Avir At Town Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Palestine, Texas.
- Location
- 1816 Tile Factory Rd, Palestine, Texas 75801
- CMS Provider Number
- 455565
- Inspections on file
- 43
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Avir At Town Creek during CMS and state inspections, most recent first.
Two male residents with significant cognitive impairments were involved in a resident-to-resident altercation when one resident was observed by an LVN striking another in the face with a closed fist. The LVN immediately separated the residents, notified the DON, NP, and responsible party, and completed a skin assessment that showed no injuries, while both residents were later observed clean, well groomed, and without bruising or skin tears. One resident had autism, severe intellectual disability, and behavioral symptoms such as yelling, while the other had dementia, a psychotic disorder, and severely impaired cognition but no prior documented aggression. Despite facility policies and staff training requiring immediate reporting of suspected abuse to authorities, the DON and ADM decided the incident was not reportable based on their belief that the aggressor’s limited cognition meant he could not willfully act, resulting in a failure to report the alleged abuse as required.
Surveyors found that food items in the kitchen refrigerator and freezer were not consistently labeled or dated, including premade waffles, chicken, fruit cups, ground beef, and ham. Staff interviews confirmed that food should be labeled and dated upon delivery or when opened, but this was not done according to facility policy and federal food codes.
The facility did not establish or maintain a required infection prevention and control program, as observed by surveyors during their review of facility practices.
A resident with a gastrostomy tube and intact cognition was left exposed to the hallway during tube care when the ADON did not pull the privacy curtain or close the door. Staff and the resident confirmed that this lack of privacy caused embarrassment, and facility policy required privacy to be maintained during care.
A resident with significant medical and cognitive needs was left in a room with a broken window frame that was detached from the wall, exposing screws and nails. Staff and department heads failed to notice or report the issue despite daily environmental rounds and established reporting procedures, resulting in the maintenance problem going unaddressed until discovered during a survey.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided according to regulatory standards.
A designated smoking area was found with a fire can containing a plastic liner, cigarette butts, and paper and plastic trash, contrary to facility policy. Staff interviews revealed confusion about responsibility for maintaining the smoking area, and the Maintenance Director was unaware of proper procedures. The facility's policy required metal containers for ash disposal, but this was not followed, resulting in an unsafe smoking environment.
A facility failed to ensure safe and sanitary storage of a resident's food items, as a personal refrigerator contained expired cheese. The resident, with cerebral palsy and mild intellectual disabilities, required assistance with eating. There was confusion among staff about who was responsible for checking food expiration, leading to non-compliance with the facility's policy and potential risk for foodborne illnesses.
A resident with diabetes and chronic ulcers developed facility-acquired wounds due to inadequate care. The facility failed to conduct regular skin assessments and did not provide a bed of appropriate size, leading to the resident's feet pressing against the footboard. Despite staff reporting the issue, the problem persisted, resulting in harm to the resident.
A resident in a facility was not provided with a bed of proper size, leading to discomfort and the development of diabetic ulcers. Despite being 80 inches tall, the resident's feet hung over the edge of the mattress, and the footboard was removed after ulcers developed. Staff acknowledged the bed was too small, but the facility initially failed to provide a suitable alternative, resulting in harm to the resident.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, on four days in June 2024. This occurred due to the departure of the DON and the unavailability of corporate travel nurses, with agency nurses calling in and no replacements provided. The facility's policy required RN services daily, which was not met during these days.
The facility's kitchen failed to maintain sanitary conditions, with the dish machine's sanitizer levels consistently above the manufacturer's guidelines. A scoop was improperly stored in a flour bin, and baking sheets had baked-on buildup. The Dietary Manager and Administrator were unaware of the correct sanitization levels, leading to these deficiencies.
The facility failed to submit complete RN staffing data to CMS for several dates in 2024 due to an oversight in capturing hours for the DON, traveling nurses, and agency nurses. The absence of RN coverage on specific dates was due to the departure of the DON and lack of available corporate RNs.
A resident was administered multiple psychotropic medications without obtaining informed consent, as required by facility policy. The resident, with complex medical conditions, received medications such as mirtazapine, risperidone, and others without documented consent. Facility staff acknowledged the oversight and began an audit to address the issue.
