Avir At Waco
Inspection history, citations, penalties and survey trends for this long-term care facility in Waco, Texas.
- Location
- 9101 Panther Way, Waco, Texas 76712
- CMS Provider Number
- 676343
- Inspections on file
- 30
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Avir At Waco during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and obstructive sleep apnea required nightly CPAP therapy with distilled water in the humidifier, as ordered and care planned. One night, an RN could not locate the usual distilled water in the room, found a large bottle labeled as purified water stored under a refrigerator, and poured it into the CPAP reservoir without confirming it was distilled water. The bottle actually contained a tap water and sugar mixture prepared by the family as hummingbird water and had been kept in the room for months. Video and staff interviews confirmed the RN’s actions and the presence of the unlabeled hummingbird water, and clinicians noted that CPAP humidifiers are intended to be filled only with sterile or distilled water per facility policy.
A resident with severe cognitive impairment and obstructive sleep apnea, ordered to use CPAP nightly, did not receive respiratory care consistent with professional standards and the care plan when an RN filled the CPAP humidifier with hummingbird sugar water stored in a bottle labeled as purified water instead of using distilled water as required. The RN acknowledged knowing purified water was not the same as distilled water and attempted to clean the reservoir after learning the bottle contained hummingbird food. The CPAP was then taken out of service, and the resident was without the ordered CPAP therapy for at least one night. Staff interviews and video review confirmed the use of the incorrect fluid, the presence of the misleadingly labeled hummingbird water in the room, and the facility policy requiring the humidifier to be refilled with fresh distilled water in the evening before use.
The facility failed to ensure timely administration of ordered medications for three residents, including antipsychotic, antiseizure, and antidepressant drugs, which were repeatedly given more than one hour outside the prescribed administration times. One resident with schizophrenia and severe cognitive impairment received Risperidone late on multiple consecutive mornings, while another resident with schizophrenia and depression had late doses of Risperidone documented on audit reports. A third resident with a seizure disorder and depression received Valproic Acid and Venlafaxine outside the standard time frame over several days. A medication aide described a two-hour window for "on time" dosing, and the DON acknowledged that late medication reports were not monitored daily, despite facility policy requiring administration within one hour of the scheduled time.
Surveyors found that kitchen staff failed to follow food storage, labeling, dating, and sanitation standards. Opened cereal and cornstarch were left inadequately sealed and exposed in the pantry, while chopped squash in bags lacked labels and use-by dates and an opened box of frozen biscuits was exposed in the freezer. The top of the low-temperature dishwasher had visible food particle buildup at both the dirty and clean dish doors. The DM, DON, and ADM each confirmed expectations that food items be properly labeled, dated, sealed, and stored, and that kitchen sanitation, including cleaning the dishwasher, follow facility policy.
A resident with multiple comorbidities and a chronic non-healing wound required Enhanced Barrier Precautions (EBP) per the care plan and facility policy, which mandated gown and gloves for high-contact care such as wound care. During an observed wound dressing change to the resident’s lower extremity, the infection prevention nurse did not use EBP despite posted signage indicating their need. In interviews, the nurse admitted she should have used EBP and had been educated on infection control, and the DON confirmed that all nurses are expected to use EBP for wound care.
A resident with Alzheimer’s disease, influenza, and a UTI had physician orders for antibiotic therapy and droplet isolation, and was observed with droplet precaution signage and PPE outside the room. The comprehensive care plan included goals and interventions related to influenza and dehydration but did not document that the resident was on droplet precautions, and a separate UTI care plan listed a goal for resolution of the infection without any interventions. The MDS nurse and DON, who shared responsibility for care planning, acknowledged that droplet precautions and UTI interventions should have been included but were omitted, while CNAs and LVNs reported they rely on electronic care plans to guide care. The facility’s written policy required comprehensive, person-centered care plans with measurable objectives, timeframes, and interventions based on assessment data, which was not fully implemented for this resident’s droplet precautions and UTI.
The facility's kitchen was found to have multiple sanitation and food safety deficiencies, including unlabeled and undated food items, improper hair restraint use by staff, and incomplete equipment temperature logs. Observations revealed dirty equipment, unsecured trash cans, and improper storage of food items, potentially placing residents at risk of foodborne illness.
