Avir At Weatherford

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to store, label, and date food properly, and to maintain sanitary conditions in the kitchen, refrigerators, freezers, and pantry. During a kitchen observation, surveyors found a white Styrofoam container with a gray liquid substance in a side-by-side refrigerator with no label or date, and a large Ziplock bag of sliced turkey also without a label, date, or use-by date. In a large side-by-side freezer, there were two plastic bags of yellow sliced bread and three clear bags of small green Brussels sprouts, all lacking labels, dates, or use-by dates, as well as a clear plastic bag of small yellow pancakes with ice crystals and no label or date. In another refrigerator at the front of the kitchen, a plastic container of purple jelly had no label or date and the lid could not be properly sealed. In the pantry, large plastic containers of corn flakes and fruit loop cereal were observed with lids that did not fit properly and could not be sealed. The facility also failed to maintain clean floors, food-contact surfaces, and equipment in the pantry and kitchen. The pantry floor was black and sticky in the middle area, with lighter tiles under the shelves, and the same black substance extended into the hall outside the pantry toward the back door. A liquid substance was observed seeping from under the back of the stove, which felt greasy and appeared cloudy, and there was grease buildup with unknown particles between the stove and fryer. The window sill above the sink had stains and dirt buildup. An industrial toaster had a large amount of toast crust caked on the bars of the top and bottom trays. The back of the stove had burnt stains and was greasy to the touch, and when the stove was pulled out, the stove trap contained a black, crusty substance on old, used tinfoil. A tray holding dishes on a shelf contained crumbs of an unknown source next to clean dishes intended for service. The facility further failed to ensure kitchen staff followed proper hand hygiene, glove use, and hair restraint practices while handling and serving food. One staff member removed gloves and donned a new pair without washing hands, then continued scooping food at the serving table. A Dietary Aide cut plastic wrap off a pumpkin pie, rinsed scissors under the faucet, handled multiple cardboard pie boxes, opened and closed a 55-gallon trash container, and then returned to place glasses on a serving tray without changing gloves or washing hands. The same aide later picked up cups while gloved, rubbed her ear, and pushed her hair back before continuing to handle cups; her hairnet did not fit properly, with a large amount of hair hanging out and several strands extending about three inches on one side, and about two inches of hair exposed across her temple. Another staff member at the holding and serving stations repeatedly handled bread rolls and plates, touched the eating surfaces of plates with fingers and full palm, touched the side of her nose and her sleeve, and continued to handle plates and food items such as broccoli without washing hands or changing gloves. In interviews, staff acknowledged they had been trained on proper sanitation and hand washing, including washing hands between glove changes and not touching food with hands, but stated they forgot, were nervous, or were unaware they needed to wash hands when changing gloves. The Dietary Manager and Administrator both stated that the observed practices, including unlabeled food, lack of cleaning, improper hand hygiene, and touching food, did not meet their expectations and were unacceptable. Record review showed that facility policies required food to be stored in clean, dry, contaminant-free areas, with opened packages placed in plastic containers with tight-fitting covers or sealable bags, and all containers or bags legibly and accurately labeled and dated. Leftovers were to be stored in covered containers, clearly labeled and dated before refrigeration. Policies on cleaning and sanitation required a posted cleaning schedule for all cleaning tasks, with staff initialing tasks as completed and being held accountable for cleaning assignments. The sanitization policy required all kitchens, kitchen areas, and dining areas to be kept clean, and all equipment, food-contact surfaces, and utensils to be cleaned using heat or chemical sanitizing solutions. The hand washing policy required employees to wash hands as frequently as needed, including before food preparation, when entering the kitchen at the start of a shift, after touching bare human body parts other than clean hands and wrists, after handling soiled equipment or utensils, during food preparation as often as necessary to prevent cross-contamination when changing tasks, and before donning disposable gloves for working with food and after gloves are removed. The observed conditions and staff actions did not comply with these written policies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide required written notices regarding Medicare and Medicaid coverage, non-coverage, and potential financial liability to certain residents and/or their representatives. For two residents reviewed for rights, the facility did not obtain signatures on the Notice of Medicare Non-Coverage (NOMNC) forms and did not document that written copies were provided. The facility’s own policy requires that residents be informed in writing when Medicare may not pay for skilled services, of their potential liability, and that a NOMNC be issued at least two calendar days before Medicare Part A or Part B therapy benefits end, including information on the right to an expedited review by a Quality Improvement Organization. For one resident, an older female with metabolic encephalopathy, seizures/convulsions, and spastic quadriplegic cerebral palsy, the NOMNC dated 08/06/2025 showed no resident or representative signature, even though the effective date of Medicare coverage ending was 08/08/2025. A note on the form stated that verbal NOMNC was given to the resident’s POA by phone due to the resident’s cognitive impairment. Her MDS showed a BIMS score of 99, indicating severely impaired cognition, and she was receiving PT, OT, and speech therapy. Her care plan and physician orders documented ongoing PT and OT services for mobility limitations and contractures, and continued therapy orders were in place during the period when the NOMNC should have been properly issued and acknowledged in writing. For another resident, an older male admitted with hyperkalemia, acute respiratory failure with