The facility failed to maintain proper infection control practices during care for two residents. A CNA did not change gloves or perform hand hygiene during incontinent care for a resident with hemiplegia, while an LVN used improperly cleaned scissors during ostomy care for another resident. Both staff members were aware of the correct procedures but did not follow them, posing a risk of infection.
The facility failed to implement comprehensive care plans for four residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. This included not providing necessary meal assistance, missing fortified foods, and failing to perform required weekly weight checks.
The facility failed to maintain acceptable nutritional status for 15 residents, including inadequate communication with dietary staff, insufficient monitoring of weight changes, and failure to provide therapeutic meals and necessary assistance during meals. These deficiencies placed residents at risk of severe weight loss, delayed interventions, and worsening health conditions.
A resident with a history of dysphagia choked on every bite of food during breakfast, but the facility failed to notify the physician and responsible party. The resident's diet was downgraded without proper notification, and the resident was observed eating alone and without assistance. Staff interviews revealed that the facility's policy for notifying significant changes was not followed.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed expired and improperly labeled food items in the dry storage area and refrigerator. The Dietary Manager confirmed the oversight, citing staff shortages as a contributing factor. The Administrator emphasized the importance of discarding expired food to prevent foodborne illnesses, in line with the facility's food storage policy.
The facility failed to ensure that licensed nurses had the necessary competencies to care for a resident with dysphagia. After a choking incident, the resident's diet was changed without proper assessment or physician notification. The resident, who required assistance during meals, was observed eating alone and quickly, leading to coughing and potential aspiration risks. Staff interviews revealed that facility policies were not followed, and the necessary evaluations were delayed.
The facility failed to ensure RN coverage for at least eight consecutive hours a day, seven days a week, as required. Specifically, RN coverage was missing on one day in December 2023. The ADON, new to her role, was still learning her responsibilities, which contributed to the oversight. The DON and ADON typically provide coverage themselves if no other RN is available, but this did not occur on the specified day.
The facility failed to ensure proper labeling of an insulin vial for a resident with multiple diagnoses, including dementia and type 2 diabetes. The insulin was found opened and undated, posing a risk of reduced effectiveness in controlling blood sugar levels. The nurse responsible was unaware of the opening date, and the ADON confirmed the labeling should have been done upon first use.
Failure to Timely Report Resident-to-Resident Physical Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged resident-to-resident physical abuse incident to the appropriate authorities as required. On the date in question at approximately 3:38 p.m., an LVN (LVN A) heard someone call out for the nurse, exited a resident’s room, and observed one resident (Resident #2) make contact with another resident (Resident #1) on the cheek with what appeared to be a closed fist. LVN A separated the residents, notified the DON, NP, and responsible party, and completed a skin assessment on Resident #1, which revealed no injuries or alterations in skin integrity. The incident was documented as physical aggression on an incident report. Resident #1 was a male with autistic disorder, muscle wasting and atrophy, diabetes mellitus, and severe intellectual disability. A recent MDS indicated he was rarely or never understood, and he required varying levels of assistance with toileting hygiene, dressing, personal hygiene, eating, oral hygiene, and footwear. His care plan, dated 2/4/26, documented behavioral symptoms related to severe intellectual disability, including self-biting and yelling out when agitated, with interventions such as maintaining a calm environment, using calming techniques and words, and removing him from the area if his behavior interfered with others. Following the incident, Resident #1 was assessed as nonverbal and not appearing emotionally distressed, and later observation showed him clean, well groomed, and without suspicious marks, skin tears, or bruising. Resident #2 was a male with unspecified dementia and a psychotic disorder with delusions due to a known physiological condition. His admission MDS showed severely impaired cognition with a BIMS score of 4 and indicated he required supervision or assistance with eating, oral hygiene, dressing, personal hygiene, toileting hygiene, showering/bathing, and footwear, with no documented physical or behavioral symptoms directed toward others. His care plan, dated 2/4/26, identified risk for impaired social interactions related to mood and psychotic disorders, with interventions including administering medications as ordered and monitoring for side effects and effectiveness. The DON and ADM acknowledged being notified of the altercation and stated they determined it was not reportable to the state because, in their view, Resident #2’s limited cognition meant he could not willfully act. This decision was made despite facility policies stating that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the administrator and other officials according to state law and HHSC reporting guidelines, and despite staff training on abuse and reporting requirements.