Avir At Weatherford
Inspection history, citations, penalties and survey trends for this long-term care facility in Weatherford, Texas.
- Location
- 521 W 7th St, Weatherford, Texas 76086
- CMS Provider Number
- 455574
- Inspections on file
- 31
- Latest survey
- February 12, 2026
- Citations (last 12 mo.)
- 12 (2 serious)
Citation history
Health deficiencies cited at Avir At Weatherford during CMS and state inspections, most recent first.
Surveyors identified multiple failures in dietary services, including unlabeled and undated food items in refrigerators and freezers, improperly sealed dry cereal containers, and dirty pantry and kitchen areas with greasy, stained equipment and floors. Food-contact surfaces and equipment, such as a stove, toaster, and dish storage areas, had visible buildup of grease, crumbs, and debris. Kitchen staff repeatedly failed to follow hand hygiene and glove-use protocols, handling trash, touching hair, face, and other surfaces, and then handling clean dishes and ready-to-serve food without washing hands or changing gloves. Hairnets were not used effectively, with exposed hair observed while staff handled food and dishes. These practices did not comply with the facility’s own policies on food storage, cleaning and sanitation, sanitization, and hand washing.
The facility failed to provide and document required written Medicare non-coverage notices and financial liability information for two residents receiving skilled PT, OT, and ST services. In both cases, NOMNC forms lacked signatures from the residents or their representatives, and there was no clear documentation that paper copies were given, despite facility policy requiring written notice of non-coverage, potential liability, and appeal rights. An LPN reported giving verbal notifications by phone and stating that copies would be left in residents’ rooms, but this was not documented, and a family representative stated he never received or signed any form. The administrator confirmed that written consent was the preferred method 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.
A resident with dementia and multiple comorbidities had a pommel cushion placed on his wheelchair to address frequent falls and sliding, but the facility did not obtain a physician order, document the medical symptoms being treated, or secure consent from the resident’s representative. The MDS did not reflect use of a restraint, and there was no restraint consent in the record. The resident’s representative reported she was told by staff that the pommel was used to keep him from falling out of the wheelchair and that she had not been notified beforehand. The DON initially did not consider the pommel a restraint, while the ADON and the physician stated it was a restraint and that policy required prior physician involvement and informed consent, in contrast to the facility’s written restraint policy.
Surveyors found an overflow medication cart unlocked and unattended across from the nurses' station, with a male resident in a wheelchair approximately four feet away. The cart contained multiple medications, including antihypertensives, anti-diabetic agents, diuretics, potassium supplements, anti-platelet drugs, and anticoagulants. An LVN reported she was responsible for locking the new overflow cart but forgot after being called to the secure unit, and acknowledged that a resident could have taken medications not intended for them. The DON stated that carts were required to be locked when not in use, that nurses were responsible for monitoring this, and that there was no set routine for monitoring medication carts, despite a written policy requiring all medication compartments to be locked and not left unattended if open.
A resident with severe cognitive impairment, incontinence, and multiple comorbidities was sitting in a common-area chair when a CNA, who was the only CNA assigned to the memory care unit on that shift, loudly demanded the resident get up for incontinent care. According to staff interviews and confirmed by video, the CNA lifted the resident under the arms, causing the resident to fall to the floor, then grabbed the resident by the ankles and dragged her on her back down the hallway to her room while the resident screamed. An LVN and two CNAs were present, observed the incident, and did not intervene until the resident reached her room, despite facility policy stating residents have the right to be free from abuse and neglect. Surveyors determined this failure to protect the resident from physical abuse and to intervene constituted Immediate Jeopardy.
A resident with severe cognitive impairment and multiple comorbidities was physically abused when a CNA dragged her by the ankles along the floor from a chair in a common area to her room while she screamed and resisted. Several staff, including CNAs and an LVN, witnessed the incident but did not immediately intervene to stop the abuse or promptly report it to the abuse coordinator as required by facility policy. The administrator was notified hours later, delayed reporting the allegation to state authorities and law enforcement while seeking additional information and corporate input, and did not immediately remove the CNA from resident contact, allowing the CNA to work full shifts on two consecutive days after the incident. These failures show that the facility did not implement its abuse-prevention and reporting policies and did not promptly protect residents from an alleged perpetrator.
The facility failed to provide residents with food that was palatable and at the correct temperature, as evidenced by resident complaints and a test tray showing food items below required temperatures. The Dietary Manager acknowledged issues with food preparation and serving methods, while the Administrator noted potential equipment failure.