The facility did not adhere to posted cycle menus for two lunch services, serving meals that differed from the planned menus. Residents reported issues with the food, such as squash being too hard to eat. The dietary manager acknowledged making substitutions without detailed documentation. The facility's policy requires noting any menu changes, but this was not done. The Director of Nursing and Administrator expected the kitchen staff to follow menus and inform residents of changes, which was not consistently practiced.
The facility failed to provide meals that were palatable and attractive, with observations revealing unappealing and flavorless food, missing condiments, and improperly cooked items. A resident on a pureed diet received an unappetizing meal, while two residents complained about hard-to-eat squash. The dietary manager was unaware of these issues, despite the facility's policy emphasizing visually appealing and varied food service.
A facility failed to ensure a resident's gastric tube was flushed according to physician's orders during medication administration, risking tube clogging and potential replacement. Despite clear orders and previous grievances, RN-A omitted the pre-flush step, although a post-medication flush was conducted. Staff interviews confirmed the importance of flushing to prevent complications.
The facility failed to remove expired medical supplies from the medication storage room, as observed with three expired IMED Dressing Change Kits. Staff interviews revealed that the policy required expired items to be destroyed or given to the DON, but the responsibility for checking the room was not effectively executed. The use of expired supplies could lead to negative outcomes for residents.
The facility failed to maintain an effective infection prevention and control program in the laundry area, as clean linens were improperly stored on the designated dirty side. Staff interviews confirmed awareness of the importance of separating clean and dirty laundry to prevent cross-contamination, yet the practice was not followed, leading to a deficiency in the infection control program.
A resident with complex medical conditions was verbally abused by a CNA in a discouraging manner when requesting assistance to use the toilet. The incident was recorded by the resident's family member, and the DON confirmed the inappropriate tone used by the CNA. The resident's care plan required calm and positive interactions, which were not followed, leading to the resident's distress.
Unlabeled Hummingbird Water Used in CPAP Humidifier
Penalty
Summary
The deficiency involves the facility’s failure to keep the resident environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents, specifically related to the use of a CPAP machine. An elderly female resident with severe cognitive impairment, dementia, and a diagnosis of obstructive sleep apnea required nightly CPAP therapy with distilled water in the humidifier reservoir, as ordered by her physician and reflected in her care plan. The care plan and facility policy required the CPAP humidifier to be filled with fresh distilled water in the evening before use. Despite this, a large plastic bottle containing a mixture of tap water and granulated sugar, prepared by the family as hummingbird water and stored under the resident’s refrigerator near bird seed, was present in the resident’s room in a container labeled as purified water. On the evening in question, video evidence showed an RN entering the resident’s room, waking the resident, and assisting her with the CPAP mask. The RN observed that the CPAP water reservoir was empty and did not see the usual distilled water bottle on the nightstand or floor. The RN searched the room, verbally asked where the water was, and then located a bottle labeled purified water under the refrigerator. Without verifying that it was distilled water or otherwise confirming its contents, the RN poured this liquid into the CPAP reservoir and returned the bottle to its place. The RN later stated she believed purified water was acceptable because it was not tap water, acknowledged that purified water is not the same as distilled water, and reported she had not received specific CPAP training at the facility. She also reported attempting to clean the reservoir with water and tissues after being informed that the bottle contained hummingbird water. Subsequent interviews and observations confirmed that the bottle used by the RN was the family’s hummingbird water, which had been in the room since approximately July of the previous year. The resident’s responsible party reported this to staff, prompting another nurse to enter the room, remove the CPAP from the resident, and take the hummingbird water bottle to the medication room. Staff, including the RT, MD, FNP, and DON, described the mixture as tap water and sugar stored in a bottle labeled purified water and noted that it was not clearly labeled as hummingbird water. The RT and other clinicians explained that CPAP humidifiers are intended to be filled with sterile or distilled water and that the presence of this sugar-water mixture in the machine could lead to bacterial buildup over time. The facility’s own CPAP/BiPAP policy specified the use of distilled water in the humidifier, but this was not followed when the RN used the unlabeled hummingbird water from the resident’s room in the CPAP reservoir.