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen inspection, multiple food items in both the refrigerator and freezer were found to be undated and unlabeled, including premade waffles, precooked and uncooked chicken, breaded squash, fruit cups, ground beef, and ham. Staff interviews confirmed that food should be dated and labeled upon delivery, when opened, or when removed from original containers, but this was not consistently done. The facility's own policy and federal food codes require all food items to be properly labeled and dated to ensure safety and prevent contamination. Staff members, including the dietary manager, cooks, dietitian, and administrator, acknowledged during interviews that the lack of dating and labeling could result in the use of expired or contaminated food, and that proper procedures were not followed. Record review of facility policy and federal regulations further supported the requirement for labeling and dating all food items. No specific residents were identified as being directly affected at the time of the deficiency.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection control measures were not established or maintained as mandated. The report specifically notes the absence of a comprehensive program designed to prevent and control infections within the facility. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
A deficiency occurred when the Assistant Director of Nursing (ADON) failed to provide full privacy to a male resident during gastrostomy tube care. The resident, who had a history of tracheostomy, gastrostomy, cerebral ischemia, muscle wasting, and dysphagia, was observed receiving care with the privacy curtain not pulled and the door to the hallway left open. This allowed the resident to be visible from the hallway while visitors, staff, and other residents passed by. The resident was dependent on staff for gastrostomy tube care and had intact cognition, as indicated by a BIMS score of 14. Interviews with the ADON, a CNA, the Director of Nursing (DON), and the Administrator confirmed that all staff had been trained on the importance of maintaining resident privacy and dignity, and that the privacy curtain should have been used during care. The resident indicated feeling exposed and embarrassed when privacy was not maintained. Facility policy also required that each resident be cared for in a manner that promotes well-being and self-esteem, which was not followed in this instance.
Failure to Repair Broken Window Frame Compromises Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for a resident by not repairing a broken window frame in the resident's room. The window frame was detached from the wall, with exposed screws and nails protruding about half an inch, and this issue was not reported or addressed until it was observed during the survey. Staff members, including CNAs and the social worker, were either unaware of the problem or had not checked the window due to closed blinds or lack of observation. Maintenance records showed no prior request for repair, and the Maintenance Supervisor was not aware of the issue until the day of the survey. The resident affected had multiple medical conditions, including schizoaffective disorder, atherosclerotic heart disease, and polyosteoarthritis, and required substantial assistance with personal hygiene and bed mobility. The facility had procedures in place for staff to report maintenance issues, such as scanning QR codes or reporting during morning meetings, but these were not utilized in this instance. Daily environmental rounds were conducted by department heads, but the deficiency was not identified or communicated, resulting in the resident living in a room with an unrepaired, unsafe window frame.
Inappropriate Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and with resident agreement, as well as deficiencies in the ongoing care and management of residents with feeding tubes.
Failure to Maintain Smoking Area Safety and Enforce Smoking Policy
Penalty
Summary
The facility failed to enforce its smoking policy and maintain smoking safety in one of two designated smoking areas, specifically the secured unit smoking area. During an observation, a red fire can in the smoking area was found to contain a plastic liner, cigarette butts, and paper and plastic trash. Staff interviews revealed uncertainty about who was responsible for maintaining the fire cans, with a CNA stating that everyone was responsible but unsure who placed the liner or trash in the can. The Maintenance Director, who was new to the position, was also unaware of the proper procedures for the fire cans and acknowledged the potential fire hazard. The facility's Resident Smoking Policy required accessible metal containers with self-closing covers for ash disposal, but the observed fire can did not meet these requirements due to the presence of inappropriate materials. The Administrator confirmed that the Maintenance Director was responsible for maintaining the smoking areas, but all staff assisting residents with smoking should ensure proper use of the fire cans. The lack of clear responsibility and adherence to the smoking policy led to improper disposal of trash in the fire can, creating an unsafe smoking environment.