The facility failed to properly label and date food items in storage, leading to potential foodborne illness risks. Additionally, kitchen staff did not adhere to proper hand hygiene protocols, increasing the risk of cross-contamination. The administration and dietary manager acknowledged the lack of oversight and the need for improved staff training.
Two residents were administered psychotropic medications without appropriate oversight. One resident received Valium PRN for anxiety without a 14-day stop date, and another was given Seroquel for unspecified dementia without behavioral disturbances, which is not an appropriate indication. The facility's ADON and DON acknowledged the lack of appropriate diagnoses for these medications.
A LTC facility failed to implement Enhanced Barrier Precautions (EBP) for residents with medical devices or wounds, leading to potential cross-contamination and infection risks. An LVN did not wear a gown while administering medications via a gastrostomy tube, and a CNA was unaware of EBP requirements, relying on color-coded tabs for PPE guidance. Additionally, residents or their responsible parties were allowed to decline EBP, contradicting the facility's infection control policy.
A facility failed to ensure a resident's advance directive rights were honored, as a resident admitted with a DNR status lacked a completed OOH-DNR consent form in her records. Despite a physician's order for DNR, there was no documentation of the required signatures. Staff interviews revealed inadequate follow-up and documentation, leading to confusion about the resident's code status. The facility's policy emphasized the importance of recognizing residents' rights, but the lack of proper documentation resulted in a deficiency.
A treatment cart was left unlocked and unattended in a hallway with a resident nearby, containing various medicated items. The Treatment Nurse admitted to not securing the cart, and both the ADON and DON confirmed the expectation for carts to be locked when not in use. This breach in protocol could lead to resident harm.
Widespread Kitchen Sanitation, Food Storage, and Hand Hygiene Failures in Dietary Services
Penalty
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.
Failure to Provide and Document Written Medicare Non-Coverage Notices and Financial Liability Information
Penalty
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.
Failure to Obtain Order and Consent for Pommel Cushion Used as Restraint
Penalty
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.
Unlocked Overflow Medication Cart Left Unattended Near Resident
Penalty
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.
Resident dragged by CNA while staff fail to intervene to prevent abuse
Penalty
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.
Failure to Protect Resident From Abuse and to Immediately Report and Remove Alleged Perpetrator
Penalty
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.
Deficiency in Food Temperature and Palatability
Penalty
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.
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
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.
Inappropriate Use of Psychotropic Medications
Penalty
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.
Inadequate Infection Control Practices in LTC Facility
Penalty
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.
Failure to Ensure Resident's Advance Directive Rights
Penalty
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.
Failure to Secure Treatment Cart
Penalty
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.
Latest citations in Texas
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe cognitive impairment and multiple pressure injuries received twice-daily wound care without a corresponding pain care plan or documented pain assessments, despite having a PRN acetaminophen order. During an observed wound care attempt, the resident winced, cried out, and showed facial expressions consistent with pain when repositioned, while staff were unsure of her primary language, whether she had been assessed or medicated for pain, or even what pain medications were ordered. CNAs and the treatment nurse noted foul odor and colored drainage from the wounds and that the resident felt warm, but the LVN initially reported no indication of pain or need for vital signs and only checked a temperature after surveyor prompting, without performing a clear pain assessment. The wound care NP later reported the resident had increased necrotic tissue, odor, and frequent combative behavior during prior treatments that had not been considered as possible pain responses, and the resident’s representative stated they were unaware of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain medication while video showed wound care being attempted without it.
Surveyors found three mechanical lifts repeatedly parked unlocked and unsecured in a hallway adjacent to the 300 Hall, where they were stored and charged when not in use. An RN and a CNA assigned to the hall both stated they were unaware the lifts were unsecured, despite prior in‑service training on lift safety and storage, and each could not recall when that training last occurred. The DON confirmed that all lifts were expected to be locked when not in use, acknowledged unawareness of the unsecured lifts over several days, and stated that while staff had been educated on lift safety, there was no facility policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing mechanical lift policy lacked such content.
Surveyors found multiple food safety and storage deficiencies in the kitchen, including an unsealed bag of meat, sauce containers with dried drippings on the handle and rim, a container of overripe bananas with black peels, and uncovered whole eggs in an unlabeled, undated bowl. Temperature logs for reach-in refrigerators and a freezer were missing required PM shift temperature checks and staff signatures. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions did not follow facility policies requiring open food to be securely covered, labeled, dated, properly cleaned, and monitored with completed temperature logs.
