Avir At Weston
Inspection history, citations, penalties and survey trends for this long-term care facility in Temple, Texas.
- Location
- 2505 S 37th St, Temple, Texas 76504
- CMS Provider Number
- 675797
- Inspections on file
- 41
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Avir At Weston during CMS and state inspections, most recent first.
A resident with severe protein-calorie malnutrition, dysphagia, and other comorbidities had a standing physician order for nighttime PEG tube feeding with Nutren 2.0 at 65 ml/hr over 10 hours, along with a mechanically altered diet. On one night, the ordered tube feeding was not administered by the night-shift LVN, who later stated she was confused about the timing of the feeding and did not verify the order. The DON confirmed the feeding was missed and that the order should have been followed, and documentation showed the NP was notified the next morning that the tube feeding had not been provided.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A resident with a seizure disorder and complex medical history did not receive two scheduled doses of Lacosamide after readmission, due to medication order entry errors and lack of medication availability. The missed doses led to seizure-like activity and hospital admission for acute respiratory failure and encephalopathy. Staff interviews and record reviews confirmed failures in medication administration and communication processes.
Three residents who required assistance with ADLs did not receive adequate oral or nail care. One resident with quadriplegia and complex medical needs was observed with poor oral hygiene and reported not having his teeth brushed for a month, while two other residents had excessively long, unclean fingernails despite care plans specifying regular nail care. Staff interviews confirmed that these care tasks were the responsibility of CNAs, but observations indicated they were not performed as required.
Surveyors found that food items in the kitchen cooler were not consistently labeled or dated, with some items past their recommended use-by dates and others missing labels entirely. Staff interviews confirmed that all kitchen staff were responsible for ensuring proper labeling and dating, and that failure to do so could result in expired or incorrect food being served. The facility's food storage policy and the FDA Food Code were not followed, leading to this deficiency.
The facility did not maintain accurate documentation of controlled drug counts at shift changes, with multiple instances of missing signatures and incomplete narcotic count sheets across several halls and shifts. Staff interviews confirmed the expectation for narcotic counts and signatures at each shift change, but the process was not consistently followed or included in new employee orientation, contrary to facility policy.
A resident with complex medical needs was not given scheduled anticonvulsant, antipsychotic, antidepressant, and pain medications before leaving for a painful offsite procedure. The nurse responsible did not adjust the medication schedule or consult with clinical leadership, resulting in the resident experiencing increased pain and distress after the appointment.
An LVN failed to disinfect a blood pressure cuff between use on two cognitively intact residents with hypertension, despite facility policy and available supplies. The LVN, unfamiliar with the supply locations, did not sanitize the equipment before, between, or after use, resulting in a breach of infection control protocols.
A resident with significant cognitive and physical impairments did not have PASRR Level II recommendations incorporated into their assessment and care plan, and the facility failed to submit required NFSS forms for PT, OT, SLP, and a customized wheelchair within the mandated 20 business days after the IDT meeting, as confirmed by staff interviews and record review.
A resident's narcotic medications, including Oxycodone and Tramadol, were misappropriated due to inadequate medication management and security protocols. The medications were delivered and signed for by an RN but went missing after being improperly stored in the medication room. Staff interviews revealed confusion and lack of communication regarding the handling and storage of the medications, leading to their disappearance.
Two residents in an LTC facility did not receive necessary wound care, leading to the worsening of their pressure ulcers. One resident's Stage 3 ulcer progressed to Stage 4 due to missed treatments and delayed wound doctor consultation. Another resident did not receive prescribed wound vac changes, and their care plan was outdated. Staff interviews revealed inadequate training and documentation practices, contributing to the deficiencies.
A facility failed to provide effective pain management for a resident with a recent above-the-knee amputation, leading to an Immediate Jeopardy finding. Despite having a care plan, the facility did not adjust pain medication or notify the NP, resulting in persistent severe pain. The resident's pain levels were inconsistently documented, and a Buprenorphine patch was not applied as ordered. The resident's representative reported insufficient pain relief, and the resident required a procedure for an infection at the amputation site.
