importance of maintaining clean kitchen facilities and proper food labeling to minimize the risk of infection and foodborne illness.
Malfunctioning Call Light System Causes Discomfort in Memory Care Unit
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in the 200 Hall Memory Care Unit due to a malfunctioning call light system. A loud, continuous alarm from the call light system was observed on multiple occasions over several days, causing discomfort and difficulty in communication during medication administration. The alarm was first noted on 05/13/24 and continued to sound through 05/14/24, affecting the environment for residents and staff. Interviews with staff, including RN D, the ADON, the Maintenance Supervisor, the DON, and the Administrator, revealed that the issue with the call light system had been ongoing since at least 05/10/24. Despite awareness of the problem, the facility was unable to silence the alarm due to wiring issues, and attempts to have the system repaired were delayed as the repair company did not arrive as scheduled. The Maintenance Supervisor indicated that disabling the alarm would require removing a fuse, which would deactivate the entire system. The facility's maintenance request log did not document any request for repair of the call light alarm.
Deficiencies in Mechanical Lift Transfers and Smoking Material Security
Penalty
Summary
The facility failed to ensure safe mechanical lift transfers for two residents, leading to potential accident hazards. For Resident #15, CNA A and the DON conducted a mechanical lift transfer with the lift legs in the narrow position, which was not in accordance with the facility's training standards. Although Resident #15 reported feeling safe during transfers, the improper use of the lift could have led to instability and potential injury. Similarly, for Resident #19, CNA B and CNA C performed a mechanical lift transfer with the lift legs in the narrow position until the resident was almost over the wheelchair. Both CNAs acknowledged the importance of spreading the lift legs to ensure stability and prevent tipping, yet the procedure was not followed correctly. Despite the residents not having been injured during these transfers, the improper technique posed a risk of accidents. Additionally, the facility failed to secure Resident #201's smoking materials, which were found in her room contrary to the facility's smoking policy. The policy required that all smoking materials be stored at the nurse's station to prevent unsupervised use and potential hazards. The presence of cigarettes and a lighter in Resident #201's room indicated a lapse in adherence to this policy, posing a risk of fire or injury.
Failure to Maintain Functioning Call Light System
Penalty
Summary
The facility failed to ensure that a resident's room was adequately equipped with a functioning call light system, which is essential for residents to call for staff assistance. Specifically, Resident #201, an elderly female with intact cognition and requiring supervision for various activities, reported that her call light was not working. Upon inspection, the surveyor confirmed that the call light system in Resident #201's room was malfunctioning, as the light above her door did not turn on when the button was pressed. The resident mentioned that she had been unable to call for help and had to wait for staff to enter her room, which could lead to unmet needs and potential risks for the resident. The issue was reportedly fixed the following day, but the resident had been without a functioning call light for at least a week prior to the repair. Interviews with the Maintenance Supervisor, Administrator, and Director of Nursing (DON) revealed that the call light system had been experiencing intermittent problems, particularly in the 300 hall. The Maintenance Supervisor had reached out to the service company, but repairs were delayed due to staffing issues. The Administrator and DON were aware of the problem and had provided bells to residents as a temporary measure, although Resident #201 did not receive one. The facility's policy mandates maintaining a functioning call light system and reporting any failures to maintenance and the administrator for prompt action, which was not adequately followed in this case.
Resident's Call Light Inaccessible
Penalty
Summary
The facility failed to ensure that a resident had reasonable accommodation of needs, specifically regarding the accessibility of a call light. The resident, an elderly male with a history of pressure ulcers, protein-calorie malnutrition, and a urinary tract infection, was found to have a touch pad call device on the floor, out of reach, while he was lying in bed. The bed was in a high position, making it impossible for the resident, who was dependent on assistance for most activities of daily living, to reach the call device. Despite the call light being functional, the resident was unaware of this as he had not been informed that it was working again. During the survey, it was observed that the resident's call light was not within reach, and the resident confirmed that he could not use it to request assistance. The resident's care plan indicated that he was provided with a touch system call device, but it was not accessible to him at the time of observation. Interviews with the Director of Nursing and the Administrator highlighted the risk posed to residents who are unable to signal for help, emphasizing the importance of ensuring that call devices are accessible and that residents are informed about their functionality.
