Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Tierra Este during CMS and state inspections, most recent first.
A resident with a Foley and a history of urinary retention was taken off catheter after bladder training, but staff did not monitor urine output as ordered and did not promptly assess repeated reports that he had not voided. An LPN later reinserted the catheter, but there was no urine return and blood was noted; irrigation also failed. Ultrasound showed severe retention and hydronephrosis, and the resident was sent to the hospital with traumatic Foley exchange, hematuria, bladder outlet obstruction, septic shock due to UTI, and ICU admission.
A resident with a suprapubic catheter and G-tube was on EBP, but an LVN entered the room without hand hygiene or PPE and exposed the resident’s stoma sites without gowning or gloving. The resident said staff did not clean the G-tube or suprapubic sites and did not use gowns and gloves for personal care. Staff interviews and room observations showed confusion about which residents were on EBP and that gowns and masks were not readily available in multiple rooms or storage areas, despite the facility’s EBP policy requiring PPE for high-contact care with residents who have indwelling devices.
Incomplete Documentation of Urinary Retention Assessment and Foley Irrigation: An LVN failed to document assessments, urinary output, and Foley irrigation for a resident with an indwelling catheter, obstructive uropathy, and renal failure. Staff reported the resident had not voided, had abdominal distention, and required Foley reinsertion and NS irrigation, but the LVN stated he did not chart the assessments or the procedure details in the EHR.
Dietary staff failed to follow hand hygiene practices during meal service, including handling a cell phone, propping a door open with a can placed on the floor, and then immediately resuming food tray handling without washing or sanitizing hands. The staff member also provided tray covers and additional food items to an LVN and continued working the tray line before later returning with gloves on, with no confirmation that hand hygiene was performed before donning them. Facility leadership and another dietary staff member reported that staff are trained and expected to wash hands before handling food trays and after touching non-food items, in accordance with the facility’s hand hygiene policy.
A resident with severe cognitive impairment, dysphagia, renal failure, and a documented history of dehydration and related hospitalizations did not have a comprehensive, person-centered care plan addressing dehydration, despite facility policy requiring such plans. Record review showed no specific dehydration diagnosis order and no dehydration-focused care plan, only a generic "risk for altered fluid balance" plan with limited interventions. The DON and Administrator acknowledged that the care plan lacked content on dehydration prevention, while the MDS nurse stated that existing fluid balance interventions were being used, even though they did not specifically address the resident’s dehydration diagnosis.
A facility failed to maintain resident dignity in several areas. A cognitively intact resident reported ongoing difficulty getting briefs and wipes because supplies were limited on the floor and often had to be searched for, while staff and leadership acknowledged the issue had been ongoing. The facility also delayed a resident’s transfer because a mechanical lift net was not available in a timely manner, leaving the resident in bed longer. In dining, a resident with severe cognitive impairment was served lunch after tablemates had already been served, and staff identified the delay as a dignity and self-esteem issue.
Failure to maintain fingernail hygiene for two residents was identified. One resident with hemiparesis and moderate cognitive impairment had long, dirty fingernails, and another resident with dementia and severe cognitive impairment had fingernails about one inch past the nail bed on both hands. Staff stated CNAs and nurses were responsible for keeping nails clean and trimmed, and the facility policy called for daily cleaning and regular trimming.
Dirty oxygen concentrator filters were observed for three residents receiving oxygen via nasal cannula, including residents with acute respiratory failure with hypoxia and a resident with a history of pneumonia. The MDS and care plans showed oxygen therapy was ordered, but the concentrator air filters were noted with dust and lint. An LVN said filters were checked and cleaned weekly, while the DON was unsure who was responsible for cleaning them and said there had been no staff inservice on clean air filters.
Unlabeled cups containing zinc oxide cream and a tongue depressor were found at the bedside of two residents with intact cognition who needed assistance with ADLs and brief changes. Both residents said CNAs left the cream out for reuse during the day to treat brief-related rash. Staff, including the CMA, LVN, DON, IP, CNAs, and Administrator, stated the cream should not be left uncovered, unlabeled, or at bedside, and the DON said the facility had no policy addressing bedside medication storage.
Two residents had call lights out of reach during observation. One resident with dementia and a seizure disorder had her call light on the floor while asleep, and a CNA confirmed it had not been placed within reach. Another resident with severe cognitive impairment and right-sided weakness had a touch pad call light clipped to the bed and out of reach despite limited ROM on the right side. Staff, including the ADON, DON, and Administrator, stated call lights were meant for resident communication and should be kept within arm's reach.
A resident with severe cognitive impairment, AKI, dementia, and postoperative urinary retention requiring a Foley catheter did not have the catheter addressed in the care plan. Staff interviews confirmed that MDS nursing and the IDT were responsible for compiling and reviewing care plans, and the DON and Administrator stated resident conditions such as an indwelling catheter needed to be included so staff could provide condition-specific care.
A resident with insomnia and moderate cognitive impairment received Temazepam, but the individual control drug record had missing LPN/RN signatures after administration. The MAR and narcotic record showed the medication was ordered and given, while interviews with the DON, RN, and Administrator confirmed that staff were expected to sign the controlled substance record immediately after giving the dose and that the record was used to track administration and prevent diversion.
Catheter drainage bag was observed on the floor with a side table wheel resting on top of it, creating an infection control deficiency. The resident had severe dementia, CKD, AFib, CAD, a BIMS score of 0, and required maximal assistance with ADLs; the care plan also identified risk for UTI related to incontinent bladder and bowel and an indwelling catheter. The CMA, an LVN, the DON, and the IP all stated the bag was improperly positioned and should not have been touching the floor or pinched by the wheel.
The facility did not have a full-time DON for an extended period after the previous DON resigned, as confirmed by staff timecards and interviews with the ADON, HR, and the Administrator. During this time, coverage was provided by an LVN ADON, a PRN RN, and a Regional Clinical Support Specialist, but no full-time or interim DON was designated.
A resident with a stage 4 pressure ulcer did not receive wound care consistent with physician orders, as the wound vac was set at 125mmHg instead of the prescribed 115mmHg. The DON admitted to not checking the settings during care, acknowledging the risk of increased bleeding. Despite the incorrect setting, the resident reported no discomfort, and observations showed no signs of infection. The facility lacked a specific policy for wound vac management.
A resident with an indwelling catheter was found with the catheter bag touching the floor, contrary to facility policy, which requires bags to be hung to prevent infection. Despite the facility's guidelines, staff interviews revealed a lack of adherence to proper catheter care procedures, posing a risk of contamination and infection.
The facility failed to provide a safe and clean environment due to insufficient housekeeping staff, leading to unclean conditions and safety hazards. Observations included unclean floors, full sharps containers, water leaks, and inadequate safety measures during cleaning. Staff interviews revealed a lack of awareness and responsibility for maintaining cleanliness and safety.
The facility exhibited several environmental deficiencies, including dusty and stained floors, water leaks from a condensation pipe, and inadequate housekeeping practices. Observations revealed that caution signs were not always adhered to, and there was a lack of sufficient signage during mopping. Additionally, debris such as a dead cricket and white tablets were found in the hallways, compromising the residents' right to a safe and clean environment.
The facility failed to provide adequate pharmaceutical services, resulting in several deficiencies. A resident's Voltaren Gel order lacked a dosage, leading to incorrect application. Another resident's refusal to take Lactulose was not reported, causing a missed dose. Additionally, a resident did not receive Zinc Sulfate due to supply issues. Staff also failed to follow controlled substance protocols, signing audit records before completing required counts.
The facility failed to ensure appropriate use of psychotropic medications for several residents, leading to unnecessary administration of antipsychotics without proper diagnoses or documentation. Residents were given medications like Risperidone, Aripiprazole, and Olanzapine without attempts at gradual dose reductions or documented clinical contraindications. Additionally, some residents were prescribed psychotropic medications without a 14-day stop date, violating facility policy.
The facility experienced a 22% medication error rate due to Med Aide E's failure to administer medications correctly to two residents. One resident choked on a capsule that should have been crushed, and another did not receive critical medications due to unavailability. The facility's protocols for medication administration and reporting were not followed, contributing to these deficiencies.