Failure to Ensure Safe Storage of Resident's Food
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of a resident's food items, specifically in the personal refrigerator of a resident with cerebral palsy, mild intellectual disabilities, and GERD. The resident's refrigerator contained a plastic bag of sliced cheese that was not in its original packaging and was dated beyond the facility's policy of disposing of food within five days. The resident, who required supervision or assistance with eating, mentioned that his best friend helped him with food from the refrigerator, but there was a discrepancy in their accounts regarding the preparation of a sandwich using the cheese. The facility's policy required housekeeping and/or nursing staff to clean the refrigerators weekly and discard any non-compliant foods. However, there was confusion among staff about who was responsible for checking the expiration of foods in personal refrigerators. Housekeeping staff believed they were only responsible for cleaning and checking temperatures, while the nursing staff were supposed to check for expired foods. The Director of Nursing and the Administrator were unaware of the expired food in the resident's refrigerator, indicating a lack of communication and adherence to the facility's policy, which could place residents at risk for foodborne illnesses.
Inadequate Care Leads to Wound Development in Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, leading to the development and worsening of two facility-acquired wounds. The resident, a male with a history of type 2 diabetes, end-stage renal disease, and chronic ulcers, was admitted without any pressure injuries. However, the facility did not conduct weekly skin assessments as required, with only two assessments documented over a period of time. This lack of regular monitoring contributed to the resident developing diabetic ulcers on his toes. Additionally, the facility did not provide a bed of appropriate size for the resident, who was 6 feet 8 inches tall. The resident's feet were pressing against the footboard, which was later removed, and a mattress extension was added. Despite these adjustments, the resident's feet were still not adequately supported, leading to discomfort and potential skin breakdown. The staff, including a CNA and an LVN, reported the bed size issue to the administration, but the problem persisted until corrective actions were taken. The facility's failure to adhere to professional standards of practice and the resident's comprehensive care plan resulted in harm to the resident. The lack of timely skin assessments and the inappropriate bed size were significant factors in the development of the resident's wounds. These deficiencies highlight the facility's inability to prevent the development and worsening of pressure injuries, placing residents with limited mobility at risk.
Inadequate Bed Size Leads to Resident Harm
Penalty
Summary
The facility failed to provide a resident with a bed of proper size and height, which was necessary for the resident's safety and comfort. The resident, who was 80 inches tall, had been admitted with diagnoses including end-stage renal disease and chronic diabetic ulcers on both feet. Upon admission, the resident informed the staff that the bed was too small and uncomfortable, as his feet pressed against the footboard. Despite this, the facility did not initially provide a suitable bed, leading to the resident's feet hanging over the edge of the mattress and resting on a mattress extension. Interviews with staff revealed that the resident's bed was indeed too small, and the footboard had been removed after the resident developed diabetic ulcers on his feet. The Licensed Vocational Nurse (LVN) reported the issue to the Administrator (ADM), Director of Nursing (DON), and Assistant Director of Nursing (ADON), but was told that the bed was the largest available. The DON acknowledged that a mattress extension had been ordered upon the resident's admission but was misplaced, necessitating a reorder. The ADM confirmed the bed's length was measured and deemed sufficient, but the resident's mobility caused him to slide down, exacerbating the issue. The facility's policy on bed safety required the interdisciplinary team to assess the resident's sleeping environment, considering factors such as safety, medical conditions, and comfort. However, the failure to provide a bed of appropriate size resulted in harm to the resident, as evidenced by the development of diabetic ulcers on January 9, 2025. The facility's actions and inactions in addressing the resident's needs led to this deficiency, as the resident's comfort and safety were compromised due to inadequate bed accommodations.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified for four days in June 2024, specifically on the 15th, 16th, 29th, and 30th. During this period, the facility did not have any RN coverage due to the departure of the Director of Nurses (DON) and the unavailability of corporate travel nurses. The facility relied on agency registered nursing staff to meet the required coverage, but on these occasions, the scheduled nurses called in prior to their shifts, and the staffing agency did not provide replacements. Interviews with the facility's Administrator and the corporate compliance officer confirmed the lack of RN coverage on the specified dates. The Administrator, who had been employed since August 2023, acknowledged the absence of RN staff during the reporting period and noted that the DON was the only RN on staff at that time. The corporate compliance officer corroborated that there was no RN employed by the facility on those dates, and corporate RNs were unavailable. The facility's policy, dated September 28, 2023, stated the requirement for RN services for at least eight consecutive hours daily, seven days a week, which was not met during the identified days.