The facility failed to develop baseline care plans within 48 hours of admission for three residents, including a male with no documented diagnoses, a female with altered mental status, and another female with multiple diagnoses. Staff interviews revealed confusion over responsibility for completing these plans, which are crucial for understanding residents' needs. The facility's policy requires these plans to be developed within 48 hours, but this was not followed, potentially compromising care.
The facility failed to administer medications as ordered for two residents, leading to missed doses of critical medications. A resident with chronic conditions did not receive several prescribed medications, while another resident missed doses of Atorvastatin, Latanoprost, and Levothyroxine. Staff interviews revealed expectations for proper medication administration and documentation, but these were not consistently followed. The facility's policy lacked guidance on medication administration, contributing to the deficiency.
The facility failed to document nursing notes in the EMRs of three residents for several days post-admission, lacking admission MDS assessments and baseline care plans. Interviews with staff, including an LVN, DON, and ADM, confirmed that this deficiency could lead to errors in care, as it hindered communication and awareness of residents' conditions.
The facility failed to maintain an effective infection prevention and control program, resulting in inadequate PPE use during high-contact care for residents with medical devices or wounds. Staff did not consistently wear gowns and gloves, and there was a lack of signage indicating PPE requirements. Additionally, staff were not adequately trained on Enhanced Barrier Precautions, contributing to potential infection risks.
The facility failed to develop comprehensive care plans for two residents, omitting necessary interventions for a stage 4 pressure ulcer and other medical needs. One resident's care plan lacked instructions for NPWT, while another's did not address ADL status, catheter use, and CPAP. Staff interviews revealed confusion over care plan responsibilities, contributing to these deficiencies.
The facility failed to maintain proper nail care and hygiene for three residents, leading to long, dirty, and jagged fingernails despite care plans indicating the need for assistance. Interviews with staff revealed inadequate monitoring and execution of nail care responsibilities, and the facility lacked a specific policy addressing this aspect of resident hygiene.
The facility failed to secure medication carts and properly store medications, as observed with two unlocked and unattended medication carts near the nurses' station. An unopened bag containing medication bottles was also improperly stored on a treatment cart. Interviews with the RN and DON confirmed awareness of the storage requirements, but the facility did not adhere to its policy, allowing unauthorized access to medications.
The facility failed to ensure that four residents were free from physical restraints, specifically wheelchair seat belts, without proper documentation or assessment. The residents, with conditions like cerebral palsy and quadriplegia, used seat belts perceived as safety devices. However, the facility lacked a restraint policy, and there were no consents or assessments for the seat belts, leading to a deficiency.
A facility reported a medication error rate of 6.72%, exceeding the acceptable threshold, due to two errors involving two residents. One resident did not receive Vitamin D 100 mg, and another did not receive Terazosin 1 mg, as the medications were unavailable during administration. The MA responsible did not restock the cart due to being off for two days and running behind schedule. The DON confirmed the expectation for medications to be administered as ordered and reported if unavailable.
The facility failed to ensure a resident's drug regimen was free from unnecessary medications and did not monitor for side effects or effectiveness of prescribed psychotropic medications, despite recommendations from the pharmacist and facility policy.
The facility failed to post daily nurse staffing data, including total numbers and actual hours worked by RNs, LPNs, and CNAs, for several days. The CNA Scheduler, responsible for posting, did not work over the weekend and was unaware of the requirement to post actual hours. The DON acknowledged the oversight, attributing it to a missed update over the weekend, with no immediate negative outcomes reported.