The facility failed to ensure proper storage and security of medications, with issues such as dried drippings on bottles, improper storage by administration route, and unlocked medication carts. Additionally, opened Acidophilus Probiotic Dietary Supplements were not refrigerated as required. These deficiencies were confirmed through staff interviews and observations.
The facility failed to prepare instant mashed potatoes according to the manufacturer's serving chart, impacting the nutritional value of meals for 16 residents on pureed diets. A staff member estimated the amount of water and potato flakes needed, rather than following the exact instructions. The Dietary Manager confirmed the requirement to follow manufacturer directions, but the Dietary Supervisor was unaware of the concern.
The facility's kitchen was found to have significant sanitation and food safety deficiencies, including unclean food preparation areas, improper food storage, and inadequate dishwashing procedures. The lack of supervision and oversight, exacerbated by the absence of a dietary manager, contributed to these issues, potentially putting residents at risk of foodborne illnesses.
The facility's kitchen had multiple sanitation and storage deficiencies, including food particles and stains on surfaces, improper storage of food items, and undated or improperly sealed food in refrigerators. The Dietary Manager lacked written cleaning assignments, and staff did not follow manufacturer directions for pureed foods. Observations revealed issues with cleanliness and food storage practices.
The facility did not ensure the Medical Director or a representative attended 5 out of 9 QAPI meetings reviewed, as required by policy. The absence of the Medical Director from these meetings could lead to unidentified quality deficiencies and lack of appropriate action plans.
The facility failed to maintain an effective infection prevention and control program, with issues such as unsealed dirty linen hampers, improperly stored gauze sponges, mattresses on the floor, and personal items in clean linen closets. These practices were observed across multiple halls and were contrary to the facility's infection control policies.
A resident with moderate cognitive impairment and bladder dysfunction was found with an uncovered urinary catheter bag, violating their privacy. Facility staff, including the RN and DON, acknowledged the oversight, which contradicted the facility's policy requiring catheter bags to be covered to maintain resident dignity.
A facility failed to accommodate a resident's monitoring preferences by obstructing an electronic camera placed by the family to monitor care. Despite the family's request to keep the camera unobstructed, staff were instructed to block it during care to protect the resident's privacy. The facility's policy states that obstructing a monitoring device is a misdemeanor, yet the practice continued, prioritizing privacy over the family's monitoring needs.
Two residents in the facility did not receive their prescribed medications due to unavailability and dosage errors. One resident with multiple health issues did not receive several medications as they were not stocked, and the physician was not notified. Another resident had a medication order without a specified dosage, and the physician was not informed to correct this. The facility's policies on medication unavailability and notification of changes were not followed, leading to potential delays in medical treatment.
A resident and their family raised privacy concerns about the use of cameras in the resident's room, leading to actions such as covering the camera for privacy. The DON instructed staff to block cameras, citing dignity concerns. There was confusion about the use of the TV and lights at night, and the camera's placement raised a potential fire concern. The family expressed uncertainty about the care provided, highlighting a balance issue between resident privacy and family rights.
A facility failed to conduct a required PASARR screening for a resident after a new diagnosis of schizophrenia was added to her records. Despite the facility's policy requiring evaluations for serious mental illnesses, the oversight was acknowledged by staff, including the MDS Nurse and DON, who noted the importance of rescreening to ensure residents receive necessary services.
A facility failed to ensure proper wound care for a resident with an LVAD by not dating the dressing and allowing drainage onto the resident's gown, increasing infection risk. Despite physician's orders for regular dressing changes and antibiotics, the dressing was found undated and soiled. Interviews with staff confirmed that the dressing should have been dated and changed as needed, highlighting a lapse in adherence to care protocols.
A resident requiring continuous oxygen therapy was found without her nasal cannula, which was uncovered and not in use, posing an infection risk. Additionally, oxygen cylinders were improperly stored in a scale room without appropriate signage, contrary to facility policy.
A facility failed to ensure timely physician response to a Pharmacist Consultant's recommendation regarding a resident's medication regimen. The resident, with multiple health conditions, was on iron sulfate therapy, and the pharmacist advised evaluating its necessity beyond eight weeks. The recommendation was not acted upon promptly due to the absence of a system to ensure timely physician action.
A facility failed to maintain proper communication and coordination with a dialysis center for a resident with end-stage renal failure. The resident's care plan lacked directives for communication, and dialysis communication forms were often incomplete. Staff interviews revealed a lack of awareness and follow-up on these discrepancies, and the facility's hemodialysis policy was not adhered to, posing a risk of missing changes in the resident's condition.
A facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and incident reporting. An allegation by a resident of being called 'stupid' and handled roughly by a CNA during ADLs was not documented, nor was an incident report completed. Additionally, a resident-to-resident altercation was not accurately documented, and no incident report was filed. These oversights were confirmed through staff interviews, revealing a lack of adherence to the facility's policy on incident reporting.
A facility failed to repair a broken window in a resident's room, compromising the safety and comfort of residents who were on oxygen therapy. The broken window, covered with cardboard and plastic, allowed dust and air to enter, affecting residents' respiratory health. Despite multiple reports and follow-ups, the window remained unfixed for several months due to delays in ordering a replacement.
The facility failed to conduct a criminal background check on the Administrator before she began her duties, contrary to its policies on preventing abuse. The Administrator started working without a completed background check, which was only done after an HR audit. Interviews revealed inconsistencies in the background check process, with no documentation from corporate confirming a check was done prior to her start date.
A facility failed to report an altercation between two residents, where one allegedly hit the other with a cane. Despite staff awareness and documentation of the incident, it was not reported to the necessary authorities as required by state law. The facility's corporate office deemed the incident non-reportable due to insufficient evidence, contrary to the facility's policy.
A facility failed to provide necessary treatment and services for a resident with venous ulcers, as dressings were not dated or initialed, and edges were peeling off. Despite orders for wound care three times a week, discrepancies in care frequency were noted. Staff interviews revealed a lack of adherence to standard procedures, posing a risk of infection.
The facility failed to complete a comprehensive facility-wide assessment, including a staffing plan, necessary for competent resident care during regular operations and emergencies. The assessment was overdue, and the Director of Nursing had not finished her section on staffing. The Administrator acknowledged being out of compliance with the annual assessment policy, attributing the delay to issues with a previous interim DON.
Failure to Monitor Urinary Retention and Catheter Care
Penalty
Summary
The facility failed to ensure appropriate care for a resident with an indwelling catheter and a history of urinary retention, obstructive and reflux uropathy, and acute renal failure. The resident was admitted from the hospital with a Foley catheter in place and a discharge recommendation to follow up with urology within 10 to 14 days. The care plan included catheter care, intake and output monitoring, and monitoring for signs and symptoms of urinary tract infection and urinary retention. Physician orders later directed bladder training for 3 days, then discontinuation of the Foley catheter, followed by monitoring of urinary output for 24 hours. On the day the catheter was removed, licensed staff did not ensure the resident was monitored appropriately after removal. The record and staff statements showed the resident did not void during the day shift, reported feeling the urge to urinate but being unable to do so, and had abdominal distention. CNA B reported multiple times to LVN A that the resident had not urinated, including reports at several rounds during the shift. LVN A stated he did not assess the resident during the shift to verify whether the resident had voided and relied on the CNA’s report. He later assessed the resident after the repeated reports and found abdominal distention, then notified the NP and received an order to reinsert the Foley catheter. When the catheter was reinserted, there was no urine return and minimal blood was noted. The catheter was irrigated with normal saline, but no urine output was obtained. A bladder ultrasound showed approximately 1500 to 1586 cc of urinary retention and hydronephrosis, and the resident was sent to the hospital. Hospital documentation described a traumatic Foley exchange, gross hematuria, bladder outlet obstruction, septic shock due to acute UTI, acute blood loss anemia, and ICU admission. The facility also failed to ensure the catheter was removed on the day bladder training was completed and failed to ensure urinary output was monitored for 24 hours after catheter removal as ordered.