hypoxia, muscle weakness, and encephalopathy, the NOMNC dated 12/31/2025 also lacked any signature. A note indicated verbal notification was given to his son, but there was no documentation that a written copy was provided or signed. His MDS showed a BIMS score of 15, indicating intact cognition, and he was receiving PT, OT, and ST minutes as part of a Medicare Part A skilled stay per physician orders. During interviews, the MDS LPN stated she gave verbal information to both residents’ representatives and said she would leave copies of the forms in the residents’ rooms but did not document that copies were left or picked up. The resident representative for the male resident reported he was called about skilled days ending but never received, saw, or signed any form. The administrator stated the preferred method was written consent and that she expected NOMNCs to be completed and signed by the resident or representative, and acknowledged that the failure could result in residents not being aware of the appeals process or having time to prepare for discharge from therapy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure a resident’s right to be free from physical restraints unless required to treat a medical symptom. A male resident with dementia, malnutrition, anxiety disorder, depression, hypertension, and dysphasia had a pommel cushion placed on his wheelchair. His Quarterly MDS showed use of a wheelchair, no documented use of physical restraints or alarms, and limited behavioral symptoms, including physical behavior toward others on 1–3 days and wandering on 1–3 days. The MDS did not identify the pommel cushion as a restraint, and there was no documentation in the record describing the medical symptoms being treated by the device. Record review showed no signed consent for the pommel cushion and no physician order in the electronic medical record. Nursing progress notes documented that after the pommel cushion was installed, the resident was no longer sliding to the edge of the chair, and that the IDT had met and, due to frequent unsafe attempts to get up and falls, applied a pommel seat to the wheelchair. During observation, the resident was seen seated in a wheelchair at the nurse’s station with a pommel cushion in place. The resident’s representative reported she was told by nursing staff that the pommel was used to keep him from falling out of the wheelchair and that she had not been called or asked to sign a consent before it was placed. Interviews with facility staff and the physician confirmed that the pommel cushion was implemented without prior physician notification, order, or consent. The DON stated the resident fell frequently and that the facility had tried other interventions before resorting to the pommel for safety, and initially did not consider it a restraint, so no consent was obtained, although she acknowledged an order should have been in the chart. The ADON stated she considered the pommel cushion a restraint and that policy required speaking to the physician and obtaining an order before use. The physician stated she was not aware the pommel cushion had been put in place until contacted by the DON, considered it a restraint, and stated the family should have been notified and consent obtained, including information on risks and benefits. The facility’s restraint policy defined physical restraints as devices that the resident cannot remove easily and that restrict freedom of movement, and required documentation of the medical symptoms warranting restraint use, which was not present in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified a deficiency related to medication storage and security when an overflow medication cart (Cart #1) on the south side of the facility was observed unlocked and unattended across from the nurses' station. During the observation, a male resident in a wheelchair was approximately four feet from the unattended cart, which contained blister packs of blood pressure medications, anti-diabetic medications, diuretics, potassium supplements, anti-platelet medications, and blood thinners. The cart was not under the direct supervision of staff at the time it was observed. In an interview, an LVN stated that Cart #1 was new and used to store overflow medications, and acknowledged she was responsible for ensuring the cart was locked when not in use. She reported that she had been called to the secure unit and forgot to lock the cart, and stated that if a resident opened the cart, they could have taken a medication not intended for them and had a negative reaction. In a separate interview, the DON stated that medication carts should be locked when not in use and acknowledged that if a cart was unlocked and unattended, a resident, visitor, or staff member could steal or ingest a medication not meant for them and possibly have an adverse reaction. The DON also stated that nurses were responsible for monitoring medication carts to ensure they were locked, and that she did not have a set routine to monitor the carts. Review of the facility’s Medication Labeling and Storage policy, dated 2001, showed that all medications and biologicals were to be stored in locked compartments, with carts and trays not left unattended if open or otherwise available to others, and that only authorized personnel were to have access to keys.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Failure to provide appropriate peri-care was identified for a female resident with diagnoses including fracture of the left femur, protein-calorie malnutrition, urinary tract infection, history of falling, anxiety disorder, and schizoaffective disorder. Her annual MDS indicated a BIMS score of 05, showing severe cognitive impairment, and her care plan identified bladder incontinence related to dementia. During observation of incontinent care, CNA C was seen wiping the resident from back to front and using the same wipe repeatedly by folding, wiping, and re-wiping the resident with it. During interview, CNA D stated peri-care should be done with one swipe per wipe and that incorrect technique could lead to infections such as UTIs. CNA C stated she had been taught to fold and wipe twice and did not know the facility policy, though she acknowledged that not changing the wipe between strokes could cause infection. The DON stated the facility policy required one wipe, one swipe, no folding, and no reuse of the wipe, and that staff had been trained on peri-care in January 2026. The facility policy also stated female peri-care should be performed front to back with a new wipe used for each stroke.