Failure to Follow Physician Order for Nighttime Enteral Feeding
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for enteral nutrition for a resident with significant nutritional and medical needs. The resident had diagnoses including unspecified severe protein-calorie malnutrition, dysphagia, gastritis, cerebral palsy, vitamin D deficiency, and iron deficiency, and required extensive assistance with ADLs. The care plan included a feeding tube and mechanically altered diet, with a physician order for Nutren 2.0 at 65 ml/hr continuously for 10 hours from 8 p.m. to 6 a.m., providing specified calories, protein, and free water, with no end date to the order. Despite this standing order, the resident’s nighttime tube feeding was not administered during the 8 p.m. to 6 a.m. shift on 01/27/2026. The missed feeding was confirmed through record review and staff interviews. A progress note documented that the NP was notified the following morning that the tube feeding had not been done by the night shift nurse. The DON stated that the night nurse did not give the ordered feeding and acknowledged that the nurse should have followed the physician’s order. In an interview, the LVN responsible for the night shift admitted she did not follow the physician’s order and failed to provide the tube feeding, explaining she was confused and thought the feeding was to be done during the day shift and that she should have double-checked the order. The facility’s enteral nutrition policy stated that adequate nutritional support through enteral nutrition is to be provided as ordered, but this was not followed in this instance, resulting in the resident missing the prescribed nighttime tube feeding.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Significant Medication Error Due to Missed Anticonvulsant Doses
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, seizures, and nontraumatic intracerebral hemorrhage was not administered two consecutive doses of a prescribed anticonvulsant medication, Lacosamide, following readmission to the facility. The resident's medication administration records showed missed doses on two occasions, and interviews with nursing staff revealed that the medication was not available on hand and that there was a discrepancy between the ordered tablet form and the available liquid form. The agency nurse entered incorrect medication administration times, and the issue was not resolved in time to administer the missed doses. Following the missed doses, the resident exhibited seizure-like activity, including facial twitching and head turning, which prompted notification of the nurse practitioner and subsequent transfer to the emergency department. Hospital records indicated the resident was admitted for acute hypercapnic and hypoxemic respiratory failure, acute metabolic encephalopathy, and seizure disorder. The medical director confirmed that the missed doses of Lacosamide could have contributed to the resident's seizure activity. Record reviews and staff interviews confirmed that the medication error resulted from failures in medication order entry, communication regarding medication availability, and timely notification of providers. The facility's policy required that medications be administered as prescribed and that staff be properly oriented to the medication distribution system, but these procedures were not followed, leading to the significant medication error.
Failure to Provide Adequate Oral and Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. Specifically, one resident with quadriplegia and multiple complex medical conditions, including dysphagia and cerebral palsy, was not provided with adequate oral care. Observations over several days revealed the resident had bad breath, dry lips, and a thick white film on his teeth. The resident reported that his teeth had not been brushed in a month and denied refusing oral care. Staff interviews confirmed that the resident required total assistance and that oral care was the responsibility of the CNAs assigned to his hall. Two other residents, both with intact cognition and requiring assistance with personal hygiene, were not provided with adequate nail care. Observations showed that their fingernails were more than half an inch past the fingertips, jagged, and had dark debris underneath. Both residents expressed dissatisfaction with the condition of their nails and stated they wanted them trimmed. Despite care plans indicating that nail care should be performed on bath days and as needed, there was no evidence that nail care was provided during the survey period. Staff interviews confirmed that CNAs were responsible for providing nail care, except for diabetic residents, and that nail care was typically performed on shower days. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene. However, the observed lack of oral and nail care for these residents demonstrated a failure to follow care plans and facility policy.
Failure to Properly Label and Date Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, label, and date food items in accordance with professional standards and the facility's own food storage policy. During an inspection of the kitchen cooler, several food items were found either not labeled, not dated, or past their recommended use-by dates. Specifically, hamburger patties, mayonnaise, juice, tortillas, and tomato soup were either missing labels or had dates indicating they were expired. Staff interviews confirmed that all kitchen staff were responsible for labeling and dating food, and that there was a posted list in the cooler specifying how long items could be stored. Staff also acknowledged that serving out-of-date food could result in residents being served expired or incorrect food items. Record review of the facility's food storage policy indicated that all food should be covered, labeled with the name, date stored, and date to be used or discarded, with a recommended use-by date of three days after preparation or purchase. The FDA Food Code was also referenced as applicable to these failures. The facility's failure to consistently label and date food items in the kitchen could result in expired food being served to residents, as confirmed by staff and administrative interviews.