Failure to Follow EBP and Keep PPE Available
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for a resident with indwelling medical devices. Resident #4 had a history of multiple sclerosis, neurogenic bladder, urinary retention, frequent UTIs, and a chronic suprapubic/indwelling catheter. The resident’s care plan identified the suprapubic catheter and included monitoring for signs and symptoms of UTI. The resident also had a G-tube, and the record review showed the resident was cognitively intact and required substantial to maximal assistance with toileting and bed mobility. During observation, the resident was in bed with an indwelling catheter draining light yellow urine, and an EBP sign was posted on the door. Although isolation gowns and gloves were present in the room, an LVN entered the room, did not wash hands or use hand sanitizer, and did not don gloves or a gown before uncovering the resident and showing the surveyor the G-tube stoma. The stoma had a moderate amount of dried yellow drainage, and the nurse stated she had not cleaned the site yet and did not place a dressing on the stoma because it made the resident itch. The nurse also demonstrated the suprapubic catheter and stated she had forgotten to put on PPE when entering the room. The resident stated that nursing staff never cleaned the G-tube site or the suprapubic site and never used gowns and gloves when entering the room to assist with personal care. CNAs stated they were trained to use gowns and gloves for residents on EBP, but later interviews showed they did not always know which residents were on EBP, especially with new admissions and rotating assignments. Observations in multiple rooms showed EBP signs posted, but PPE was not readily available in the rooms or nearby storage areas; in several rooms there were no gowns or masks in the bins, drawers, closets, or hallway cabinets. The DON and ADON stated EBP applied to residents with foleys, G-tubes, PICC lines, and wounds, and that PPE should be stocked in resident rooms, but the surveyor observed rooms where the PPE bins were empty. The facility’s policy stated that EBP requires gown and glove use for high-contact care activities for residents with indwelling devices and that PPE should be available outside or inside resident rooms, but the requested infection control policies and PPE invoices were not provided before exit.
Incomplete Documentation of Urinary Retention Assessment and Foley Irrigation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident when an LVN did not document assessments related to urinary retention and possible UTI symptoms during the morning shift on 03/24/26, and did not document the bladder irrigation that was completed later that day. The resident had been admitted on 03/09/26 with a history that included anxiety, PTSD, right flank pain, indwelling catheter use, obstructive uropathy, and renal failure. The care plan directed staff to monitor and document intake and output, monitor for urinary symptoms, and report signs of UTI, pain, burning, blood-tinged urine, cloudiness, no output, fever, chills, altered mental status, and changes in behavior or eating pattern. The record showed that the resident’s Foley catheter had been removed after bladder training, and the physician order summary directed urinary output to be documented every shift. On 03/24/26, the nurse treatment administration record for the 6-2 shift was left blank for output. The LVN later documented in an IDT note that the resident was unable to urinate throughout the shift, had abdominal distention, and that the NP was notified. The note also stated that the Foley was reinserted, there was minimal blood output and no urine output, the catheter was flushed with normal saline, and a STAT ultrasound of the bladder and abdomen was ordered. During interviews, the LVN stated he checked the resident one to three times during the shift but did not assess or ask whether the resident had voided, and he did not document his assessment in the electronic record. He also stated he did not document when the Foley was reinserted, when the catheter was irrigated, or when the ultrasound was completed. The CNA assigned to the resident stated she reported multiple times that the resident had not voided and was complaining that he felt like urinating but could not pass urine. The NP stated she received a text message that the Foley had been removed and the resident had not voided, and she gave an order to place it back. The facility policy required documentation of objective observations, treatments performed, changes in condition, and care-specific details including date, time, findings, and notification of staff.
Failure to Ensure Proper Hand Hygiene During Food Handling and Tray Service
Penalty
Summary
The deficiency involves a failure to maintain sanitary food service practices by not ensuring proper hand hygiene by dietary staff during food handling and meal service. During a lunch observation, a dietary staff member used her cell phone immediately before beginning to place resident lunch trays onto carts and did not perform hand hygiene between handling the phone and handling the trays. After placing several trays on a cart, she was asked by an LVN to prop open a door; she picked up a food can, placed it on the floor to hold the door open, and then returned directly to the food line and continued placing food trays on carts without washing or sanitizing her hands. Further observation showed that the same dietary staff member continued to handle food service items without hand hygiene. She provided tray covers with both hands, handed salsa and ground chicken to an LVN, and resumed placing trays on the food cart, all without observed handwashing or sanitizing. She later left the food line and returned wearing gloves, but it was not known whether she had performed hand hygiene before donning the gloves. In interviews, the dietary manager, DON, and administrator each stated that staff are expected to wash their hands before handling food trays and after touching non-food items or moving between tasks, and that the observed conduct did not comply with facility expectations. Another dietary staff member reported that he consistently practiced proper hand hygiene and that the facility trains staff, including new hires, to wash or sanitize hands immediately after touching anything outside the food tray line. The facility’s hand hygiene policy stated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and that all personnel are expected to adhere to these practices.
Failure to Develop Person-Centered Dehydration Care Plan for High-Risk Resident
Penalty
Summary
Surveyors identified a failure by the facility to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with a medical history of dehydration. The resident, an elderly female with diagnoses including type 2 diabetes with hyperglycemia, dehydration, acute kidney failure, TIAs, hyperlipidemia, dysphagia, and renal failure, had been admitted and later readmitted to the facility. Her MDS reflected a BIMS score of 02, indicating severe cognitive impairment, and physical impairments in one upper extremity and both lower extremities. Despite this history and a hospital history and physical documenting dehydration, the facility did not have a specific care plan addressing dehydration. Record review showed that the resident’s care plan dated 01/15/2026 did not include any problem, goal, or interventions related to her medical diagnosis of dehydration. The Physician’s Order Summary also did not contain an order for maintaining the medical diagnosis of dehydration. The DON acknowledged during interview that the resident’s care plans contained nothing regarding dehydration or how to prevent it, and stated that the risk of having no care plan for dehydration would be that the resident could dehydrate again and be readmitted to the hospital. The Administrator similarly stated that, given the resident’s medical diagnosis of dehydration and history of hospitalization for dehydration and UTIs, there should have been a care plan. The MDS nurse reported that care plans are developed on admission, quarterly, and with any change in condition, and that nursing staff share responsibility for reviewing care plans and ensuring they are correctly entered into the electronic system. The MDS nurse stated there was no specific order for the resident’s medical diagnosis of dehydration, but asserted there was no risk because a care plan for “risk for altered fluid balance” existed, with interventions such as evaluating blood pressure and educating the resident/representative on methods to relieve dry mouth while maintaining fluid restriction. However, this care plan did not specifically address the resident’s dehydration diagnosis. Facility policy on comprehensive person-centered care plans required measurable objectives and timetables to meet residents’ needs, reflect current standards of practice, address underlying sources of problems, and be revised upon changes in condition or readmission from the hospital, but these requirements were not met for this resident’s dehydration.