Penalty

Inspection fine: $22,356

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to protect a cognitively impaired resident from abuse and neglect when a CNA dragged the resident by her ankles down a hallway after the resident refused incontinent care. The resident was an elderly female on the memory care unit with vascular dementia, severe cognitive impairment (BIMS score of 4), anxiety disorder, peripheral vascular disease, osteoarthritis of both knees, and lipodermatosclerosis. Her admission MDS documented bowel and bladder incontinence, wandering, inattention, and disorganized thinking, and indicated she did not resist care or display behavioral symptoms or aggression toward others. Her care plan included mixed bladder incontinence with checks every two hours and an ADL self-performance deficit requiring assistance of one staff for toileting and total assistance with transfers, but it did not specify the number of CNAs required for transfers. The care plan was later updated after the incident to reflect resistance to care and potential physical aggression, and to include approaches such as allowing the resident to make decisions, giving clear explanations, and leaving and returning if she resisted ADLs. On the morning of the incident, CNA A was the only CNA assigned to the memory care unit on the 6:00 a.m. to 2:00 p.m. shift. According to LVN D, around 6:00 a.m. CNA A reported that the resident was “acting up,” was dirty, and refused to be changed. When LVN D went to the unit, she observed the resident sitting in a chair, smelling of feces, while CNA A stood in front of her talking loudly. LVN D stated that CNA A attempted to get the resident up, the resident refused and continued to yell, and CNA A then reached under the resident’s arms to pick her up. The resident grabbed the chair to resist and slid to the floor. LVN D reported that CNA A then grabbed the resident’s ankles and dragged her on the floor down the hall to her room while the resident screamed, yelled, and resisted. LVN D did not intervene, stating she was shocked and afraid that intervening would aggravate the situation because CNA A was very agitated and physically large. CNA B reported that shortly after 5:00 a.m. she asked CNA A for assistance, and that when CNA A entered the unit she began screaming at the resident to get up and gave her a countdown to three. CNA B stated the resident was sitting in a gray chair by the television when CNA A grabbed her, picked her up out of the chair, lowered her to the floor, then grabbed her by the ankles and dragged her from the lobby chair to her room. CNA B stated that she and CNA C only intervened once they reached the room, as directed by LVN D, and that she did not immediately intervene or report the incident herself because she believed LVN D had notified the abuse coordinator/administrator. CNA A, in her interview, claimed the resident threw herself out of the chair, kicked at her, and wrapped her arms around CNA A’s legs, and that she pulled the resident by the legs to her room out of concern for the safety of other residents nearby, while LVN D, CNA B, and CNA C did not assist. Video footage of the event, later reviewed by the administrator, police, and surveyors, showed the resident sitting in a chair in the memory care lobby with six other residents visible. LVN D stood behind the resident and did not intervene while CNA A stood over the resident, pointing and shaking her finger in the resident’s face. The video showed the resident looking up at CNA A and not resisting or striking out. CNA A then grabbed the resident under the arms, jerked her up while the resident held onto the chair arms, causing the resident to fall to the floor. CNA A immediately grabbed the resident’s right leg, then both ankles, and dragged her on her back down the hallway to her room and halfway inside the doorway before the video ended. Throughout the incident, CNA A, CNA B, CNA C, and LVN D were observed standing calmly, and no one intervened to protect the resident. The facility’s abuse, neglect, and misappropriation prevention policy stated that residents have the right to be free from abuse and neglect, including physical abuse and corporal punishment, and emphasized protecting residents from abuse by anyone and maintaining a culture of compassion and caring, particularly for residents with behavioral, cognitive, or emotional problems. The surveyors determined that the facility failed to ensure residents were free from abuse and neglect, resulting in an Immediate Jeopardy situation that began on the date of the incident and was later abated.