A resident with lymphedema and multiple comorbidities had physician orders for bilateral lower extremity ace wraps each morning with removal in the evening, along with edema checks every shift. On the survey day, the resident was observed in a wheelchair without leg wraps, while the MAR showed the morning treatment as completed. The resident reported his legs were supposed to be wrapped daily and that they had not been wrapped for about a week, and he described inconsistent staff response to his call light. The charge nurse admitted it was not normal practice to document treatment before completion and stated the resident usually received wraps after a shower, which had not yet occurred. CNAs gave conflicting accounts about how consistently the wraps were applied, and leadership confirmed expectations that treatments be performed per orders and documented only after completion, in line with the facility’s documentation policy prohibiting false entries.
Surveyors found that the facility failed to provide pressure ulcer care consistent with professional standards for three residents. One resident with hemiplegia and vascular dementia had a sacral wound that was omitted from the care plan and repeatedly left off weekly skin assessments, while heel wounds were documented without consistent measurements or staging and ordered treatments were not always recorded as given. A second resident with multiple comorbidities developed a sacral wound that progressed from MASD to an unstageable and then Stage 4 pressure injury with surgical debridement, yet the care plan was not updated to reflect the active pressure ulcer and specific interventions, and weekly skin assessments often lacked complete staging and measurements. A third resident with dementia and incontinence had an unstageable sacral ulcer and MASD, but weekly skin assessments were inconsistent, some ordered wound treatments and topical medications were not documented on the TAR, and nursing notes did not show that care was provided on those dates. Staff interviews revealed that the treatment nurse handled nearly all weekly skin assessments and wound care documentation, relied on the DON or wound physician for staging and measurements, and that facility policies requiring complete wound assessment and documentation were not consistently followed.
The facility failed to ensure call lights were accessible for four residents who were identified as fall risks and required assistance with ADLs or had significant mobility or cognitive impairments. Observations found residents lying in bed with call lights placed at the head of the bed, on the floor, on a roommate’s bed, or on a nightstand, all out of reach, despite care plan interventions requiring call lights to be kept within reach. A CNA, an LVN, and the DON each confirmed that all staff are responsible for keeping call bells within residents’ reach and acknowledged that inaccessible call bells could lead to accidents, falls, avoidable injuries, delayed care, and unmet needs, contrary to the facility’s written call light policy.
Surveyors found that multiple resident rooms and two halls were not maintained in a clean and sanitary condition. Bathrooms in several rooms had brown or gray stains in corners and around toilets, and some showers and room floors had dark or built-up dirt along edges, near closets, and by beds and walls. Air conditioning vents and filters in several rooms were observed with black grime or thick dust. Handrails on two halls had debris, including tissue with a red-brown substance, candy wrappers, gum, plastic, and paper wedged between the rails. Sharps containers in several rooms had used gloves and trash placed on top. The Administrator and housekeeping staff confirmed that housekeeping was responsible for cleaning rooms, bathrooms, floors, handrails, and air conditioning units, and staff acknowledged that the observed conditions were a health hazard and could cause infection.
The facility failed to follow its own infection control practices and physician orders for three residents requiring respiratory care. A resident with COPD had a nasal cannula and nebulizer mask connected to equipment that were not bagged or dated when not in use, despite orders for weekly changes. Another resident with asthma had an unbagged, undated nasal cannula and an oxygen humidifier bottle that was partially full, cracked, and dated from a prior week. A third resident with COPD had both nasal cannula and nebulizer mask unbagged and undated, despite orders for weekly equipment changes and monitoring of pulse, O2 sat, treatment time, and lung sounds. Staff, including a CNA, an LVN, and the DON, acknowledged that equipment should always be bagged, dated, and changed per schedule to prevent infection, consistent with the facility’s infection prevention and control policy.