Failure to Maintain Accurate Narcotic Count Documentation at Shift Changes
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically, the facility did not establish or maintain a system of record for the receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation at each shift change. Record reviews revealed missing documentation on the Change of Shift Narcotic Count Sheets for multiple halls and shifts, with several instances where both on-coming and off-going staff did not sign or complete the required narcotic counts. Interviews with certified medication aides (CMAs) and the Assistant Director of Nursing (ADON) confirmed that it was the facility's expectation for both off-going and on-coming staff to count narcotic medications and sign the count sheets at each shift change. The Regional Director of Clinical Services acknowledged that the narcotic count process was not consistently included in new employee orientation. Review of the facility's contracted pharmacy policy indicated that a system must be in place to record the receipt, usage, and disposition of all controlled substances in sufficient detail for accurate reconciliation, which was not followed as evidenced by the missing documentation.
Failure to Administer Scheduled Medications Prior to Offsite Procedure
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including epilepsy, major depressive disorder, quadriplegia, and chronic pain, was not administered his prescribed and scheduled medications prior to leaving the facility for a post-surgical appointment. The resident was nonverbal, received medications via PEG tube, and had a care plan that required timely administration of medications for seizure control, pain management, and behavioral health. On the morning of the appointment, the nurse responsible did not administer the resident's scheduled 9:00am medications, including CarBAMazepine, Keppra, RisperDAL, Venlafaxine, and HYDROcodone-Acetaminophen, marking them as 'Out on Appointment' in the MAR. The nurse stated that the resident left the facility at 7:45am, which was outside the standard medication administration window, and therefore the medications were not given. She also indicated unfamiliarity with the specifics of the appointment and did not consult with the nurse practitioner or physician about adjusting the medication schedule. As a result, the resident underwent a painful procedure without having received his scheduled pain and other essential medications. Upon return, the resident exhibited signs of distress, agitation, and pain, which were not present prior to leaving for the appointment. Interviews with facility staff and the resident's family member confirmed that the resident was calm before leaving but became agitated and in pain after the procedure, with the family member noting the absence of mood and pain medications. The nurse practitioner and assistant director of nursing both acknowledged that the resident should have received his medications before leaving for the appointment, and the facility's policies required anticipation and management of pain and administration of medications as ordered. The failure to administer scheduled medications prior to the appointment constituted a deficiency in providing pharmaceutical services to meet the resident's needs.
Failure to Disinfect Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of an LVN who did not disinfect a blood pressure cuff between use on two residents. Observations showed that the LVN, who was an agency nurse filling in for an absent medication aide, did not sanitize the blood pressure cuff before, between, or after checking the blood pressure of two residents. The LVN acknowledged awareness of the need to disinfect equipment between residents but stated she was unfamiliar with the location of sanitizing supplies on the medication cart and did not ask for assistance before beginning her medication pass. Both residents involved were cognitively intact and had medical histories including hypertension, with care plans requiring regular blood pressure monitoring. The facility's policy, revised in September 2022, required that reusable resident-care equipment be cleaned and disinfected between residents according to CDC recommendations. Interviews with facility leadership confirmed that supplies were available and that the expectation for disinfection was clearly outlined in policy, but the LVN did not follow these procedures during her shift.
Failure to Timely Submit PASRR Specialized Services Requests
Penalty
Summary
The facility failed to incorporate PASRR Level II recommendations into the assessment and care planning process for a resident with multiple diagnoses, including cerebral palsy, epilepsy, intellectual disabilities, and dysphagia. Despite the resident being identified as PASRR positive and requiring specialized services such as PT, OT, SLP, and a customized wheelchair, the facility did not submit the Nursing Facility Specialized Services (NFSS) forms for these services within the required 20 business days following the interdisciplinary team (IDT) meeting. The MDS Coordinator acknowledged that the NFSS forms were not accepted multiple times and that attempts were made to resolve the issue, but the forms were still not submitted on time. Interviews with facility staff and the PASRR Program Specialist confirmed that the required forms were not sent within the mandated timeframe, regardless of the resident's hospitalization and readmission. Observations showed the resident in a high-back wheelchair and unresponsive to verbal interaction. The facility's own PASRR policy required initiation of specialized service requests within 20 business days of the IDT meeting, but this was not followed, resulting in a failure to ensure timely access to needed care and services for the resident.