Improper CPAP Humidifier Water Use and Interruption of Ordered CPAP Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with professional standards and the resident’s care plan for a resident requiring CPAP therapy for obstructive sleep apnea. The resident was an elderly female with severe cognitive impairment, dementia, and a cognitive communication deficit, who had a physician’s order for nightly CPAP use at a prescribed setting. A prior sleep study documented severe obstructive sleep apnea with numerous obstructive apneas and hypopneas, significant respiratory arousals, and oxygen desaturations, leading to the order for nightly CPAP use. The resident’s comprehensive care plan required that the CPAP humidifier reservoir be filled with distilled water only each night and that the CPAP equipment be cleaned according to specified procedures. On the evening in question, RN A entered the resident’s room, woke the resident, and had her apply the CPAP mask. RN A observed that the CPAP water reservoir was empty and did not see the usual distilled water bottle on or near the nightstand. Instead of obtaining distilled water from the medication room as per her training and facility practice, RN A located a bottle labeled “purified water” under the resident’s refrigerator and used it to fill the CPAP reservoir. This bottle was later identified as hummingbird water, a mixture of tap water and granulated sugar that had been prepared by the family months earlier and stored near bird seed in the resident’s room. Video footage showed RN A searching for water, picking up a blue-labeled bottle from beneath the area of the camera, pouring its contents into the CPAP reservoir, and returning the bottle to where she found it. RN A acknowledged in interview that she knew purified water was not the same as distilled water and that she had been trained that distilled or sterile water was to be used in CPAP humidifiers. She stated she thought using purified water was acceptable because it was not tap water and reported attempting to clean the reservoir with water and tissues after being informed that the bottle contained hummingbird food. The respiratory therapist confirmed that CPAP humidifier water should be sterile or distilled and that she had initially set up the resident’s CPAP. Following discovery of the incident, the resident’s CPAP was taken out of service, and the resident was without CPAP use for at least one night. Medical providers, including the RT, MD, and FNP, described the situation as dangerous or potentially problematic if the sugar water mixture were used repeatedly, and the facility’s own policy specified that the humidifier chamber was to be refilled with fresh distilled water in the evening before use. These actions and inactions by RN A, and the presence of an unlabeled or misleadingly labeled container of hummingbird water in the resident’s room, led directly to the deficiency in providing safe and appropriate respiratory care. The deficiency also included the resident being without her prescribed CPAP therapy for at least one night after the machine was removed from service. The RT stated it was her understanding that the resident had been without CPAP for two nights, and the DON stated the resident went one night without CPAP after it was taken out of service and before a replacement machine was delivered and used. The resident herself reported that she did not wear her CPAP often and did not recall the incident. Nonetheless, the documented physician order required nightly CPAP use, and the care plan interventions were based on the resident’s severe obstructive sleep apnea. The combination of using an inappropriate fluid in the CPAP humidifier and the subsequent interruption of ordered CPAP therapy constituted the failure to provide respiratory care in accordance with professional standards and the resident’s care plan. Interviews with staff further clarified the circumstances leading to the deficiency. LVN B reported that she did not usually work on the resident’s hall and was unaware that hummingbird water was kept in the room. After being notified by the resident’s representative that hummingbird water had been poured into the CPAP, she entered the room, removed the CPAP from the resident, and took the hummingbird water to the medication room, noting that the room was somewhat dark and that the water appeared discolored. The DON stated that the hummingbird water bottle was not clearly labeled, that the water appeared cloudy, and that the facility sometimes used similar bottles for distilled water obtained from a supplier or grocery store. The facility’s policy on CPAP/BiPAP support required the humidifier chamber to be emptied, rinsed, and refilled with fresh distilled water in the evening, underscoring that the use of hummingbird water and the failure to ensure availability and correct identification of distilled water in the resident’s environment were central factors leading to the cited deficiency.