Surveyors found that staff failed to administer multiple residents’ scheduled medications within the facility’s one-hour administration window, despite active orders for numerous drugs treating conditions such as DM, HTN, CHF, dementia, seizures, and hypothyroidism. During a morning med pass, a med tech had not completed 8:00 a.m. and 9:00 a.m. medications by late morning, and staff interviews confirmed that medications were required to be given within a defined time range. In addition, staff did not consistently check BP before dispensing medications with BP parameters, did not keep a milk-based Med Pass nutritional supplement refrigerated or on ice as required by manufacturer directions and facility protocol, and failed to date most insulin vials when opened, contrary to facility policy. These actions and inactions showed that pharmaceutical services, including accurate dispensing, administration, and storage of medications and biologicals, were not provided as required for the residents reviewed.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Manage Pain During Wound Care for a Nonverbal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide safe, appropriate pain management consistent with professional standards of practice and the resident’s needs during wound care. A female resident with severe cognitive impairment (BIMS score of 00) was admitted with multiple pressure-related skin conditions, including a left heel deep tissue injury (DTI), right heel DTI, an unstageable sacral pressure injury, a left heel ulcer, a right bunion DTI, and other bruising/discoloration. Her MDS Care Area Assessment did not trigger for pain and no care planning decision for pain was documented. The resident’s care plan contained detailed entries for her multiple wounds but did not include any care plan for pain, despite the presence of significant pressure injuries and ongoing wound care orders. Record review showed the resident had an active PRN order for acetaminophen 500 mg every 6 hours as needed for pain and an order for Doxycycline for the sacral wound, as well as twice-daily wound care orders for the unstageable sacral pressure injury. The MAR for the month showed that no acetaminophen had been administered since early in the month, even though wound care was being performed twice daily. During an observed attempt to perform wound care, the resident was dependent for mobility and required staff to roll and reposition her. When staff attempted to roll her for treatment, she winced, cried out "Oh my God" in Spanish, and displayed furrowed eyebrows and facial expressions consistent with pain. CNAs assisting with care noted that she appeared to be lying on the wound, that her wounds often drained, and that there was a foul odor and visible brownish-green drainage on her brief and positioning towels. Despite these signs, the treatment nurse could not confirm whether the resident had been assessed for pain or medicated prior to the procedure and was unsure of the resident’s primary language. During this same encounter, the resident was noted by the surveyor and CNAs to feel warm to the touch, and her wounds and dressings showed green, brown, or red drainage. The treatment nurse and CNAs acknowledged the resident felt warm, but the charge nurse (LVN) initially stated there was no indication the resident was in pain or needed vital signs assessed and only checked the resident’s temperature after being prompted by the surveyor. The LVN reported a normal temperature using a contactless thermometer, was unsure if the resident had any pain medication orders, and did not initially perform a direct pain assessment. Subsequent interviews revealed that the wound care NP had observed increased necrotic tissue and odor in the sacral wound the prior week and that the resident had been frequently combative, refusing wound care by kicking and biting, but this behavior had not been considered as a possible reaction to pain. CNAs later described the resident’s facial expressions and reactions during repositioning as indicating pain, while the LVN reported feeling pressured and nervous during the surveyor’s questioning and could not clearly describe having assessed the resident for pain during her shift. The resident’s responsible party stated they had not been informed of wound odor, infection concerns, or antibiotic orders and believed the resident was receiving pain and fever medications, later expressing shock upon reviewing video that showed wound care being attempted without medication. The facility’s own pain assessment and management policy stated that residents should be assessed for pain at admission and ongoing, monitored for pain with changes in condition, and that procedures such as moving or wound care can cause pain. It also directed that pain management interventions be consistent with the resident’s goals and documented in the care plan, and that underlying causes of pain, including skin/wound conditions like pressure ulcers, be addressed. In this case, the resident with multiple pressure injuries and ongoing wound care had no pain care plan, no documented pain assessment using appropriate tools for severe dementia, and no administration of ordered PRN pain medication in the weeks preceding the observed event, despite clear non-verbal signs of pain during wound care attempts. These actions and omissions led surveyors to determine that the facility failed to ensure pain was assessed and treated prior to wound care, resulting in the resident crying out and exhibiting pain behaviors when touched or moved.
Removal Plan
- Amend treatment orders to require pain evaluation prior to treatments and medication if indicated upon re-admission.
- Provide additional 1:1 education to CNA A, CNA B, LVN A, and the facility treatment nurse specific to issues identified in the preliminary fact analysis.
- Nursing leadership (DON/designees) to conduct facility rounds on all residents to ensure no unreported or undocumented changes in pain levels; audit all wound care orders to ensure pain management orders are present as indicated.
- Complete house-wide pain assessments; communicate any reported pain to the charge nurse for medication administration if indicated and complete follow-up assessment to ensure effectiveness.
- Re-educate licensed nurses on change in condition, pain assessment and management, administering pain medications, and the pain-clinical protocol (including identifying situations where increased pain may be anticipated such as wound care, ambulation, repositioning, and reviewing the critical element pathway for pain recognition and management).