Failure to Maintain Resident Dignity With Supplies, Transfers, and Meal Service
Penalty
Summary
The facility failed to treat residents with respect and dignity in several areas involving supplies, transfers, and dining. Resident #9, a cognitively intact female with diagnoses including COPD, schizophrenia, CHF, depressive disorder, anxiety disorder, and fibromyalgia, was identified as being at risk for UTI and skin breakdown and had a care plan intervention for incontinent briefs as needed. During interview, she stated there was a limit on briefs provided each shift and that staff were often searching other resident rooms for briefs or wipes because supplies were not readily available. She stated this happened more on weekends and caused delays in care that she considered a dignity issue. Record review and interviews showed staff and leadership were aware of ongoing difficulty obtaining briefs and wipes for approximately 3 months, with exceptional difficulty over the past month. CNA and LPN staff stated supplies were limited on the floor and had to be requested from Central Supply, and several staff said the issue had been reported to the ADON, DON, and Administrator without resolution. Central Supply stated orders were placed weekly and were subject to review by the Administrator and corporate, with a strict weekly budget for briefs and wipes. On observation of the Central Supply room, a surplus of wipes, briefs, and other supplies was present. The facility also failed to provide a mechanical lift net to the assigned resident within a reasonable timeframe. Resident #9 stated she had been told to wait in bed until staff could find a mechanical lift net, and she described the wait as prolonged and upsetting. Staff interviews indicated that each resident requiring a lift net was assigned one, that soiled nets needed laundering, and that delays in returning nets to service could keep residents in bed longer. The Housekeeping Supervisor stated dirty lift nets were sometimes left in rooms instead of being placed in dirty linen, and the Administrator stated she had ordered more nets at the end of July 2025. The DON and Administrator acknowledged that delays in having lift nets available could delay transfers out of bed. The facility also failed to promote dignity during dining when Resident #7 was served lunch after his tablemates. Resident #7, a male with severe cognitive impairment, bipolar disorder, dementia, and a cognitive communication deficit, was observed waiting for his tray while three of four residents at the table had already been served. He was served after the surveyor intervened, by which time two of his tablemates had finished eating. Staff stated nursing and CNA staff were responsible for ensuring all residents were served in a timely manner, and they identified being served after others as a self-esteem and dignity issue.
Failure to Maintain Residents’ Fingernail Hygiene
Penalty
Summary
The facility failed to provide ADL care for two residents by not maintaining their fingernails clean and free from debris. One resident was a 63-year-old female with right-sided hemiparesis due to a prior CVA, a BIMS score of 11 indicating moderate cognitive impairment, and a care plan identifying an ADL self-care deficit related to disease process and hemiparesis. During an observation and interview, she was found with long, dirty fingernails on her left hand and stated that she wanted them cleaned and trimmed. The second resident was a male with unspecified dementia, a BIMS score of 05 indicating severe cognitive impairment, and a care plan identifying a self-care performance deficit related to dementia. During observation, his fingernails were noted to be long, about one inch off the nail bed on both hands. Staff interviews stated that CNAs and nurses were responsible for keeping residents’ fingernails clean and trimmed, with nail care to be completed daily and reviewed by nursing and CNA staff. The facility policy stated that nail care includes daily cleaning and regular trimming.
Dirty oxygen concentrator filters observed for residents receiving oxygen
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained when the facility failed to keep the oxygen concentrator filters free from lint and dust for 3 of 6 residents reviewed for oxygen use. Resident #5 was a male with diagnoses including acute respiratory failure with hypoxia, had oxygen therapy noted on the MDS and care plan, and was observed lying in bed receiving oxygen via nasal cannula at 2 liters per minute while the oxygen concentrator air filter was observed with dust and lint. Resident #29 was a male with acute respiratory failure with hypoxia, had a BIMS score of 00, had oxygen therapy noted on the MDS and care plan, and was also observed receiving oxygen via nasal cannula with the oxygen concentrator air filter observed with dust and lint. Resident #58 was a female with a history of pneumonia, had oxygen therapy noted on the MDS and care plan for altered respiratory status/difficulty breathing, and was observed lying in bed receiving oxygen via nasal cannula while the oxygen concentrator air filter was observed with dust and lint. An LVN stated that air filters were checked and cleaned every Sunday night and that dirty air filters could affect delivery of oxygen, while the DON stated she was not sure who was responsible for cleaning the filters and believed central supply and nurses on the floor monitored them; she also stated there had been no inservice to staff regarding clean air filters. The oxygen concentrator manual provided by the facility stated the air filter cleaning interval was 7 days.
Unlabeled zinc oxide cups left at bedside
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles and failed to keep them stored appropriately when two residents had an unlabeled clear plastic cup at bedside containing Zinc Oxide pomade and a tongue depressor. The cups were left exposed and within reach of other residents. The deficiency involved Resident #38 and Resident #72, both of whom had intact cognition by BIMS score of 15 and required varying levels of assistance with ADLs, including toileting hygiene, dressing, bathing, and transfers. Resident #72 was observed sitting in a wheelchair with a clear, unlabeled cup on a nightstand behind her containing white cream and a tongue depressor. She stated the cream was applied by CNAs to help with a rash from wearing briefs and that staff usually left the cream there for reuse during brief changes. Resident #38 was observed in bed with a clear plastic cup containing white cream residue and a tongue depressor on her nightstand. She stated the cream had been applied earlier that morning to treat a rash from wearing briefs and that CNAs regularly left cups with the cream on her nightstand. During interviews, the CMA, LVN, DON, IP, CNA A, CNA B, and the Administrator all identified the contents as zinc oxide used to prevent or treat brief-related rash and stated it should not be left uncovered, unlabeled, or at bedside. Staff stated the cup should be discarded after use and that leaving it exposed created a risk of contamination. The DON also stated there was no facility policy addressing leaving medications at residents’ bedside.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences when call lights were not kept within reach for 2 of 6 residents reviewed for call lights. Resident #1 was a 74-year-old female with diagnoses of dementia and seizure disorder, a BIMS score of 03 indicating severe cognitive impairment, and a care plan that included keeping the call light within reach due to seizure-related injury risk and medication side effects. During observation, her call light was found on the floor while she was asleep in bed, and CNA D later confirmed it was not appropriate and that she had not ensured it was within reach before leaving the room. Resident #21 was an 80-year-old female with diagnoses of hemiparesis and acute right-sided weakness, a BIMS score of 02 indicating severe cognitive impairment, and a care plan intervention to keep the pad call light within reach due to self-care deficits related to a CVA with right-sided hemiparesis. During observation, the resident required a touch pad call light for communication, but it was clipped to the top right of the bed and out of reach. The resident had limited range of motion on the right side and could not reach the call light if needed, and CNA D confirmed the call light was out of reach based on the resident's condition. Interviews with LVN C, the ADON, the DON, and the Administrator established that call lights were used for residents to communicate needs and were supposed to be within arm's reach. Staff stated that all staff were responsible for ensuring call lights were within reach, that call lights should be repositioned if found out of reach, and that residents with limited range of motion or severe contractures should have pad call lights within reach. The facility policy titled Call System stated residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or centralized workstation.
Incomplete Care Plan for Foley Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives and timeframes for Resident #13’s urinary indwelling Foley catheter. Resident #13 was an [AGE] year-old female admitted on 06/02/25, with a Quarterly MDS showing a BIMS score of 1 and indicating severe cognitive impairment. Her history and physical dated 08/11/25 documented acute urinary retention postoperatively requiring Foley catheter placement, AKI, and dementia. The care plan reviewed for the resident did not include or address the indwelling Foley catheter. During an observation on 09/02/25 at 10:45 AM, Resident #13 was in bed with her Foley catheter placed on the side of the bed. In interviews, the LVN stated MDS nursing were responsible for the care plan and that residents with care plans lacking information about conditions such as a Foley catheter would not have staff able to provide catheter-specific care. The MDS Nurse stated nursing was responsible for compiling the care plan for medical needs such as a Foley catheter and that Foley catheters needed to be included because the care plan was centered to the resident and their conditions. The DON stated resident conditions such as an indwelling Foley catheter needed to be included in the care plan, and the Administrator stated care plans were the responsibility of multiple departments and that incomplete care plans could result in staff being unaware of monitoring for symptoms of infection for Foley care.
Missing Controlled Drug Record Signatures
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident when it did not ensure that licensed staff signed the individual control drug record after administering controlled medication for one resident. Resident #51 was an [AGE]-year-old male admitted on 02/14/2025 and readmitted on 07/05/2025 with a diagnosis of insomnia. His 5-day MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and his care plan identified sedative/hypnotic therapy with Temazepam for insomnia. The September 2025 MAR showed Temazepam 7.5 mg by mouth at bedtime for insomnia. Review of the resident’s individual control drug record on 09/04/2025 at 11:35 AM showed two missing nurse signatures for Temazepam on 09/02/2025 and 09/03/2025. During interviews, the DON stated nurses were trained to review orders, administer the correct medication to the correct resident, and sign the individual control drug record immediately after administration, and that she and the ADONs were responsible for auditing narcotic records. An RN stated the narcotic record was used to track controlled medications, confirm the correct resident and dose, and avoid drug diversion. The Administrator stated the individual narcotic sheet tracked who administered the medication and when, and that it was important for nurses to sign it when administering the medication. The facility policy titled Controlled Substances stated that when a controlled medication is administered, the licensed nurse immediately enters the date and time of administration, amount administered, and signature on the accountability record.