Failure to Administer Psychotropic and Antiseizure Medications Within Prescribed Time Frames
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured timely administration of medications as prescribed for three residents. For one male resident with schizophrenia, acute kidney failure, moderate intellectual disabilities, and severe cognitive impairment (BIMS score of 1), the care plan included monitoring for medication side effects and providing medications as ordered. His active order for Risperidone 1 mg twice daily for schizophrenia was not administered within the facility’s required one-hour window on three consecutive mornings, with doses scheduled for 9:00 a.m. instead given at 10:20 a.m., 11:36 a.m., and 10:16 a.m. respectively. A female resident with muscle weakness, schizophrenia, major depression, and moderate cognitive impairment (BIMS score of 10) also had an active order for Risperidone 0.5 mg twice daily for schizophrenia and a care plan that included observing for side effects and providing medications as ordered. The medication administration audit report for this resident, filtered for administrations more than one hour late, showed that her antipsychotic medication was not consistently given within the prescribed time frame, although the specific late times are partially truncated in the report. Another resident with a history of seizures and depression had active orders for Valproic Acid 15 ml twice daily and Venlafaxine 75 mg once daily, and the audit report showed these medications were administered outside the standard time frame over several days. Interviews and policy review further described the circumstances leading to the deficiency. A medication aide stated that medication aides were responsible for ensuring residents received medications on time, which she defined as within a two-hour window, and that if medications were going to be late, she would notify the nurse, who would then notify the physician. The DON stated that all nurses and medication aides were responsible for timely medication administration, that administration did not run late medication reports daily and therefore had not monitored late medications, and that medications should be given within one hour before or after the designated time on the order. The facility’s written policy on administering medications required that medications be administered in a safe and timely manner, within one hour of their prescribed time unless otherwise specified.
Food Storage, Labeling, and Dishwashing Sanitation Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper storage, labeling, dating, and sanitation practices in the kitchen. During an observation of the pantry, opened bags of cereal were found placed inside plastic labeled and dated bags that were not properly sealed, allowing exposure to outside air. An opened package of cornstarch was observed in the dry pantry with its contents exposed to the air rather than being placed inside a clear plastic bag and labeled and dated. In the freezer, two bags of chopped yellow squash had no label or use-by date, and an opened box of frozen biscuits was left exposed to freezer air. These conditions were inconsistent with the facility’s written policy, which required all refrigerated and frozen foods to be covered, labeled, and dated, and dry foods to be stored in a manner that maintains the integrity of the packaging until use. In a separate observation of the facility’s only kitchen, the top of the low-temperature dishwashing machine, at about eye level, was found covered in food particle buildup at both the door where dirty dishes were inserted and the door where clean dishes were removed. In interviews, the Dietary Manager stated that kitchen staff were normally expected to individually label and date food items in the pantry or freezer after serving a meal and acknowledged that the cereal and cornstarch were not properly sealed or stored. The DON reported that she did not oversee the kitchen and that the ADM was responsible, but stated her understanding that all food items should be dated and stored to prevent debris from getting into the food and to avoid serving expired or contaminated foods. The ADM stated that kitchen staff were expected to label and date food items when delivered and per facility policy, and that improperly sealed food could allow bugs into the packaging. He also stated that the kitchen was expected to follow company policies for cleaning and sanitation and that the top of the dishwasher should probably be cleaned after each meal, noting that cross-contamination could occur if clean dishes passed through a dirty machine.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program when the infection prevention nurse (IP A) did not follow the facility’s Enhanced Barrier Precautions (EBP) policy during wound care for Resident #68. Resident #68 was an adult male with heart failure, hypertension, diabetes mellitus, and depression, with a BIMS score of 15 indicating intact cognition. His comprehensive care plan documented a chronic non-healing wound or indwelling medical device, placing him at increased risk for transmission of multidrug-resistant organisms (MDROs), and included interventions requiring staff to change personal protective equipment (PPE) before caring for other residents and to use PPE, including gown and gloves, during specific resident care activities such as dressing changes. The facility’s written EBP policy, dated March 2024, specified that gown and gloves are required for high-contact resident care activities, including wound care for any skin opening requiring a dressing. On the observed date and time, IP A performed wound care to Resident #68’s right lower extremity wound, cleansing the wound, drying it, applying calcium alginate, and covering it with a dry dressing. During this procedure, IP A did not use enhanced barrier precautions, despite EBP signage being posted at the resident’s door indicating the need for such precautions. In a subsequent interview, IP A acknowledged that she should have used enhanced barrier precautions during the wound care, stated that it “slipped her mind,” and confirmed she had been educated on EBP and infection control, as well as that not using EBP could spread infection. The DON later confirmed that all nurses are expected to use enhanced barrier precautions when performing wound care and that nurse management is responsible for monitoring infection control and EBP use.