- Re-educate all non-licensed nursing staff on recognizing change in condition/status including changes in pain levels and proper reporting using STOP AND WATCH Alert in PCC/point-of-care documentation and/or direct communication to the charge nurse; re-educate staff not working prior to their next scheduled shift.
- Educate the Facility Administrator and DON by the Divisional President of Operations on standards of care, pain management, and quality oversight.
- Validate staff education via completion of a quiz and acknowledgement covering recognition of changes in condition, proper notification procedures, and pain assessment and management.
- Review and validate the pain assessment and management policy to ensure alignment with regulatory requirements (no changes required).
- Implement monitoring: change in condition/pain assessment audits (review 24-hour summary report and nurse progress notes; ensure changes are reported to the provider and documented; ensure pain assessments are completed prior to treatments); review audit results in IDT/QAPI meetings and address issues immediately, including provider communication.
Unsecured Mechanical Lifts Left Unlocked in Resident Hallway
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment as free of accident hazards as possible in the hallway adjacent to the 300 Hall, specifically related to unsecured mechanical lifts. Surveyors repeatedly observed three mechanical lifts parked in this hallway that were unlocked and unsecured on multiple occasions over three consecutive days at various times. These observations showed that the lifts remained in an unsecured state while not in use, in an area used for storing and charging them. During interviews, an RN assigned to the 300 Hall stated she was unaware that the three mechanical lifts parked in the adjacent hallway were unlocked and unsecured, despite being stationed at the nearby nurses’ station. She reported having received in‑service training on mechanical lift safety and storage but could not recall when the training occurred. The RN acknowledged that mechanical lifts were supposed to be locked when not in use and confirmed that the three lifts observed were the only ones she used for residents and that they were stored in that hallway to be charged when not in use. She also stated that she typically did not check the parked lifts to verify they were locked and secured. A CNA assigned to the same hall similarly reported being unaware that the three mechanical lifts were unlocked and unsecured, despite also having received in‑service training on mechanical lift safety and storage and being unable to recall when that training last occurred. The DON stated she was unaware that the three lifts had been left unlocked and unsecured over the three days of observation and confirmed her expectation that all mechanical lifts be locked when not in use. The DON stated that all staff had been educated on proper mechanical lift usage and safety but could not recall when the last in‑service training occurred. The DON and Administrator both reported that the facility did not have a policy addressing accidents and hazards related to mechanical lift safety and storage, and the existing “Total Mechanical Lift” policy did not contain information on accidents and hazards related to lift safety and storage.
Food Storage, Labeling, and Temperature Monitoring Deficiencies in Kitchen
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the main kitchen. During an observation of the walk-in refrigerator, they found a zip-top bag containing meat slices that was not fully sealed and exposed to air. They also observed one gallon container of sauce with black drippings on the handle and one jar of sauce with yellow, dried drippings around the rim. A container held approximately ten overripe whole bananas with black peels, and three whole eggs were left uncovered and exposed to air in an unlabeled and undated bowl. Additionally, temperature logs for two reach-in refrigerators and one reach-in freezer were missing the PM shift temperature checks and signatures for a specific date. In interviews, dietary staff, the Dietary Manager, and the Administrator confirmed that these conditions were inconsistent with facility policies and expected practices. Dietary staff stated that temperature logs were to be completed at the start and end of each shift by cooks and dietary aides, and that the Dietary Manager was responsible for ensuring completion. They explained that eggs should be returned to their original container or stored sealed, labeled, and dated; overripe bananas should be discarded; zip-top bags should be fully sealed; and jars and gallon containers should be wiped down after each use. The Dietary Manager and Administrator reiterated that all open food must be securely covered, labeled, and dated, and that fruits and vegetables showing visible damage or rot should be discarded, consistent with written facility policies on food storage and dietary food service personnel responsibilities.