Catheter Drainage Bag Left on Floor and Pinched by Side Table Wheel
Penalty
Summary
Provide and implement an infection prevention and control program was deficient for one resident when the resident’s catheter drainage collection bag was observed on the floor with the wheel of the resident’s side table resting on top of it. Resident #63 was admitted on [DATE] and had a history of significant dementia, chronic kidney disease, atrial fibrillation, and coronary artery disease. The admission MDS showed a BIMS score of 0, indicating severely impaired cognition, and documented that the resident required maximal assistance with eating, oral care, toileting, showering, and dressing. The MDS also indicated the resident was occasionally incontinent of urine and always incontinent of bowel, and the care area assessment triggered for urinary incontinence and an indwelling catheter. The care plan dated 08/01/2025 identified the resident as at risk for urinary tract infections related to incontinent bladder and bowel and stated the goal was for the resident to remain in a clean, dry state by checking and changing the resident at regular intervals. During observation on 09/02/2025 at 10:35 AM, the catheter drainage collection bag was seen on the floor with the side table wheel on top of it. The CMA stated the wheel was dangerously clamping the bag and could cause it to tear and spill. LVN C later stated the bag was improperly touching the floor and should not have the wheel on top of it. The DON and IP both stated the bag should not have been on the floor and that the wheel could tear it and spill its contents.
Failure to Maintain Full-Time Director of Nursing Coverage
Penalty
Summary
The facility failed to designate a registered nurse to serve as the Director of Nursing (DON) on a full-time basis. Review of staff timecards showed that there was no DON present in the facility from 03/20/25 through 03/31/25, and on 04/01/25, the position remained vacant. The previous DON submitted a letter of resignation on 03/23/25, with immediate effect as of 03/24/25, leaving the facility without a DON for at least eight days. Interviews with the Assistant Director of Nursing (ADON), Human Resources, and the Administrator confirmed that the facility did not have a full-time or interim DON during this period. The ADON, who is an LVN, and a PRN RN, along with a Regional Clinical Support Specialist (also an LVN), attempted to provide coverage in the absence of a DON. The Administrator acknowledged that the facility was required to have a DON to manage the nursing department and that the absence of a DON led to issues with policies and regulations.
Failure to Follow Physician Orders for Wound Vac Settings
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice. Specifically, the facility did not set the wound vac for a resident with a stage 4 pressure ulcer on the sacrum at the physician-ordered setting of 115mmHg. Instead, the wound vac was set at 125mmHg, which was not in accordance with the physician's orders. This discrepancy was observed during an interview and observation with the Director of Nursing (DON), who admitted to not checking the wound vac settings during wound care. The DON acknowledged that the wound vac was supposed to be set at 115mmHg and noted the risk of increased bleeding from suction due to the incorrect setting. The resident involved was a male with a history of sepsis, a pressure ulcer to the sacrum, and hemiplegia, with a severely impaired cognition as indicated by a BIMS score of 4. Despite the incorrect wound vac setting, the resident denied any discomfort or concerns with his wound care. Observations noted less necrotic tissue, granulation present, minimal drainage, some slough around the area, and no signs of infection. The facility's policy on wound treatment management required treatments to be provided in accordance with physician orders, but there was no specific policy for wound vac management. The physician confirmed that the nursing staff was expected to follow treatment orders as written and highlighted potential risks of not setting the wound vac correctly, such as increased drainage, discomfort, and pain.
Deficiency in Catheter Care Leads to Infection Risk
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in preventing urinary tract infections. The resident, a male with a history of urinary tract infection and neurogenic bladder, was observed with his catheter bag touching the floor, which is against the facility's policy. The resident was unable to recall when the staff last attended to him, indicating a lapse in regular monitoring and care. Interviews with the nursing staff, including an LVN and the DON, confirmed that catheter bags should be hung on the bed or wheelchair to prevent contamination and infection. The facility's policies on indwelling catheter use and infection prevention emphasize the importance of keeping catheter bags off the floor to reduce the risk of infection. Despite these policies, the staff failed to ensure the catheter bag was properly positioned, as observed during the survey. This oversight in catheter care could potentially expose residents to increased risks of disease and infection, highlighting a significant deficiency in the facility's adherence to its own care standards.
Environmental Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public across multiple areas. Observations revealed that the facility was not cleaned over a weekend due to insufficient housekeeping staff, resulting in unclean conditions such as dust, stains, and debris on floors in various halls. Additionally, a sharp container was found full, and there was confusion among staff about who was responsible for replacing it. Water leaks were observed from a condensation pipe in the Mechanical Room, causing water to overflow into the hallway and Janitor's Room. The Maintenance Supervisor acknowledged the issue but stated that he was not informed about the leak. Further observations highlighted inadequate safety measures during cleaning activities, with caution signs being disregarded or insufficiently placed, leading to potential hazards. In the Laundry Room, chemical dispensers were leaking solution onto walls and floors, and there was calcium buildup around the hand sink. The Oxygen Storage Room was found to be dusty and littered with debris. Interviews with staff revealed a lack of awareness and responsibility for maintaining cleanliness and safety in these areas.
Environmental Deficiencies and Inadequate Housekeeping Practices
Penalty
Summary
The facility was observed to have several environmental deficiencies that compromised the residents' right to a safe, clean, and comfortable environment. Observations revealed that the tile floors by the entrance and resident halls were dusty and stained, with paper particles scattered. A white tablet was found on the floor by the decentralized nurse's station in the 300 Hall. Additionally, a white sheet soaked with water was observed on the floor near the Janitor's Closet, with a caution sign placed directly in front. Water was leaking from a condensation pipe in the Mechanical Room, causing overflow into the hallway and Janitor Room, with the floor covered in dust and debris. The Maintenance Supervisor identified a rusted and cracked flapper as the cause of the leak, noting that the drain was checked only once a week. Housekeeping practices were also found to be inadequate. A housekeeper was observed mopping only 3/4 of the hallway and placing caution signs, as per her training. However, a Social Worker disregarded the caution sign and walked on the wet floor to reach resident rooms. Another housekeeper was seen mopping near the nurses' station with only one caution sign available, using her housekeeping cart to block the area due to a lack of additional signs. Furthermore, a dead cricket was found in the 200 Hall, and another white tablet was observed on the floor in the 400 Hall, confirmed by an LVN assigned to that area.
Deficiencies in Pharmaceutical Services and Medication Management
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of its residents, as evidenced by several deficiencies observed during the survey. For Resident #6, the facility did not ensure that a physician's order for Voltaren Gel included a specific dosage. This oversight was not reported to the physician or nurse practitioner, resulting in the medication being applied incorrectly by a medication aide. The Director of Nursing (DON) was unaware of the missing dosage, highlighting a lapse in communication and adherence to medication administration protocols. Resident #296 experienced a failure in communication when a medication aide did not notify the nurse after the resident refused to take Lactulose as prescribed. The resident expressed concerns about potential side effects, but the refusal was not documented or reported, leading to a missed dose. This incident underscores the importance of following procedures for reporting medication refusals to ensure proper care and documentation. For Resident #80, the facility did not administer Zinc Sulfate as ordered due to a lack of medication supply. The central supply clerk acknowledged the oversight in maintaining an adequate stock of over-the-counter medications, which resulted in the resident missing a scheduled dose. Additionally, the facility's staff failed to adhere to controlled substance protocols, with several instances of staff signing off on audit records before completing the required count with the on-coming nurse. These deficiencies indicate a need for improved medication management and adherence to established procedures.