Failure to Care Plan Droplet Precautions and UTI Interventions for a Cognitively Impaired Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes for a resident with multiple acute and chronic conditions. The resident was an elderly female with diagnoses including Alzheimer’s disease, anemia, osteoporosis, influenza, and a urinary tract infection (UTI). A Quarterly MDS assessment documented that she was severely cognitively impaired with a BIMS score of 00, required supervision or touching assistance with eating, was dependent for toileting, needed substantial to maximum assistance with showering and personal hygiene, and was always incontinent of bowel and bladder. Physician’s orders dated 01/30/26 showed that the resident was on antibiotic therapy for UTI/flu, was receiving levofloxacin 750 mg orally with an end date of 02/06/26, and was ordered to be on droplet isolation with specific PPE and equipment handling requirements. Record review showed that the resident’s care plan dated 01/31/26 addressed Influenza A with a goal that the resident would be free from signs and symptoms of dehydration, and included interventions such as encouraging fluid intake, offering favorite beverages, administering antipyretics and analgesics as ordered, and monitoring for side effects and signs of dehydration. However, despite the physician’s order for droplet isolation, the comprehensive care plan did not include that the resident was on droplet precautions. Additionally, a care plan dated 02/04/26 documented that the resident had a UTI with a goal that the infection would resolve without complications by the review date, but this UTI care plan contained no interventions. Observations on 02/04/26 confirmed that droplet precaution signage and a PPE cart were present outside the resident’s room, and the resident was observed sitting in a wheelchair in her room, pleasantly confused, clean, groomed, and with her call light in reach. Interviews with facility staff further clarified the deficiency. The MDS nurse stated she was responsible for care plans, had been trained on completing them, and that droplet precautions should be care planned; she believed she had care planned droplet precautions for this resident but was not aware they were missing, and she also was not aware that no interventions had been added for the UTI care plan. The DON confirmed that she, the MDS nurse, the ADON, and the care plan nurse were responsible for completing care plans, that staff were regularly in-serviced on following care plans, and that droplet precautions should be part of a resident’s care plan when applicable. She acknowledged that she had care planned the resident for the flu but failed to include droplet precautions, and that she had entered the UTI care plan but had not added interventions. Multiple CNAs and LVNs reported they had been in-serviced on following residents’ care plans, knew where to find them in the electronic record, and relied on them to provide care. The facility’s written policy on comprehensive person-centered care plans required measurable objectives, timeframes, and interventions derived from comprehensive assessment data, and stated that care plans must be revised as residents’ conditions change, which was not fully carried out for this resident’s droplet precautions and UTI. The facility’s own policy, revised in March 2022, specified that the IDT, in conjunction with the resident and representative, must develop and implement a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet physical, psychosocial, and functional needs. It further required that care plan interventions be based on thorough assessment, reflect recognized standards of practice, and be revised as resident conditions change. In this case, despite clear physician orders and observable implementation of droplet precautions at the room level, the omission of droplet precautions from the written care plan and the absence of any documented interventions for the resident’s UTI demonstrated a failure to follow the facility’s own care planning policy and to ensure that all necessary care and services were captured in the comprehensive care plan.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple sanitation and food storage deficiencies observed in the kitchen. Observations revealed that the hand wash sink near the kitchen entrance was out of paper towels, and several food items in the refrigerator were unlabeled and undated, including sandwiches, drinks, and a pitcher of tea. The juice dispenser machine had sticky buildup, and the can opener had black and brown buildup. Additionally, trash cans in the kitchen were found without secured lids, and the microwave was dirty with rust and peeling paint. Further observations highlighted that the kitchen's equipment temperature logs were incomplete, and several food items were improperly stored, unlabeled, and undated. A dented can of mandarin oranges was found in the dry storage area, and various cereals and other food items were not properly labeled or dated. The dish machine was found to have undetectable sanitizer levels, and the ice machine in the nourishment room had mold-like substances. Staff were observed not wearing hair restraints properly, with beard guards not covering facial hair as required by the facility's policy. Interviews with staff and management confirmed the facility's policies on hair restraints, labeling, and dating of food items, and the importance of maintaining proper sanitation practices. However, the observed deficiencies indicate a failure to consistently implement these policies, potentially placing residents at risk of foodborne illness. The facility's expectations for sanitation, labeling, and equipment temperature monitoring were not met, as evidenced by the numerous observations of non-compliance during the survey.