Failure to Follow Physician Orders for Lymphedema Leg Wraps and Accurate Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for one resident with lymphedema. The resident was an adult male with multiple diagnoses including cardiac arrhythmia, musculoskeletal symptoms, osteitis deformans of multiple sites, eye and adnexa disorder, lymphedema, major depressive disorder, prostate disorder, chronic pain, hypokalemia, COPD, muscle weakness, lack of coordination, epilepsy with complex partial seizures, unsteadiness on feet, and other gait and mobility abnormalities. His Quarterly MDS showed a BIMS score of 15, indicating intact cognition, and he was dependent for toileting hygiene, showering/bathing, and personal hygiene. Physician orders on the March MAR included ace wraps to both lower extremities every morning and removal every evening, along with edema checks every shift. On the survey date, record review of the March MAR showed that the charge nurse had documented completion of the resident’s morning leg wrap treatment, but when the surveyor reviewed the resident at 11:21 a.m., he was observed sitting in his wheelchair with his legs not wrapped. At 11:50 a.m., the MAR still reflected that the treatment was completed, despite the wraps not being in place. The resident reported he had severe leg swelling due to lymphedema and stated his legs were supposed to be wrapped daily, but the last time they had been wrapped was about a week prior. He stated that whether his call light requests for treatment were answered depended on who responded, and that staff sometimes did not return to complete his care, which made him feel bad. In interviews, Charge Nurse A acknowledged that it was not normal nursing practice to document treatment before completion and stated that the resident normally received leg wraps after his shower, but that morning the resident had not yet had a shower. CNAs provided differing accounts: one CNA stated the wraps were always on during bed baths but did not bathe the resident that day; another CNA stated that sometimes the resident’s legs were wrapped and sometimes not, that his legs were not wrapped that day, and that she had given him a bed bath that morning; a third CNA stated she had never seen his legs unwrapped. The NP explained that the purpose of the wraps was to enhance circulation due to lymphedema. The DON confirmed the resident had bilateral leg wrap orders in the morning and removal in the evening, and that she was informed around midday that his legs were not wrapped. The Administrator stated she knew the resident’s legs were wrapped but did not know why, and both the DON and Administrator stated that documentation of treatment should occur after the treatment is performed, consistent with the facility’s documentation policy, which prohibits false information in the medical record.
Failure to Accurately Assess, Care Plan, and Treat Pressure Ulcers for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards, including accurate assessment, staging, measurement, care planning, and implementation of ordered treatments for multiple residents with pressure injuries. For one resident with hemiplegia, vascular dementia, incontinence, low body weight, and an admission Braden score indicating risk, the facility did not consistently identify and document all existing wounds. Her care plan listed only a left heel pressure wound and omitted a sacral wound. Weekly skin assessments from late January through March repeatedly failed to document the sacral wound after its initial identification, and heel wounds were inconsistently documented without required measurements or staging. On several dates, the weekly skin assessment was left blank or lacked measurements, despite physician documentation that the left heel wound progressed from Stage 3 to Stage 4 with increasing size. The treatment administration record (TAR) also showed missing documentation of ordered wound treatments to the sacrum and left heel on multiple dates, with no corresponding nursing notes indicating that care was provided. A second resident with hemiplegia, vascular dementia, diabetes, malnutrition, peripheral vascular disease, incontinence, and significant weight loss was identified as at risk for pressure ulcers but initially had no documented pressure wounds. Her care plan, last updated the previous year, addressed only potential for pressure ulcer development and other skin integrity risks, and did not reflect a current sacral pressure wound. However, physician orders and TAR entries showed daily treatment to a sacral wound, and weekly skin assessments documented a sacral wound beginning in mid-February. These assessments frequently lacked staging and, at times, lacked complete measurements. Over several weeks, documentation showed the sacral wound increasing in size and evolving from MASD to an unstageable wound and then to a Stage 4 pressure injury requiring surgical debridement of devitalized tissue, including subcutaneous tissue, muscle fascia, and tendon. Despite this progression and ongoing wound physician involvement, the resident’s care plan was not updated to reflect the current pressure injury and specific wound care interventions. A third resident with dementia, Alzheimer’s disease, muscle weakness, incontinence, and an initially non-risk Braden score that later declined to moderate risk had an unstageable sacral pressure ulcer present on admission and MASD. Her care plan included potential for pressure ulcer development, an unstageable sacral pressure ulcer related to immobility, and a wound infection requiring oral antibiotics. Physician orders directed weekly skin assessments and specific daily and evening wound treatments to the sacral area. However, the March TAR showed multiple dates where ordered sacral wound treatments and topical medication for left upper buttock redness were not documented as given, and nursing progress notes did not show that wound care was provided on those dates. Weekly skin assessments for this resident were inconsistent, with several assessments in early January documented as refused or limited, alternating between noting arm discoloration and no skin issues, and later assessments intermittently omitting the sacral wound or lacking measurements and staging. Wound physician notes documented an unstageable sacral pressure injury with rapid clinical decline and later a Stage 3 pressure injury that had increased in size, but these changes were not consistently mirrored in the facility’s weekly skin assessment documentation. Interviews with nursing staff and leadership further described systemic issues contributing to the deficiency. The treatment nurse stated she could not stage wounds and relied on the DON or wound physician for staging, and that she was responsible for updating care plans when new pressure injuries were identified, though she was unsure of the required timeframe. She also reported that she performed nearly all weekly skin assessments for approximately 96 residents Monday through Thursday, with no assessments scheduled on Fridays unless there was a new admission, and that wound measurements were typically taken only when the wound physician visited, after which she transferred his measurements into the weekly skin assessments. The DON and ADON indicated that the treatment nurse was responsible for all wound care planning, weekly skin assessments, and ensuring documentation, and acknowledged that missing or inconsistent wound measurements and documentation on weekly skin assessments would prevent the facility from determining whether wounds were improving or worsening. Facility policies required full assessment and documentation of pressure ulcers, including location, stage, length, width, depth, exudate, and necrotic tissue, as well as complete wound care documentation, but the records for these three residents showed repeated omissions and inconsistencies in assessment, staging, measurement, care planning, and documentation of ordered treatments.