Failure to Ensure Appropriate Use of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents who had not previously used psychotropic drugs were not administered these medications unless necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficiency was identified in five residents who were reviewed for unnecessary medications. The facility did not attempt gradual dose reductions (GDR) or document clinical contraindications for the continued use of these medications. Resident #6 was administered the antipsychotic medication Risperidone for agitation, despite having a diagnosis of non-Alzheimer's dementia and depression, with no symptoms of delirium, depression, or psychosis. The physician did not document GDR as clinically contraindicated, and the diagnosis for Risperidone was later changed to a mood disorder without appropriate justification. Similarly, Resident #18 was given Aripiprazole for depression, although it is not approved for use in older adults with dementia-related psychosis. The facility did not ensure that the medication was necessary for the resident's condition. Resident #32 received Olanzapine for dementia with psychosis, a diagnosis deemed inappropriate for the use of this antipsychotic medication. The diagnosis was later changed to delusional disorder, but the appropriateness of this diagnosis for Olanzapine use was still under question. Additionally, Residents #44 and #45 were prescribed psychotropic medications without a 14-day stop date, contrary to facility policy. The lack of proper documentation and adherence to medication protocols could lead to residents receiving unnecessary medications, posing potential risks to their health.
Medication Administration Errors and Unavailability
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 22% error rate during a medication administration observation. This was due to 12 errors out of 53 opportunities involving two residents. Med Aide E was responsible for these errors, which included failing to administer eight morning medications to one resident and not administering several medications to another resident according to physician's orders. One resident, who had a history of anxiety, depression, hypertension, and other conditions, experienced a significant issue when Med Aide E did not crush her medications as required. This led to the resident choking on a fish oil capsule, which was eventually expelled with assistance. The Med Aide did not attempt to administer the remaining medications or apply a prescribed Lidocaine patch. Additionally, the Med Aide failed to report the incident to the supervising nurse, which was against the facility's protocol. Another resident, recently admitted with a history of gastrointestinal bleed, atrial fibrillation, and other conditions, did not receive several critical medications due to their unavailability. The facility's process for obtaining medications after hours was not followed, leading to missed doses. The DON was unaware of the medication unavailability until after the fact, and the facility's policy for handling unavailable medications was not adhered to, resulting in a failure to notify the physician or obtain alternative treatment orders.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure the proper storage and security of medications, as observed in multiple medication carts across different halls. Specifically, liquid medications stored in medication carts on three halls had dried drippings on the sides of the bottles, indicating improper handling or storage. Additionally, medications were not stored according to their routes of administration, with oral medications being stored alongside nasal medications. One medication cart was found unlocked and unattended, posing a risk for drug diversion. Furthermore, a bottle of Betadine in the treatment cart had dried drippings, suggesting a lack of cleanliness and attention to detail in medication storage. The facility also failed to refrigerate opened bottles of Acidophilus Probiotic Dietary Supplement as required by the manufacturer's instructions. This was observed in all seven medication carts checked, with staff either unaware of the requirement or neglecting to follow it. These deficiencies in medication storage and handling could potentially affect residents by placing them at risk of not receiving their prescribed medications and increasing the likelihood of cross-contamination. Interviews with staff, including a Med Aide, LVN, and the DON, confirmed these lapses in adherence to the facility's medication storage policy, which mandates proper storage conditions and security for all medications.
Failure to Follow Manufacturer's Directions for Food Preparation
Penalty
Summary
The facility failed to prepare food by methods that conserve nutritive value, specifically in the preparation of instant mashed potatoes. During an observation and interview, it was revealed that a staff member responsible for preparing meals for 16 residents on pureed food diets did not follow the manufacturer's serving chart for instant mashed potatoes. Instead, the staff member estimated the amount of water and potato flakes needed to achieve the desired consistency for 20 servings, disregarding the manufacturer's instructions. In a subsequent interview and record review, the Dietary Manager confirmed that the recipe for mashed potatoes required following the manufacturer's directions for exact amounts. However, the Dietary Supervisor expressed confusion about the concern over not following these directions, as long as the consistency of the potatoes was deemed adequate. This deviation from the prescribed preparation method could potentially impact the nutritional value of the meal provided to the residents.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen, as observed during a survey. The kitchen was found to have multiple sanitation issues, including food preparation areas with food particles, white stains, and grease build-up on equipment and floors. Spice bottles and food coloring bottles were not clean, and trash cans were left uncovered. Additionally, food was not stored properly, with items in refrigerators and freezers not sealed or labeled, and perishable foods were not discarded when spoiled. The facility also failed to ensure that food was stored promptly after delivery, with boxes of food left on the floor. The dietary staff were reportedly not supervised adequately, leading to a lack of cleanliness and proper food storage practices. The dietary manager did not have written cleaning assignments, and staff were observed using cell phones during meal preparation instead of focusing on their tasks. The facility had been without a dietary manager for two months, contributing to the oversight issues. Furthermore, the facility did not follow proper procedures for washing dishes in the three-compartment sink, as the chemical levels for sanitization were not checked correctly. The dietary manager was unaware of the correct procedures and failed to ensure that the sanitizing solution was at the appropriate concentration. These deficiencies in food safety and sanitation practices could potentially place residents at risk of foodborne illnesses.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility's kitchen was found to have multiple sanitation and storage deficiencies during an initial tour. Observations included food particles and dried stains on various surfaces, such as shelves, tables, and floors. The deep fryer contained crumbs and chicken pieces, while the tile floor had black stains and food debris. Spice bottles and other containers were greasy and improperly sealed, and a large trash can was uncovered. Additionally, the ice scoop was stored improperly, and food items were left on the floor due to a recent delivery. The Dietary Manager admitted to a lack of written cleaning assignments, relying on staff to clean their own areas. In the dry storage area, containers were found with grease buildup and food particles, and some onions were moldy and mushy. Refrigerators contained undated and improperly sealed food items, including cornflakes, whipped cream, broccoli, and various meats. The bottom shelves of the refrigerators had food particles and stains, and several cardboard boxes were not sealed. The facility's pureed food preparation process was also scrutinized, revealing that staff did not follow manufacturer directions for consistency, particularly with mashed potatoes. The dishwashing area had a broken drain cover with black stains, and food temperatures were checked, revealing some items below the required temperature. The Dietary Manager confirmed that the deep fryer should be cleaned after each use, and there was a misunderstanding regarding the importance of following manufacturer directions for pureed foods. The facility's failure to maintain cleanliness and proper food storage practices led to these deficiencies, as observed by the surveyors.
Failure to Maintain Required QAPI Committee Members
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required members, specifically the Medical Director or their representative, for 5 out of 9 Quality Assurance and Performance Improvement (QAPI) meetings reviewed. Interviews and record reviews revealed that the Medical Director attended only one QAPI meeting in 2023 and none in 2024, despite the facility's policy requiring their presence. The Director of Nursing (DON) confirmed that the Medical Director was expected to attend these meetings, but the signature sheets for the meetings on 07/13/23, 08/23/23, 04/24/24, 05/22/24, and 07/24/24 showed their absence. The facility's policy, dated 07/2022, mandates that the QAA committee be interdisciplinary and include the Director of Nursing Services, Medical Director, at least three other staff members, including the Administrator and Infection Preventionist. The committee is required to meet at least quarterly to coordinate and evaluate activities under the QAPI program. The absence of the Medical Director or their designee from these meetings could lead to unidentified quality deficiencies, lack of appropriate action plans, and insufficient guidance, as noted in the report.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations across different areas. In Hall 300, a dirty linen hamper was observed to be full and not properly sealed, which could lead to cross-contamination. On the treatment cart, an opened bag of non-sterile gauze sponges was found stored improperly without being sealed in a plastic bag, as confirmed by the Treatment Nurse. This practice increases the risk of cross-contamination. Additionally, in the storage room on Hall 100, six mattresses were stored directly on the floor, which is against the facility's policy to prevent contamination. Further observations revealed that in Hall 400, a backpack was improperly stored in the clean linen closet, contrary to the facility's training for staff to avoid storing personal belongings in such areas. On Hall 200, the medication cart contained an opened package of non-woven sponges that were not stored in a sealed plastic bag, as noted by the Director of Nursing. These findings indicate a lack of adherence to the facility's infection control policies, which require proper storage and handling of resident-care equipment and environmental surfaces to prevent the spread of infections.