Misappropriation of Narcotic Medications
Penalty
Summary
The facility failed to ensure the resident's right to be free from misappropriation of property, specifically involving the diversion of narcotic medications. The incident involved a resident who was cognitively intact and had a history of chronic pain conditions, including Sciatica and Chronic Pain Syndrome. The resident was prescribed Oxycodone and Tramadol for pain management. On a specific date, the pharmacy delivered these medications to the facility, and they were signed as received by an RN. However, the medications were reported missing four days later, indicating a failure in the facility's medication management and security protocols. The investigation revealed that the medications were initially received by an agency RN who placed them in a narcotics box until the day shift arrived. The RN handed off the medications to an LVN and a CMA, who were unsure of the resident's current location within the facility. The medications were then placed in the medication room for returns, as advised by the staff present. However, the medications were not properly secured or accounted for, leading to their disappearance. Interviews with various staff members, including LVNs and CMAs, highlighted a lack of clarity and communication regarding the handling and storage of the medications, contributing to the misappropriation. The facility's policy on controlled substances required that medications be counted upon delivery and signed for by both the receiving nurse and the delivery person. This procedure was not followed, as evidenced by the missing medications and the lack of accountability among the staff. The facility's administration acknowledged the oversight and indicated that all nurses had access to the medication room during the period in question, further complicating the investigation into the missing medications. The incident underscores a significant lapse in the facility's medication management practices, resulting in the misappropriation of narcotic medications intended for a resident's pain management.
Failure to Provide Adequate Wound Care
Penalty
Summary
The facility failed to provide necessary wound care treatment and services to two residents, leading to the worsening of their pressure ulcers. Resident #9, who was admitted with no pressure injuries, developed a Stage 3 pressure ulcer on the right buttock, which was not treated as ordered on multiple occasions. The wound care was not documented on several dates, and the resident's condition deteriorated to a Stage 4 ulcer with infection. The resident was not seen by the wound doctor until two weeks after the initial referral, and the new wound care orders were not implemented until a week after the doctor's visit. Resident #1, who had a Stage 4 pressure ulcer, also did not receive the prescribed wound vac dressing changes on two occasions. The resident's care plan was not updated to reflect the current wound vac settings, and the wound clinic physician noted that the wound vac was changed less frequently than ordered. Interviews with staff revealed a lack of training and documentation regarding wound care procedures, contributing to the deficiencies in care. The facility's documentation policy requires all treatments and changes in resident conditions to be recorded, but this was not consistently followed. Staff interviews indicated that wound care was not always performed as ordered, and there was confusion about the implementation of new orders. The facility's failure to adhere to professional standards of practice for wound care placed residents at risk of worsening conditions and potential complications.
Removal Plan
- Facility had wound physician complete rounds on resident who have consented. All other wound treatments not referred or consented to wound care physician will be directed by primary care until otherwise directed by primary physician. Nurse Consultant and Director of Clinical Services have conducted an audit to ensure all wounds identified have a current treatment in place.
- Nurse Consultant and Director of Clinical Services provided in-service education to all nursing staff regarding following physician ordered wound care and documentation of wound care.
- All nursing staff will be provided with in-service following physician ordered wound care and documentation of wound care, including new hires, PRN, Vacation, Agency and Leave of Absence staff.
- Identify any new wounds through orders, weekly skin assessments and admission assessments review completed during clinical morning meeting will be referred to primary care physician and wound care physician if ordered by primary care physician.
- Wound care physician will be notified via telephone by DON or designee when wound care consultation is ordered.
- AD HOC QAPI meeting conducted to discuss plan of correction for compliance.
- Medical Director notified of alleged deficient practice.
Failure in Pain Management for Resident with Amputation
Penalty
Summary
The facility failed to provide effective pain management for a resident who had a recent above-the-knee amputation and was experiencing excruciating pain. Despite having a care plan in place that required monitoring and notifying the physician if pain interventions were unsuccessful, the facility did not adjust the resident's pain medication or notify her nurse practitioner. The resident's medical records showed inconsistent administration of prescribed pain medications, including Hydrocodone-Acetaminophen and a Buprenorphine patch, which was only applied once despite being ordered for weekly use. The resident's pain levels were documented as high, with some instances marked as ineffective or unknown in terms of pain relief. Additionally, there was a lack of documentation regarding the resident's pain during peri care, despite reports from CNAs that the resident was in significant pain and that the nurse was aware of the situation. The resident's nurse practitioner stated that she was not informed of the unmanaged pain and emphasized the importance of following the Buprenorphine patch orders. The resident's representative reported that the pain medication was insufficient and that the resident's severe pain persisted throughout her stay at the facility. The resident eventually required a procedure to address an infection at the amputation site, which contributed to her pain. The facility's failure to manage the resident's pain effectively resulted in an Immediate Jeopardy finding, indicating a serious risk to the resident's health and quality of life.