Failure to Follow Posted Menus and Document Substitutions
Penalty
Summary
The facility failed to adhere to the posted cycle menus for two observed lunch services, which could potentially place residents at risk of poor intake and weight loss. On two separate occasions, the meals served did not match the posted menus. On Sunday, the menu listed roast turkey, cheesy squash casserole, crumb-topped Brussels sprouts, fruit cobbler, and a beverage, but the meal served included roast turkey, cubed butternut squash, steamed plain Brussels sprouts, fruit cobbler, and a beverage. Residents reported that the squash was too hard to eat, indicating a deviation from the planned menu. On Tuesday, the posted menu included smothered pork, corn casserole, country green beans with bacon and onion, pineapple upside-down cake, and a beverage. However, the meal served consisted of BBQ pork ribs, creamed corn, black-eyed peas, cornbread, plain pound cake, and a beverage. The facility's dietary manager (DM) acknowledged that menu substitutions were made but were not documented in detail, only noting the number of changes in the QAPI meeting minutes. The DM stated that substitutions were sometimes necessary due to product availability or resident preferences, but a substitution log was not maintained. The facility's policy requires that any meal served that varies from the planned menu should be noted on the posted menu or in a record used for such changes. Additionally, the menus were not printed in a size large enough for residents to read from a reasonable distance. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed expectations that the kitchen staff should follow the menus and inform staff and residents of any changes, offering alternatives of the same nutritive value. The failure to follow the menus as planned could negatively impact residents' nutritional status.
Deficiency in Meal Quality and Presentation
Penalty
Summary
The facility failed to provide meals that were palatable, attractive, and prepared in a manner that conserves nutritive value, flavor, and appearance. Observations and interviews revealed that the kitchen test tray of the lunch meal was unappealing, lacked flavor, and was missing condiments. The dessert, a pound cake, was described as very dry and unappealing, with no garnishment on any of the foods or meal tray. Additionally, a resident on a pureed diet received a meal tray that was unappealing, lacked gravy or sauce, and was served with minimal condiments, leading to complaints about the food being unappetizing and often cold. Two residents complained about the lunch meal served on a specific date, which included cubed butternut squash that was not cooked properly and was too hard to eat. One resident, with a diagnosis of neurocognitive disorder with Lewy bodies, expressed dissatisfaction with the meal, noting that the squash was not soft enough to eat. Another resident, with a history of weight changes and malnutrition related to poor dentation, also reported that the squash was too hard to eat and that the food was frequently served cold. The facility's dietary manager (DM) stated that all food items are to be prepared and presented in an appealing manner and that residents who complain of cold food are provided with a hot warmer plate. However, the DM was unaware of the complaints regarding the hardness of the squash and stated that the cooks taste test the food prior to serving. The facility's food service policy emphasizes the importance of providing a well-balanced, flavorful, visually appealing, and varied food service program, yet the observations and resident interviews indicate a failure to meet these standards.
Failure to Flush Gastric Tube as Ordered
Penalty
Summary
The facility failed to ensure that a resident with a gastric tube received appropriate treatment and services to prevent complications during medication administration. Specifically, the facility did not adhere to the physician's order and facility policy requiring the gastric tube to be flushed with 30 cc of water before and after medication administration. This deficiency was observed during a medication pass for a resident who was fed by enteral means due to conditions including dysphagia and gastrostomy. The resident's care plan and physician's orders clearly indicated the necessity of flushing the tube to prevent clogging, yet this step was omitted by RN-A during the observed medication administration. Interviews with staff, including RN-A, LVN-A, LVN-B, and the DON, confirmed the importance of flushing the gastric tube to prevent clogging, which could necessitate tube replacement. Despite this understanding, RN-A did not perform the pre-flush as required, although a post-medication flush was conducted using the feeding pump. The facility had previously addressed a similar grievance in September 2024, indicating a recurring issue with adherence to the flushing protocol. The failure to follow the prescribed procedure could lead to complications such as tube clogging, potentially requiring an invasive procedure for tube replacement.
Expired Medical Supplies Not Removed from Medication Storage Room
Penalty
Summary
The facility failed to provide adequate pharmaceutical services by not ensuring the removal of expired medication administration supplies from the medication storage room. During an observation, it was found that three IMED Dressing Change Kits had expired nearly a year prior. This oversight was identified in the medication storage room located by the nurse's station. Interviews with staff, including an LVN, the Administrator, and the DON, revealed that the facility's policy required expired medical supplies to be destroyed or given to the DON. However, the responsibility for checking the medication room was not effectively executed, as evidenced by the presence of expired supplies. The staff acknowledged that using expired items could lead to negative outcomes for residents, such as reactions, infections, or reduced efficacy of medications.