Resident Privacy Violation Due to Uncovered Catheter Bag
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident by not covering the resident's indwelling urinary catheter bag. The resident, who had a moderate cognitive impairment and a diagnosis of neuromuscular dysfunction of the bladder, was observed with an uncovered foley bag hanging by the side of his bed, facing the door. This observation was made during a survey, and it was noted that the facility's policy required catheter drainage bags to be covered at all times to maintain privacy. Interviews with staff, including a registered nurse (RN) and the Director of Nursing (DON), confirmed that the exposure of the foley bag violated the resident's privacy and could lead to feelings of shame. Both the RN and DON acknowledged that all staff, including CNAs, LVNs, and RNs, were responsible for ensuring that privacy bags were used to cover catheter bags. The facility's policy on catheter care, dated July 2022, explicitly stated that privacy bags should be available and used to cover catheter drainage bags at all times.
Failure to Accommodate Resident's Monitoring Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident by obstructing the view of an electronic monitoring camera placed in the resident's room by the family. The resident, who had severe cognitive impairment and required assistance with daily activities, had a camera installed by the family to monitor the care being provided. The family member reported that facility staff regularly blocked the camera's view during care, despite having discussed this issue with both the Director of Nurses (DON) and the Administrator. The staff were instructed to block the camera during incontinent care to protect the resident's privacy, as per the facility's practice. The facility's policy on electronic monitoring, which aligns with state regulations, indicates that intentionally obstructing a monitoring device is a misdemeanor. Despite this, the facility continued to block the camera, citing the preservation of the resident's dignity as the reason. The family member, who was the resident's responsible party and Power of Attorney, had signed a document acknowledging the facility's policy on electronic monitoring. However, the family member's request to keep the camera unobstructed was not honored, as the facility prioritized privacy concerns over the family's monitoring preferences.
Failure to Notify Physician of Medication Unavailability and Dosage Errors
Penalty
Summary
The facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for two residents. Resident #295, who was admitted with a history of gastrointestinal bleed, atrial fibrillation, pneumonia, hypertension, shortness of breath, and asthma, did not receive several prescribed medications, including Amiodarone HCL, Famotidine, Budesonide Inhalation Solution, and Cholestyramine Oral Packet, during the morning medication pass. The medications were not available in the automated medication dispensing system, and the facility did not notify the physician or nurse practitioner about the unavailability of these medications. Additionally, Resident #6, who had a diagnosis of Diabetes Mellitus, Pulmonary embolism, Hypertension, and Dementia, had a physician's order for Voltaren Gel that did not specify a dosage. The medication was applied without a proper dosage, and the physician was not notified to obtain the correct dosage. Furthermore, the administration of Fluticasone Propionate nasal spray was not performed according to the manufacturer's instructions, as the resident was not asked to blow her nose prior to use, and one nostril was not closed during administration. The facility's policy on Notification of Changes and Unavailable Medications was not followed, as the staff failed to notify the physician of the inability to obtain medications and did not obtain alternative treatment orders. The lack of communication and adherence to procedures resulted in the residents not receiving their prescribed medications as ordered, which could potentially delay medical treatment.
Privacy Concerns with Camera Use in Resident Rooms
Penalty
Summary
The deficiency involves the privacy and confidentiality of residents' personal and medical records, specifically concerning the use of cameras in resident rooms. A resident and their family expressed concerns about privacy, leading to actions such as covering the camera with a pillow for privacy reasons. The Director of Nursing (DON) was involved in instructing staff to block the cameras, citing dignity concerns. There was also confusion about whether the television and lights left on at night were for the resident in question or another resident. The report mentions that the camera was moved from the head of the bed to the side, but it was then covered, preventing proper monitoring. Additionally, there was a mention of a potential fire concern due to the camera's placement near a light fixture. The family expressed uncertainty about the care provided, highlighting a balance issue between resident privacy and family rights to monitor care. The facility's policy on cameras was referenced, but it appears there was a lack of clear guidance or adherence to regulations regarding camera use and privacy.
Failure to Conduct PASARR Screening for New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASARR) program for a resident who was diagnosed with schizophrenia. The resident, who was admitted with a principal diagnosis related to a feeding tube, had a history of dementia, delusional disorders, and major depressive disorder. Despite the new diagnosis of schizophrenia being added to her records, the facility did not conduct a new Level 1 PASARR screening, which is required to determine eligibility for specialized services. Interviews with facility staff, including the MDS Nurse and the Director of Nursing (DON), revealed that the new diagnosis should have triggered a rescreening process. The MDS Nurse acknowledged the oversight and emphasized the importance of rescreening to ensure residents receive necessary services. The facility's policy required PASARR evaluations for residents with serious mental illnesses, such as schizophrenia, but did not specify procedures for new diagnoses. This oversight could potentially risk residents not receiving the specialized services they are entitled to.
Failure to Maintain Proper Wound Care for Resident with LVAD
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with an external cardiac pacemaker, specifically an LVAD, by not ensuring that the dressing on the LVAD driveline exit site was dated when changed and was not draining onto the resident's gown and skin. This oversight was observed during an interview and inspection, where it was noted that the dressing was not dated, and there was visible brownish-red drainage on the resident's gown. The LVN acknowledged that the dressing should have been dated and changed as needed to prevent infection. The resident, who had a history of heart failure, cardiomyopathy, kidney failure, and other significant health issues, was dependent on staff for various activities of daily living. The resident's care plan indicated a risk for complications due to the LVAD. Despite having physician's orders for regular dressing changes and antibiotic treatment for an LVAD infection, the facility did not adhere to these orders, as evidenced by the undated and soiled dressing. Interviews with the LVN and the DON revealed that the facility's protocol required wound dressings to be dated to track when care was provided and to prevent infections. The DON confirmed that the condition of the dressing should have been identified during routine nursing rounds and addressed promptly. The failure to maintain proper wound care practices increased the resident's risk of infection, as indicated by the positive test results for infection and the subsequent antibiotic treatment.
Deficiency in Respiratory Care and Oxygen Storage
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #192, who required continuous oxygen therapy. The resident, who had diagnoses including dementia, pneumonia, and acute respiratory failure with hypoxia, was observed without her nasal cannula, which was supposed to be worn continuously as per physician's orders. The nasal cannula was found uncovered on a small chest beside her bed, posing an infection risk. The resident reported that staff had forgotten to put the cannula back on after her bath. Interviews with staff, including an LVN and the DON, confirmed that the nasal cannula should have been on the resident at all times and covered when not in use to prevent infection. Additionally, the facility failed to properly manage oxygen storage. Four metal oxygen cylinders were found stored in a scale room without an oxygen sign posted on the door, contrary to the facility's policy that required oxygen cylinders to be stored only in the designated oxygen storage room. The central supply clerk and the DON acknowledged the improper storage and the lack of signage, which could potentially impact the availability of oxygen support for residents requiring oxygen therapy.
Failure to Act on Pharmacist's Drug Regimen Recommendations
Penalty
Summary
The facility failed to ensure that drug regimen irregularities reported by the Pharmacist Consultant were acted upon by the physician for one resident. Specifically, the physician did not respond timely to the Pharmacist Consultant's recommendation to evaluate the continued need for iron sulfate beyond eight weeks of therapy, as per CMS guidelines. The medication was eventually discontinued, but not until over a month after the recommendation was made. The deficiency involved a resident with multiple diagnoses, including anxiety, depression, hyperlipidemia, hypertension, hypothyroidism, vitamin D deficiency, and GERD. The resident was receiving ferrous sulfate as a supplement, and the Pharmacist Consultant recommended evaluating its necessity. However, there was no system in place to ensure that such recommendations were promptly acted upon by the physician, leading to a delay in addressing the potential for unnecessary medication.