Removal Plan

• Conduct a skin assessment for Resident #1 to confirm no open areas or bruising.
• Notify the responsible party, Ombudsman, and Medical Director.
• Notify police.
• Reassign the involved CNA away from resident care pending investigation.
• Suspend the involved CNA pending investigation.
• Conduct skin assessments for all residents in the secured unit.
• Administer a safety survey to interviewable residents in the secured unit.
• Conduct skin assessments for residents unable to answer safety survey questions.
• Provide education to designated educators (managers) on abuse and neglect, de-escalation, aggressive behavior, mental health management, resident rights, and dignity.
• Administer a competency test to designated educators (managers).
• Provide education to all staff on abuse and neglect, de-escalation, aggressive behavior, mental health management, resident rights, and dignity.
• Administer a competency test to all staff.
• Conduct weekly interviews of five staff and five residents for four weeks to ensure allegations of abuse are reported.
• Immediately address and report any concerns identified during interviews to the administrator.
• Have Department Heads or designee conduct the interviews.
• Review progress notes and incident reports during morning clinical meetings to ensure any documented abuse or potential abuse is reported to the administrator/abuse coordinator and to HHSC per regulation.
• Have the weekend supervisor review progress notes and incident reports to ensure any documented abuse or potential abuse is reported to the administrator/abuse coordinator and to HHSC per regulation.
• Hold an ad hoc QAPI meeting with the Medical Director regarding the alleged incident and the facility's plan for compliance with regulations.

Penalty

Inspection fine: $22,356

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement its written abuse-prevention policies and procedures, resulting in a resident being subjected to physical abuse and staff failing to immediately report or intervene. The resident was an elderly female with vascular dementia, severe cognitive impairment (BIMS score of 4), anxiety disorder, peripheral vascular disease, osteoarthritis of both knees, and lipodermatosis. She resided on the memory care unit, was incontinent of bowel and bladder, wandered, showed inattention and disorganized thinking, and required assistance of one staff for toileting and total assistance with transfers. At the time of admission and prior to the incident, her care plan did not identify her as resisting care or being physically aggressive, and it did not specify the number of CNAs required for transfers. On the morning of the incident, multiple staff members described that the resident was sitting in a chair, yelling, and in need of incontinence care. CNA A reported to LVN D that the resident was “acting up,” was dirty, and refused to be changed. According to LVN D and CNA B, CNA A spoke loudly to the resident, attempted to get her up from the chair, and when the resident resisted and slid to the floor, CNA A grabbed the resident by the ankles and dragged her along the floor down the hallway to her room while the resident screamed, yelled, and resisted. CNA B stated that she saw CNA A pick the resident up from the chair, lower her to the floor, then drag her by the ankles from the lobby area to the resident’s room. CNA A herself stated that she pulled the resident by her legs on the floor to the room by her ankles because the resident was kicking and she was concerned about other residents nearby. Despite witnessing the event, staff did not immediately intervene to stop the abusive conduct or promptly report it as required by facility policy. LVN D stated she did not intervene because she was shocked, felt CNA A was very upset, and was concerned about aggravating the situation; she instead instructed CNA C to take over care once they reached the room and told CNA A to leave the unit. CNA B acknowledged that she did not intervene as she had been trained to do and did not notify the abuse coordinator, assuming LVN D would do so. The administrator was not informed until hours after the incident, and she delayed reporting to state and law enforcement while she sought additional information and corporate input, despite the policy requiring immediate reporting of suspected abuse to the administrator and external authorities. The facility also failed to immediately remove the alleged perpetrator from resident contact, allowing CNA A to complete her full shift on the memory care unit the day of the incident and to work another full shift the following day before suspension, contrary to the facility’s policy that any employee accused of abuse be placed on leave with no resident contact until the investigation is complete. The facility’s abuse policy required that suspicions of abuse, neglect, exploitation, or misappropriation be reported immediately to the administrator and to state and other authorities within specified time frames, and that any employee accused of abuse be removed from resident contact pending investigation. In this case, the incident occurred early in the morning, but the administrator was not notified until later that morning, and she did not immediately report the allegation to state and federal authorities or law enforcement. The former DON reported that staff approached her with concerns that the incident was not being handled appropriately and that written statements consistently described the resident being grabbed, dropped to the floor, and dragged by her feet. The DON further stated that when she raised the need to self-report, the administrator told her corporate had instructed not to self-report at that time. The incident was not reported to state authorities until months later, and the police report was filed three days after the event. These actions and inactions demonstrate that the facility did not follow its own abuse-reporting and investigation policies and did not ensure residents were protected from an alleged perpetrator immediately after an allegation of abuse.