Improper Linen Storage in Laundry Area
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in the laundry area, which is crucial for providing a safe and sanitary environment. During an observation, it was noted that clean linens were improperly stored on the designated dirty side of the laundry room. This included a covered shelf with clean blankets and linens near the door used for bringing in dirty laundry, and an open shelf with neatly folded clean linens, gowns, and sheets located within a few feet of used housekeeping carts. This improper storage practice was confirmed by multiple staff members, including the laundry assistant (LA), laundry supervisor (LS), licensed vocational nurse (LVN-B), administrator (ADM), and director of nursing (DON), all of whom acknowledged the importance of separating clean and dirty laundry to prevent cross-contamination. The facility's policy on linen storage, which was undated, stated that all clean linen should be stored in a secured area and that clean and soiled linens should be stored separately. Interviews with staff revealed a lack of awareness and adherence to this policy, as the LA admitted to organizing extra clean linen on the dirty side due to space constraints. The LS, LVN-B, ADM, and DON all emphasized the potential for cross-contamination and the risk of spreading infections if clean and dirty linens are not properly separated. Despite the facility's policy and staff awareness of the risks, the improper storage of clean linens on the dirty side of the laundry room was a clear deficiency in the infection control program.
Verbal Abuse Incident by CNA
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a Certified Nursing Assistant (CNA). The resident, a female with a complex medical history including hepatic encephalopathy, cirrhosis of the liver, end-stage renal disease, and diabetes, was verbally abused by CNA A. The incident occurred when the resident requested assistance to use the toilet, and CNA A responded in a discouraging and assertive manner, questioning the resident's ability to do anything on her own. This interaction was captured on an audio and video recording by the resident's family member, who reported the incident to the facility. The Director of Nursing (DON) confirmed the content of the recording and acknowledged that CNA A's tone was not encouraging. The resident's care plan indicated a need for calm and positive interactions due to her risk for decreased socialization and altered mood related to depression and impaired cognition. Despite this, CNA A's response was not aligned with the care plan's interventions, which included providing positive interaction and validation of feelings. The incident led to the resident feeling upset and calling her family member in distress.
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.
Two residents experienced significant medication administration and documentation failures involving pain management and insulin therapy. One resident with Parkinson’s disease and chronic hip pain did not receive ordered 4% lidocaine patches on multiple occasions despite MAR entries indicating administration, and received inconsistent Tramadol dosing, including unscheduled double doses and missing signatures on the controlled substance log. Another resident with diabetes, hemiplegia, and a G-tube received long-acting Rezvoglar insulin doses well outside the ordered bedtime schedule on several occasions, as confirmed by MAR review and video monitoring, while blood glucose readings fluctuated widely throughout the month. Staff interviews revealed inaccurate documentation, late administration outside the facility’s one-hour medication window, and lack of recognition of timing and dosing errors, contrary to facility policy requiring timely, accurate administration per prescriber orders.
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.
Staff failed to follow infection control practices by placing personal water bottles on medication carts on two halls and by not performing appropriate hand hygiene before resident care. Personal water bottles belonging to a med tech and an LVN were observed on top of separate med carts, despite staff and leadership acknowledging that personal items were not allowed there due to contamination concerns. In a separate incident, a med tech sanitized her hands, picked up keys from the floor, then did not re-sanitize before donning clean gloves and entering a resident’s room to administer medication, even though the resident had a dialysis access and was care-planned for Enhanced Barrier Precautions and staff recognized that hand hygiene was required between dirty and clean tasks.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
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.