Failure in Dialysis Communication and Coordination
Penalty
Summary
The facility failed to ensure proper communication and coordination with the dialysis center for a resident requiring dialysis services. The resident, a male with end-stage renal failure on hemodialysis, had a care plan that did not include maintaining communication with the dialysis center. This lack of communication was evident in the incomplete dialysis communication forms, which were meant to document vital signs, weights, dialysis times, and other critical information. Interviews with staff revealed that the charge nurse responsible for the resident was unaware of the incomplete forms due to her shift timing. The afternoon charge nurse, who was supposed to ensure the forms were completed, did not notice any discrepancies. The Director of Nursing (DON) also admitted to not noticing the discrepancies until the forms were submitted to the surveyor. The dialysis center staff acknowledged the difficulty in keeping up with the forms and stated that they had not received any follow-up calls from the facility regarding the lack of documentation. The facility's hemodialysis policy required communication with the dialysis facility through forms or telephone, including details like physician orders, vital signs, and nutritional management. However, the policy was not followed, leading to incomplete documentation and a potential risk of missing changes in the resident's condition. The DON noted that the current staff was relatively new, and there was uncertainty about the training provided by the previous administration.
Deficiencies in Documentation and Incident Reporting
Penalty
Summary
The facility failed to maintain complete and accurate medical records for three residents, leading to deficiencies in documentation and incident reporting. For Resident #2, the facility did not document an allegation of being called 'stupid' and handled roughly by a CNA during ADLs in the progress notes, nor was an incident report completed. This oversight was confirmed during an interview with the Administrator, who acknowledged the lack of documentation and incident reporting. In another case, the facility did not accurately document a resident-to-resident altercation between Residents #1 and #4. The progress notes for Resident #1 mentioned the altercation, but there was no corresponding assessment or incident report for Resident #4. Interviews with staff, including the LVN and ADON, revealed that although the incident was reported verbally, it was not documented in the facility's electronic records, and no incident report was filed. The facility's failure to document these incidents and complete incident reports as per policy could place residents at risk of not receiving needed services. The lack of documentation and incident reporting was acknowledged by the DON, who stated that the absence of incident reports could lead to inaccurate details of incidents, lack of monitoring, and failure to notify relevant parties. The facility's policy on incidents and accidents requires incident reports for resident-to-resident altercations, which were not completed in these cases.
Facility Fails to Repair Broken Window, Compromising Resident Safety
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public, as evidenced by a broken window in one of the resident rooms. The broken window was covered with cardboard and plastic, which allowed air and dust to enter the room, potentially affecting the respiratory health of the residents. This issue was first reported by the Maintenance Director in January 2024, but the window remained unfixed by June 2024, despite multiple follow-ups with the facility's President and the builder responsible for the window replacement. Resident #7, who was on oxygen therapy, reported experiencing difficulty breathing and increased sneezing due to the dust and air entering through the broken window. The resident's oxygen saturation levels were recorded between 92% and 97% during the period from June 2 to June 25, 2024. The resident's roommate, also on oxygen, was asleep during the observation. The Director of Nursing (DON) acknowledged the broken window and the associated risks, including dust, wind, and insects entering the room, but was unaware of the window's history as she had started working at the facility after the incident occurred. The Maintenance Director explained that the window was broken by a resident and that the builder was contacted to replace it under warranty. However, the replacement was delayed due to the need for a special order. The Administrator confirmed that the broken window had been reported months ago and that a work order was placed, but the facility was unaware of the need to make specific arrangements for the order, which prolonged the repair process. The facility's policy on providing a safe and homelike environment was not dated, but it emphasized the importance of ensuring a safe, clean, and comfortable environment for residents.
Failure to Conduct Timely Background Check on Administrator
Penalty
Summary
The facility failed to implement its written policies that prohibit and prevent abuse by not conducting a criminal background check on the Administrator before she began her duties. The Administrator started working on December 4, 2023, but her criminal background check was not completed until December 14, 2023. This oversight was discovered during an audit by HR in December 2023, who then conducted the background check to ensure it was on record. However, there was no documentation or proof from corporate that a background check had been completed prior to the Administrator's start date. Interviews with HR personnel revealed inconsistencies in the process of conducting background checks. The Retail HR claimed to have run the Administrator's background check on December 1, 2023, but corporate did not have a record of this check. The facility's policy on abuse, neglect, and exploitation requires that potential employees be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property, with documentation maintained as proof. The failure to adhere to this policy could place residents at risk of potential abuse.
Failure to Report Resident Altercation
Penalty
Summary
The facility failed to report an alleged abuse incident involving two residents within the required timeframe. The incident occurred when one resident reportedly hit another with a cane after a minor altercation involving a wheelchair. The facility's staff, including the LVN and ADON, were aware of the incident and took immediate steps to separate the residents and ensure safety. However, the incident was not reported to the appropriate authorities, such as the State Survey Agency and adult protective services, as required by state law. The deficiency involved two residents, one of whom had a severely impaired cognitive status as indicated by a BIMS score of 1. The altercation was documented in progress notes, but there was no evidence of a skin assessment or further documentation regarding the incident for the resident with cognitive impairment. The facility's policy required immediate reporting of such incidents, but the DON and Administrator did not ensure that the incident was reported to the necessary agencies. Interviews with staff revealed that the facility's corporate office decided the incident was not reportable due to insufficient evidence of physical harm. Despite this, the facility's policy mandates reporting all alleged violations, regardless of the perceived severity. The lack of timely reporting could place residents at risk of continued abuse, as the facility did not adhere to its own policies and state regulations.
Failure to Document Wound Care Properly
Penalty
Summary
The facility failed to provide necessary treatment and services based on the comprehensive assessment and professional standards of practice for a resident diagnosed with lymphedema, chronic venous hypertension, leg wound, and elephantiasis. The resident's care plan included wound care for venous ulcers, which required regular dressing changes and documentation. However, observations revealed that the dressings on the resident's left foot and leg were not dated or initialed, and the edges were peeling off, exposing the gauze and wound. Interviews with the resident and staff, including the Director of Nursing (DON) and Registered Nurse (RN) C, indicated discrepancies in the frequency of wound care provided. The resident stated that dressings were changed once a week, while the administration reported wound care was ordered three times a week. The DON and RN C confirmed that dressings should be dated and initialed as part of standard procedures to prevent infection and ensure accountability. RN C admitted to providing wound care but did not date or initial the dressings, and the Wound Care Nurse emphasized the importance of changing dressings with peeling edges and yellowish substances. The facility's wound treatment management policy aimed to promote wound healing through evidence-based treatments and required dressing changes to be documented. However, the failure to date and initial the dressings, as well as the lack of communication among staff regarding the condition of the dressings, contributed to the deficiency. This oversight posed a risk of infection and deterioration of the resident's condition, as noted by the staff during interviews.
Incomplete Facility-Wide Assessment and Staffing Plan
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both regular operations and emergencies. The assessment, dated April 24, 2023, was incomplete, notably lacking a staffing plan. This oversight was identified during a review of the facility's records and interviews with staff. The Director of Nursing (DON) acknowledged receiving an email from the Administrator about the overdue assessment but had not completed her section on staffing. The Administrator admitted to being out of compliance with the facility's policy, which mandates an annual assessment, and attributed the delay to issues with a previous interim DON. The Administrator further explained that the facility assessment should be completed annually and recognized the lack of a documented staffing ratio plan as a risk. Despite sending an email to department heads with the assessment template, the Administrator did not recall notifying corporate about the interim DON's inadequacies, which contributed to the delay. The facility's policy, dated July 2022, requires the assessment to be reviewed and updated annually or when significant changes occur, considering specific needs for each shift and resident unit. However, this policy was not adhered to, resulting in the deficiency.
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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.
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Nursing homes near El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Center At Zaragoza, Llc | 1.8 mi | ★★★★★ | 3 | 0 |
| Ignite Medical Resort El Paso, Llc | 2.5 mi | ★★★★★ | 23 | 3 |
| El Paso Health & Rehabilitation Center | 4.6 mi | ★★★★★ | 11 | 0 |
| Pebble Creek Nursing Center | 4.8 mi | ★★★★★ | 10 | 0 |
| Edgemere Estates | 5.3 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.