Wheelchair Brake Malfunction
Penalty
Summary
The facility failed to ensure that all patient care equipment was in safe operating condition, specifically for one resident whose wheelchair had a malfunctioning right brake. This deficiency was identified through observations, interviews, and record reviews. The resident, who had a history of falls and mobility issues, was using a wheelchair with a right brake that did not lock properly, posing a risk of falls and injury. Interviews with the resident's family member and hospice nurse revealed that the facility had been informed of the wheelchair's issues, including the broken anti-tipping device and the non-functioning right brake. Despite hospice sending new wheelchairs, they were returned by the facility due to the absence of an anti-tipping device, which hospice did not provide. The facility's staff, including CNAs and a physical therapy assistant, confirmed that the right brake was not functioning properly, allowing the resident to move the wheelchair even when the brakes were engaged. The Director of Nursing (DON) and the Administrator were unaware of the brake issue until it was brought to their attention during the survey. The facility's policy on equipment maintenance requires that unsafe equipment be reported and removed from use until repaired or replaced. However, the malfunctioning wheelchair continued to be used, indicating a lapse in adherence to this policy.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure the right to be free from abuse for one resident when a CNA raised her voice and cussed at the resident. The incident occurred on the morning of 04/02/24 when the CNA was passing out breakfast trays and yelled at the resident to sit down and used inappropriate language. This was witnessed by another staff member who later reported the incident through a handwritten note slipped under the Administrator's door. The resident involved had a history of alcohol-induced dementia, traumatic brain injury, and seizures, and was noted to have moderate cognitive impairment with a BIMS score of 8. The investigation revealed conflicting accounts of the incident. The CNA denied cussing at the resident and stated that she had to speak loudly because the resident was hard of hearing. However, the Activity Director confirmed hearing the CNA yelling and cursing at the resident. The Activity Director admitted to hearing the incident but did not report it immediately to the abuse coordinator or the Administrator. The resident herself denied any abuse when interviewed, but the DON noted that the resident might not be able to accurately report the incident due to her cognitive impairment. The facility's records showed that the CNA had received customer service education following the incident, emphasizing the need for compassionate and kind communication with residents. Both the CNA and the Activity Director had previously been in-serviced on the facility's Abuse and Neglect policy. Despite these measures, the facility failed to protect the resident from verbal abuse, as evidenced by the conflicting reports and the delayed reporting of the incident by the Activity Director.
Failure to Report Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment were reported immediately or within 2 hours. This deficiency was observed in the case of a resident with alcohol-induced dementia, a history of traumatic brain injury, and seizures. The resident, who had moderate cognitive impairment and required supervision for activities of daily living, was verbally abused by a CNA. The CNA was heard yelling and using inappropriate language towards the resident during breakfast service. Despite witnessing the incident, the Activity Director and Business Office Manager did not report the abuse to the Administrator within the required timeframe. The Activity Director heard the CNA yelling and cursing at the resident but did not report the incident immediately. Instead, she reported it to the Business Office Manager after lunch, who also failed to report it to the Administrator, assuming the Activity Director would do so. The Administrator only became aware of the incident the following day when she found an anonymous note describing the abuse. The Activity Director admitted to hearing the abuse and not reporting it promptly, while the Business Office Manager confirmed that the Activity Director had informed her but did not take further action. The facility's policy requires that all alleged violations of abuse be reported to the Administrator or other officials within two hours. Signs posted in the facility indicated the Administrator's role as the Abuse/Neglect Coordinator and provided her contact information. Despite this, the staff failed to follow the policy, leaving the resident at risk. The Director of Nursing and the Administrator both expressed that the incident should have been reported immediately to prevent further harm to the resident.
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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