Failure to Ensure Accessible Call Lights for Multiple Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to reasonably accommodate resident needs and preferences by not ensuring that call lights were accessible to four residents reviewed. For one male resident with a skull fracture, a baseline MDS showing he was a fall risk and unable to complete the BIMS interview, and a care plan indicating he required assistance with ADLs, observation showed he was lying in bed with his call light positioned at the head of the bed, out of his reach. A second male resident, with diagnoses including need for assistance with personal care, stroke, and dysphagia, and a quarterly MDS indicating he was unable to complete the BIMS interview, had a care plan intervention specifying that his call light should be within reach; however, observation found him lying in bed with his call light on the floor, out of reach. A third resident, a female with lack of coordination, unsteadiness on her feet, repeated falls, and severe cognitive impairment (BIMS score of 1), had a care plan intervention to ensure her call light was within reach, yet she was observed lying in bed with her call light placed on her roommate’s bed. A fourth male resident with right-sided paralysis, intact cognition (BIMS 14), and a care plan identifying him as a fall risk with an intervention to keep his call light within reach, was observed lying in bed with his call light on the nightstand, out of reach. During interviews, a CNA, an LVN, and the DON each stated that call bells should always be within residents’ reach and that all staff are responsible for ensuring this, and acknowledged that lack of accessible call bells could result in accidents, falls, avoidable injuries, delayed care, and unmet needs. The facility’s written policy on call lights required staff to place the call device within the resident’s reach before leaving the room.
Failure to Maintain Clean Resident Rooms and Hallway Handrails
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide a safe, clean, comfortable, and homelike environment, as required by the facility’s Resident Rights policy. During observations on the 300 and 400 halls, surveyors noted that handrails contained debris, including a piece of tissue with a red and brownish substance on the 300 hall and candy wrappers, gum, clear plastic materials, and large pieces of paper wedged between the rails on the 400 hall. Multiple resident rooms on these halls were found with unclean and unsanitary conditions. Several bathrooms had brownish or grayish stains in the corners of the floors and around toilets, as well as dark stains along floor edges, in corners, and in showers. Room floors showed built-up dirt near closet doors, door frames, and along floor edges, with brownish or dark stains near beds and walls. Additional observations revealed that air conditioning unit vents and filters in several rooms had black grime or thick dust accumulation. In multiple rooms, sharps containers used for needle disposal had used, dirty or disposable gloves and pieces of trash placed on top of them. During interviews, the Administrator stated that housekeeping services were provided seven days a week, with cleaning in the morning and evening, and that housekeeping was expected to thoroughly clean resident rooms and facility areas. A housekeeper assigned to the 300 and 400 halls confirmed responsibility for cleaning entire rooms, bathrooms, floors, and wiping down handrails, stating that handrails were wiped at least once a week and acknowledging that the observed conditions were a health hazard. The Housekeeping Supervisor confirmed that housekeeping and floor technicians were responsible for cleaning hallways, floors, handrails, entire rooms, bathrooms, and air conditioning units, and acknowledged that not thoroughly cleaning rooms and handrails could cause an infection.