Medication Administration Errors and Documentation Irregularities for Pain Management and Insulin Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide accurate pharmaceutical services, including acquiring, receiving, dispensing, and administering medications as ordered, for two residents. One resident with Parkinson’s disease, chronic right hip pain, and severe cognitive impairment had physician orders for Tramadol 50 mg by mouth three times daily, Tramadol 100 mg by mouth three times daily until a specified date, and a 4% lidocaine patch to the right hip once daily for pain. Surveyors observed this resident twice on the same day lying in bed, rubbing her right hip/thigh in a circular motion, shaking her legs, and stating she was “sore,” with no lidocaine patch present on either hip or thigh or in the bedding. The MAR showed that a medication aide documented administration of the lidocaine patch that morning, but in interview the aide admitted she did not have the patches on her cart at the scheduled time, signed that she had given the patch intending to retrieve and apply it later, and then forgot to do so. On the following day, the MAR showed that an RN documented administration of the lidocaine patch, but in interview that RN stated she had not administered any medications to this resident and was not assigned to her; she reported that another nurse had borrowed her computer earlier in the day. Record review of the same resident’s controlled substance log showed multiple irregularities in Tramadol administration over several days. Entries reflected doses of two 50 mg Tramadol tablets being given at various times without signatures identifying the administering staff, missing third daily doses, and inconsistent dosing patterns. On one date, the ADON documented administering two 50 mg tablets at an unknown time, followed by single 50 mg doses at noon and in the evening by other staff. On another date, a medication aide documented administering two 50 mg tablets in the morning and early afternoon, and another aide documented two 50 mg tablets mid-afternoon, resulting in a total of 200 mg of Tramadol within a short time frame. Additional entries showed two 50 mg tablets given in the morning and again at midday on a subsequent date. The DON acknowledged on interview that she had reviewed the controlled substance log and noted incorrect dosages but had not recognized that some administration times were too close together. The second resident involved was an older adult with hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, hypertension, severe cognitive impairment, and a gastrostomy tube in place. This resident had an order for Rezvoglar KwikPen (a long-acting basal insulin) 32 units subcutaneously at bedtime, scheduled at 8:00 p.m. Review of the MAR for March showed that the insulin was repeatedly administered outside the ordered time parameters on six different days, with documented administration times after midnight and late evening rather than at the scheduled hour. Blood sugar logs for the month showed wide fluctuations, with values ranging from 66 mg/dL to 332 mg/dL. Video monitoring from the resident’s room confirmed that on one date the night-shift LVN administered the scheduled 8:00 p.m. insulin dose after midnight. In interview, this LVN stated that bedtime medications, including insulin, were usually given between 7:00 p.m. and 9:00 p.m., that the acceptable window was one hour before or after the scheduled time, and that she believed she had not been late administering the insulin, despite documentation and video evidence to the contrary. The facility’s medication administration policy required medications to be administered safely, timely, and in accordance with prescriber orders, including within one hour of the prescribed time, and required staff to question inappropriate or excessive dosages.
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.
Improper Storage of Personal Items on Med Carts and Lapses in Hand Hygiene
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to improper storage of personal items on medication carts and inadequate hand hygiene practices. On the 200 hall, a medication technician was observed with a personal water bottle placed on top of the medication cart; she acknowledged it was her bottle, that she had brought it out to drink, and that she did not have time to put it away. She further stated that personal water bottles were not allowed on top of the medication cart because of infection control concerns. On the 100 hall, a separate medication cart was observed with another personal water bottle on top. The LVN assigned to pass medications on that hall confirmed the water bottle was hers, explained she was thirsty and needed a drink, and stated that staff were not allowed to have personal items on the medication cart due to infection control concerns. The Administrator, Corporate Nurse, and DON each confirmed that staff were not to have personal items on top of medication carts because of contamination and infection control issues. The report also details a hand hygiene failure involving a resident with identified infection risks. Resident #9 was an elderly male with dementia, severe cognitive impairment (BIMS score of 7), and an active diagnosis of dementia. His care plan documented that he was at risk of infection related to dialysis access and required Enhanced Barrier Precautions during close contact care. Physician orders specified that enhanced barrier precautions and PPE were required for high resident contact care activities, with dialysis access to be monitored every shift. During medication administration for this resident, the same medication technician was observed sanitizing her hands, then picking up her keys from the floor, and failing to sanitize her hands again before donning clean gloves and entering the resident’s room to administer medication. In subsequent interviews, the medication technician, the LVN, and the DON each stated that hand hygiene was required after touching dirty surfaces, between residents, between glove changes, and before donning and after removing gloves, and that failure to perform hand hygiene could spread bacteria or germs and make residents sick. Review of the facility’s Infection Prevention and Control Program policy showed that personnel were required to wash their hands after each direct resident contact as indicated by accepted professional practice, and that infection prevention practices were to be monitored by the infection preventionist through skills competency evaluations such as observation of hand hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
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.