Sanitation and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. The dish machine's chemical sanitizer was not maintained at the appropriate levels according to the manufacturer's guidelines. The dish machine was consistently operating with a sanitizer concentration between 100-200 ppm, whereas the manufacturer's label required a minimum of 50 ppm. This discrepancy was noted throughout September 2024, and the kitchen staff, including the Dietary Manager (DM), were aware of the issue but did not take corrective action until the surveyor's visit. Additionally, the facility did not ensure proper storage of kitchen utensils. During an observation, a scoop was found inside a bin containing flour, contrary to the facility's policy that required scoops to be stored in a protected area. The DM acknowledged this oversight and stated that all kitchen staff were responsible for ensuring proper storage of utensils. Furthermore, the facility had baking sheets with brown and black baked-on buildup, indicating inadequate cleaning practices. Interviews with the DM and the Administrator revealed a lack of understanding regarding the correct sanitization levels for the dish machine. The DM admitted to being unsure of the potential risks to residents from high sanitizer levels, and the Administrator believed the sanitization levels were within acceptable limits. The facility's policies and the Food and Drug Code require accurate testing and maintenance of sanitizing solutions to prevent foodborne illnesses, but these were not adhered to, leading to the identified deficiencies.
Incomplete RN Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the third quarter of fiscal year 2024. Specifically, the facility did not report RN hours for several dates in April, May, and June 2024. Although the monthly staffing schedules indicated that an RN was scheduled for most of these days, the time sheets provided proof of RN coverage for all dates except June 15, 16, 29, and 30. During this period, the facility lacked RN coverage due to the departure of the Director of Nurses and the absence of other RNs on staff. The corporate office was responsible for reporting the hours, but the hours of the DON, traveling corporate nurses, and agency nurses were not reflected in the payroll system, leading to incomplete reporting. Interviews with the facility's Administrator, corporate compliance officer, and corporate director of data analysis revealed that the oversight occurred because the hours were assessed through the payroll system, which did not capture hours for the DON, traveling nurses, or agency nurses. The Administrator admitted that the hours were not reviewed before submission to ensure accuracy. The corporate compliance officer confirmed that there was no RN employed by the facility on the dates without RN coverage, and the corporate RNs were unavailable. The corporate director of data analysis acknowledged that the omission of hours was an oversight and that a new system has since been implemented to ensure accurate reporting.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident in advance of the risks and benefits of proposed care and treatment related to psychotropic medications. Specifically, the facility did not obtain signed consent for several psychotropic medications administered to the resident, including mirtazapine, risperidone, trazodone, Depakote, clonazepam, and Zyprexa. This oversight was identified during a review of the resident's records, which showed no consents for these medications. The resident, who was admitted to the facility with diagnoses including manic episodes, senile degeneration of the brain, alcohol abuse with alcohol-induced psychotic disorder, anxiety, and dementia, was receiving multiple psychotropic medications. The facility's records indicated that the resident was rarely or never understood, and during a specific period, she was administered antipsychotic, antianxiety, and antidepressant medications. Despite these treatments, there was no documentation of informed consent for the medications in the resident's electronic health record. Interviews with facility staff revealed that a previous Travel DON was responsible for ensuring consents were obtained, but this was not done for the resident in question. The current ADON and Travel DON acknowledged the lack of consents and stated that they had begun an audit to address this issue. The facility's policy required consent to be obtained before administering psychotropic medications, but this was not adhered to in this case, leading to the deficiency.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and equipment cleaning practices observed during care for two residents. Resident #14, a male with hemiplegia and moderately impaired cognition, was provided incontinent care by two CNAs. During the care, CNA B did not change gloves or perform hand hygiene before applying a clean brief and barrier cream, which could lead to cross-contamination and infection. Resident #25, also a male with hemiplegia and moderately impaired cognition, received ostomy care from an LVN. During the procedure, the LVN dropped scissors on the floor, rinsed them under cold water, and continued to use them without proper disinfection. This action violated infection control protocols and posed a risk of infection to the resident. Interviews with the staff involved revealed that both CNA B and LVN A were aware of the correct procedures but failed to follow them. The facility's infection preventionist and DON acknowledged the deficiencies and noted ongoing efforts to retrain staff due to recent management turnover. The facility's policies on hand hygiene and equipment cleaning were not adhered to during these incidents.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for four residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #15, an elderly male with severe cognitive impairment and dysphagia, was observed eating without the necessary physical assistance and verbal cueing, despite his care plan indicating the need for such support. This lack of assistance led to the resident eating quickly, taking large bites, and occasionally coughing, which could pose a risk of choking or aspiration. Resident #25, an elderly female with severe cognitive impairment, was not provided with the fortified foods required by her therapeutic diet during a lunch meal. This oversight occurred despite her care plan indicating the need for fortified foods due to significant weight loss. Similarly, Resident #24, who required supervision and one-person assistance with meals, was observed eating alone without any staff assistance or supervision. Additionally, Resident #24's care plan included weekly weight checks, which were not consistently performed, missing weights on two specified weeks. Resident #33, an elderly male with dementia and dysphagia, also had a care plan that required weekly weight checks due to significant weight loss. However, the facility failed to perform these weight checks on two specified weeks. These failures in implementing care plan interventions could place residents at risk of not receiving the necessary care to meet their identified needs, particularly in terms of nutrition and safety during meals.