Improper Storage and Maintenance of Oxygen and Nebulizer Equipment
Penalty
Summary
Surveyors identified that the facility failed to provide respiratory care consistent with professional standards, physician orders, and the infection prevention and control program for three residents receiving oxygen and nebulizer treatments. For a male resident with COPD, record review showed physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly on night shift every Saturday. However, observation revealed that his nasal cannula connected to the oxygen concentrator and his nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. For a female resident with asthma, physician orders directed weekly changes of tubing, filter cleaning, and O2 water bottle changes, but observation showed her nasal cannula connected to the oxygen concentrator was not bagged or labeled, and an oxygen humidifier bottle left on the nightstand was only one-quarter full, cracked, and dated from an earlier date. A female resident with COPD had physician orders to change tubing, clean filters, and change the O2 water bottle and nebulizer kit weekly, as well as orders to obtain and record pulse, O2 saturation, treatment minutes, and lung sounds in relation to nebulizer treatments. Observation found that her nasal cannula connected to the oxygen concentrator and nebulizer mask connected to the nebulizer machine were not bagged or labeled with a date when not in use. Staff interviews with a CNA, an LVN, and the DON confirmed that facility practice and expectations were for oxygen tubing and nebulizer masks to be bagged and dated when not in use, with bags changed weekly or as needed, and for humidifier bottles to be changed regularly. The DON stated that failure to follow these practices could be an infection control issue leading to serious health consequences. The facility’s written Infection Prevention and Control Program policy emphasized decreasing infection risk, recognizing infection control practices during care, and ensuring compliance with infection control regulations, which was not followed in these observed instances.
Medication Administration, Monitoring, and Storage Failures During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications and biologicals for all 10 residents reviewed for pharmacy services. Record reviews showed that multiple residents had active physician orders for medications to treat conditions such as Type 2 diabetes, dementia, end-stage renal disease, hypertension, heart failure, schizophrenia, bipolar disorder, hypothyroidism, seizures, neuropathy, and pain. These medications included antihypertensives (such as amlodipine, hydralazine, metoprolol, benazepril, nifedipine), anticoagulants (Eliquis), antidiabetics (metformin, insulin), antipsychotics (olanzapine, quetiapine), anticonvulsants (levetiracetam), thyroid replacement (levothyroxine), heart failure medications (furosemide, carvedilol, isosorbide dinitrate), and others such as gabapentin, baclofen, galantamine, and lidocaine patches. During observation of a morning medication pass, surveyors noted that Med Tech F had not finished passing morning medications on two hallways between 10:15 a.m. and 11:14 a.m., even though those medications were scheduled for 8:00 a.m. and 9:00 a.m. This meant that residents’ medications were administered more than one hour after their scheduled administration times, contrary to the facility’s stated one-hour before or after administration window. Interviews with Med Tech F, LVN A, and the DON confirmed that facility practice and policy required medications to be given at the ordered times within that window to maintain effectiveness and comply with physician orders. The facility also failed to follow required procedures related to medication parameters and storage. Med Tech F and LVN A stated that medications with blood pressure check parameters required a blood pressure reading before dispensing the medication into a cup, but the report states the facility failed to check one resident’s blood pressure before dispensing medication. Additionally, observations and interviews revealed that the Med Pass liquid nutritional supplement, described as milk-based, was not kept refrigerated or on ice during medication administration, despite manufacturer directions and facility protocol requiring it to be refrigerated or kept on ice. Further, review of insulin storage on three halls showed that 12 of 14 insulin vials were not dated with the date of first use, even though LVN A, LVN B, and the DON stated that facility policy required insulin vials to be dated when opened and discarded after a specified period (generally 28–30 days). These failures placed residents at risk for receiving medications outside ordered time frames and using insulin vials without a known open date. Facility policy and procedure for medication administration (Policy Number 7C) required that medications be administered as prescribed by the resident’s physician, in accordance with written orders and the resident’s service plan, and that routine medications be administered per facility time ranges unless otherwise specified. The policy also required that medications be recorded on the MAR, that resident identification be verified prior to administration, and that medications be administered according to the dosage schedule on the MAR. Staff interviews confirmed awareness of these requirements, including the need to date insulin vials upon opening and to maintain proper storage conditions for nutritional supplements. Despite this, the observed late medication administration, failure to check blood pressure before dispensing certain medications, failure to keep Med Pass on ice or refrigerated, and failure to date insulin vials demonstrated noncompliance with the facility’s own medication administration and pharmaceutical services procedures for the residents reviewed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