Removal Plan

• Conduct a skin assessment for Resident #1.
• Notify the responsible party, Ombudsman, and Medical Director regarding Resident #1.
• Notify police.
• Reassign CNA A off the hallway/unit.
• Suspend CNA A pending investigation.
• Conduct skin assessments for all residents in the secured unit.
• Administer a safety survey to interviewable residents in the secured unit and conduct skin assessments for residents unable to answer.
• Provide education to designated educators/managers on abuse and neglect, de-escalation, aggressive behavior, mental health management, resident rights, and dignity, and complete competency testing.
• Provide education to all staff on abuse and neglect, de-escalation, aggressive behavior, mental health management, resident rights, and dignity, and complete competency testing prior to the next shift.
• Conduct weekly interviews of five staff and five residents for four weeks to ensure allegations of abuse are reported, and immediately address and report concerns to the administrator.
• Review progress notes and incident reports during morning clinical meetings and by the weekend supervisor to ensure any documented or potential abuse is reported to the administrator/abuse coordinator and reported to HHSC per regulation.
• Hold an ad hoc QAPI meeting with the Medical Director regarding the alleged incident and the facility’s compliance plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents received food that was palatable, attractive, and at a safe and appetizing temperature during a lunch meal tested for nutritive value, flavor, and appearance. Observations and interviews revealed that residents complained about the quality and temperature of the food. One resident mentioned that the food was not good and was cold, while another resident on a mechanical diet stated that nothing tasted right. During an observation, a test tray was found to have food items at temperatures below the required standards, with chicken at 126 degrees, beans at 118 degrees, and a hot apple dessert at 82.9 degrees. The Dietary Manager (DM) acknowledged that the temperatures were not warm enough to sustain palatability and suggested that the failure could have been due to improper stirring and serving methods. The DM also noted that the cook might not have seasoned the sauce properly, affecting the taste. The Administrator (ADMN) admitted to not being able to answer how unpalatable food could have affected the residents and mentioned that the plate warmer might not have been working correctly. The facility's policies on test trays and food holding service were reviewed, indicating that hot foods should be served at 135 F or greater and cold foods at 41 F or less.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety, as observed during a survey. The kitchen staff did not properly label and date open items in the freezer, refrigerator, and dry food storage areas. This included various food items such as blended oil, marshmallows, potato chips, mashed potatoes, seasoning, hamburger buns, bread, and several other items in both refrigerators and freezers. Some items were also found to be expired, which could potentially lead to foodborne illnesses and cross-contamination among residents. Additionally, the kitchen staff did not follow proper hand hygiene protocols during meal preparations. Observations revealed that the dish washer and another staff member did not use soap or scrub their hands for the required time to ensure proper sanitization. This lack of adherence to hand hygiene practices increases the risk of transmitting bacteria and causing cross-contamination, which is particularly concerning for residents with low immune systems. Interviews with the facility's administration and dietary manager (DM) highlighted a lack of oversight and monitoring of kitchen staff. The administrator acknowledged the need for increased in-service training for new staff and emphasized the importance of labeling and dating all products. The DM admitted that the failure was due to staff being in a hurry and not following established protocols, which could lead to cross-contamination and foodborne illnesses. The facility's policies on food storage, preparation, and hand washing were not being followed, contributing to the deficiencies observed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents' drug regimens were free from unnecessary drugs, specifically for two residents who were administered psychotropic medications without appropriate oversight. Resident #61 was prescribed Valium PRN for anxiety, but the order did not include an end date after 14 days, as required. The medication was administered multiple times over a two-week period without reevaluation or a physician's rationale for continuation beyond the 14-day limit. This oversight was noted despite pharmacy recommendations for a 14-day stop date, which the physician acknowledged but did not act upon appropriately. Resident #76 was administered Seroquel for unspecified dementia without behavioral or psychotic disturbances, which is not an appropriate indication for the use of antipsychotic medication. The resident's records did not support the use of Seroquel, as there were no documented behavioral symptoms or psychotic disturbances that would justify its administration. The facility's ADON and DON acknowledged that the diagnosis did not warrant the use of an antipsychotic and that they were responsible for ensuring appropriate diagnoses for prescribed psychotropic medications. The facility's policy on medication management emphasizes the need for appropriate diagnoses and gradual dose reductions for psychotropic medications. However, the facility did not adhere to these guidelines, resulting in the administration of unnecessary medications to residents. This failure placed residents at risk for overmedication and potential adverse effects, as noted by the ADON and DON during interviews.