Failure to Maintain Nutritional Status and Dietary Management
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for 15 of 34 residents reviewed for weight loss and nutrition. The deficiencies included a lack of communication with dietary staff on dietary changes, inadequate systems to monitor weight changes, and failure to weigh residents according to physician orders and dietary recommendations. Additionally, the facility did not provide assistance and supervision with meals as indicated by resident care plans, nor did it provide therapeutic meals as ordered by physicians and dietary recommendations. The facility also failed to obtain updated baseline weights after replacing the facility scale until state surveyor intervention. For instance, Resident #33, who had diagnoses including unspecified dementia and dysphagia, experienced significant weight fluctuations and was not weighed weekly as ordered. Observations revealed that Resident #33 received incorrect meal portions, contrary to his dietary requirements. Similarly, Resident #13, who had moderately impaired cognition, did not receive the large portions indicated on his tray card, and Resident #18, with moderate cognitive impairment, did not receive the large portions or fortified foods as ordered. Other residents, such as Resident #24, who had a cognitive communication deficit, were observed eating without the necessary supervision or assistance, leading to potential risks. Resident #25, with severe cognitive impairment, did not receive fortified foods as required, and Resident #34 was served the wrong meal tray, posing a risk of allergic reactions or choking. These failures in dietary management and monitoring placed all residents at risk of severe weight loss, delayed interventions, hospitalization, worsening health conditions, and death.
Failure to Notify Physician and Responsible Party of Choking Incident
Penalty
Summary
The facility failed to notify the resident's physician and responsible party when there was a significant change in the physical status of a resident who experienced a choking incident. The resident, who had a history of dysphagia and was at risk for aspiration, choked on every bite of food during breakfast. Despite this, there was no documentation that the resident's primary care provider or responsible party was notified of the incident. The resident's diet was downgraded to pureed with thickened liquids without proper notification to the physician or responsible party. During observations, the resident was seen eating alone and without assistance, despite requiring substantial help with eating. The resident was observed eating quickly, taking large bites, and occasionally coughing when swallowing. Interviews with staff revealed that the nurse who downgraded the resident's diet was an agency nurse unfamiliar with the resident's history. The MDS coordinator and other staff acknowledged that the physician should have been notified immediately, and the incident should have been documented. The facility's policy required prompt notification of the resident's physician and responsible party in the event of significant changes in the resident's condition. However, this policy was not followed, leading to a delay in appropriate medical intervention. The failure to notify the physician and responsible party of the resident's choking incident could have resulted in improper and untimely treatment for the resident.
Failure to Properly Store and Discard Expired Food
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. During an observation in the dry storage area, several food items were found to be expired or improperly labeled, including white frosting, bread pudding, yellow cake mix, pasta, grits, thickened coffee packets, soy sauce, and flour. Additionally, the refrigerator contained expired items such as yogurt, prune juice, strawberry topping, and an employee's energy drink. The Dietary Manager (DM) confirmed that these items were not discarded by their expiration dates and acknowledged that consuming expired foods could put residents at risk of foodborne illnesses. The DM also mentioned that the responsibility for checking the fridge, freezer, and dry storage for expired foods was shared among the dietary staff, but due to being short-staffed, these checks were not performed as frequently as required. The Administrator, who had been working at the facility for about eight months, stated that it was the DM's responsibility to ensure all expired food was removed from the kitchen. The facility's policy on food storage, dated 2018, mandates that all food served must be of good quality and safe for consumption, with specific guidelines for labeling and dating opened and bulk items in both dry storage and refrigerators. The policy also requires that leftovers be used within 72 hours and discarded if older. The failure to adhere to these policies and procedures resulted in the presence of expired and improperly stored food items, posing a risk of foodborne illness to the residents.
Failure to Ensure Competent Nursing Care for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for the residents' needs, as identified through resident assessments and described in the care plan. This deficiency was observed in the case of a resident who experienced a choking incident. The MDS coordinator changed the resident's diet from mechanical soft to dysphagia pureed with thickened liquids without performing an assessment or notifying the physician, which could place the resident at risk of not receiving appropriate care and result in deterioration in condition. The resident, an elderly male with diagnoses including unspecified dementia, dysphagia, cognitive communication deficit, and gastro-esophageal reflux disease, had a history of eating too fast and requiring staff assistance during meals. Despite this, the resident was observed eating alone and without assistance on multiple occasions following the diet change. The resident was seen eating quickly, taking large bites of pureed food, and occasionally coughing when swallowing, indicating that the necessary supervision and assistance were not provided. Interviews with facility staff revealed that the nurse who downgraded the resident's diet was an agency nurse unfamiliar with the resident's needs. The MDS coordinator and other staff members acknowledged that the physician should have been notified and that the nurse's progress note exaggerated the choking incident. The speech therapist, who was supposed to evaluate the resident, had not done so due to scheduling conflicts. The facility's policies on changes in a resident's condition and dysphagia management were not followed, leading to a lack of appropriate care for the resident.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Specifically, the facility did not have RN coverage for one day in December 2023. This deficiency was identified through a review of the CMS Payroll Based Journal (PBJ) report for the fourth quarter of 2023, which indicated missing RN hours on several dates in October, November, and December 2023. The monthly staffing schedules and time sheets confirmed that RN coverage was missing on 12/17/2023. Interviews with the Administrator, Assistant Director of Nursing (ADON), and Director of Nursing (DON) revealed that the ADON was new to her role in December 2023 and was still learning her responsibilities, which contributed to the oversight in scheduling RN coverage for that day. The DON and ADON stated that they typically provide RN coverage themselves if no other RN is available, but this did not occur on 12/17/2023. The facility's policy, dated 9/28/23, mandates the utilization of a registered nurse for at least eight consecutive hours a day, seven days a week. Despite this policy, the facility failed to adhere to it on multiple occasions, with the most notable lapse occurring on 12/17/2023. The Administrator, who had been employed since August 2023, expected RN coverage to be maintained as per the policy. However, the ADON's inexperience and the lack of a scheduled RN on 12/17/2023 led to a failure in providing the required RN coverage, potentially placing residents at risk due to the absence of supervisory RN-specific nursing activities and coordination of emergency care and disasters.
Failure to Properly Label Insulin Vial
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding the labeling of an insulin vial for a resident. During a medication cart observation, a vial of Levemir insulin was found opened and not labeled with an open date. The nurse responsible for the cart was unaware of when the insulin had been opened and admitted that it must have been missed during daily checks. The Assistant Director of Nursing (ADON) confirmed that the insulin should have been dated by the nurse who opened it and acknowledged the potential risks of administering expired insulin, including reduced effectiveness in controlling blood sugar levels. The resident involved was an elderly individual with multiple diagnoses, including dementia, schizoaffective disorder, bipolar type, type 2 diabetes, and GERD. The resident had a moderately impaired cognition with a BIMS score of 12 and had been receiving insulin injections daily. The facility's policies on medication storage and administration were reviewed, and it was found that the insulin should have been dated upon first use. Interviews with the Regional Nurse and the Administrator further confirmed that the responsibility for dating the insulin lay with the nurse who opened it, and that the failure to do so could result in the medication not being as effective.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