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the lack of adherence to Enhanced Barrier Precautions (EBP) for residents with medical devices or wounds. Specifically, an agency Licensed Vocational Nurse (LVN) did not don a gown while administering medications via a gastrostomy tube to a resident, despite being aware of the EBP guidelines. The resident's room lacked signage indicating the need for EBP, and the LVN admitted to not receiving information about residents requiring such precautions. Another resident with a stage 4 pressure ulcer was not provided with EBP during personal care, as the resident's Power of Attorney (POA) refused the use of PPE, believing it upset the resident. The facility's staff were not adequately informed about the necessity of EBP, as evidenced by a Certified Nursing Assistant (CNA) who was unaware of the meaning of EBP and relied on color-coded tabs outside residents' rooms to determine PPE requirements. This lack of understanding and communication led to the improper use of PPE, increasing the risk of cross-contamination and infection. A third resident with an indwelling catheter also did not receive EBP, as the resident expressed discomfort with staff wearing gowns. The Director of Nursing (DON) confirmed that residents or their responsible parties could decline EBP, and the facility's policy allowed for such refusals. However, this practice contradicts the facility's infection control policy, which mandates EBP for residents with wounds or indwelling medical devices. The facility's failure to consistently implement EBP and educate staff on its importance compromised the safety and well-being of its residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's right to formulate an advance directive was honored, specifically for a resident who was admitted with a Do Not Resuscitate (DNR) status. The resident, an elderly female with a diagnosis of traumatic subdural hemorrhage, did not have a completed Out of Hospital Do Not Resuscitate (OOH-DNR) consent form in her electronic chart or admission paperwork. Despite having a physician's order for DNR, there was no evidence of the required documentation, including a representative and physician signature, in the resident's records. Interviews with facility staff revealed a lack of follow-up and documentation regarding the resident's DNR status. The social worker admitted to sending the DNR paperwork to the resident's representative via email but did not receive a response or follow up adequately. The Director of Nursing (DON) acknowledged that the resident should not have been considered DNR without the proper consent form in the facility. The DON also noted that the absence of a signed consent could lead to the resident not receiving CPR if needed, potentially resulting in the resident's death. Further interviews with nursing staff indicated confusion and inconsistency in verifying the resident's DNR status. Staff members relied on the face sheet, hard copy charts, and electronic records to determine code status, but acknowledged that a signed DNR consent was necessary to confirm the resident's wishes. The facility's policy on advance directives emphasized the importance of recognizing and implementing residents' rights to make medical decisions, but the lack of proper documentation and follow-up in this case led to a deficiency in honoring the resident's advance directive rights.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that drugs and biologicals were secured and stored according to accepted professional principles. On November 13, 2024, a treatment cart was observed in the 300 hallway, unlocked and unattended, with a resident nearby and no nurse present. The cart contained various medicated items, including medicated dressings, antiseptic ointments, and other potentially harmful substances. The Treatment Nurse admitted to leaving the cart unlocked while she was three rooms away, acknowledging the risk of residents accessing the cart's contents. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the expectation was for the treatment cart to be locked when not in use or within sight of the responsible nurse. Both the ADON and DON emphasized the responsibility of the nurse in charge of the cart to ensure it was secured. The facility's policy on medication storage, dated December 2018, mandates that medication carts be locked or attended by authorized personnel, highlighting a breach in protocol that could lead to resident harm.