Removal Plan
- Regional Director of Clinical Services and Nurse Consultant began a review of residents charts for pain assessment orders.
- DON began inservice education for all nurses regarding pain assessments for all resident to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by regimen in place and how to conduct a pain assessment properly. Nursing Administration will complete a second pain assessment on 5 residents to ensure proper assessment of resident pain and level of nurse proficiency.
- All licensed nursing staff will be provided with in-service education on regarding pain assessments for all resident to include acute pain or significant changes in levels of chronic pain and when to notify the physician regarding pain not being managed by current regimen, including new hires, PRN, Vacation, Agency and Leave of Absence staff.
- Confirm that pain assessment order was placed on the resident chart for all new admissions, readmissions or new complaints.
- Review all residents currently identified for increased or change in pain during WE CARE clinical meeting to confirm ongoing interventions and physician notification.
- AD HOC QAPI meeting conducted to discuss plan of correction for compliance.
- Medical Director notified of alleged deficient practice.
Failure to Develop Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop baseline care plans within 48 hours of admission for three residents, which is a requirement to ensure effective and person-centered care. Resident #6, a male with no documented diagnoses, Resident #7, a female with altered mental status, and Resident #8, a female with multiple diagnoses including hypotension, repeated falls, dementia, and acute respiratory failure, all lacked completed admission MDS assessments and baseline care plans. This oversight was identified during a review of their electronic medical records. Interviews with facility staff revealed a lack of clarity and execution regarding the responsibility for completing baseline care plans. LVN A admitted to conducting resident assessments but not baseline care plans, highlighting the importance of these plans in understanding residents' needs, such as transfer assistance and medical equipment requirements. The DON and ADM both acknowledged that admitting nurses and charge nurses were responsible for completing these plans, which should include essential information like code status, medications, and skin issues. The facility's policy, revised in March 2022, mandates that a baseline care plan be developed within 48 hours of admission, but this was not adhered to, potentially compromising resident care.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of two residents, resulting in missed medication administrations. Resident #10, a female with multiple diagnoses including chronic respiratory failure and heart disease, did not receive several medications as ordered by her physician. These medications included Calcium, Fluorometholone Ophthalmic Suspension, Lidoderm Patch, Valacyclovir, Carvedilol, Revatio, and Levothyroxine. The missed doses were documented in the January 2025 Medication Administration Record (MAR), indicating specific dates when the medications were not administered. Resident #11, who had diagnoses such as malnutrition and osteoporosis, also experienced missed medication administrations. The December 2024 MAR showed that Atorvastatin, Latanoprost Ophthalmic Solution, and Levothyroxine were not given as prescribed. Interviews with staff, including the Assistant Director of Nursing (ADON) and the MDS Nurse, revealed expectations for medication administration and documentation, but these were not consistently met. The facility's policy on medication orders did not address the administration or documentation of medications, contributing to the deficiency. Observations and interviews with Resident #10 indicated that she was unsure if she was receiving all her medications as prescribed. The ADON and other staff members acknowledged the importance of administering medications as ordered and documenting them accurately. However, the facility's failure to adhere to these practices resulted in the potential for adverse effects on the residents' health. The absence of a comprehensive policy on medication administration further exacerbated the issue, as highlighted by the lack of documentation and communication regarding missed doses.
Deficiency in Medical Record Documentation
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for three residents, leading to a deficiency in maintaining proper records. Specifically, the facility did not document nursing notes in the electronic medical records (EMR) of three residents for multiple days following their admission. This lack of documentation included the absence of an admission Minimum Data Set (MDS) assessment and a baseline care plan for each resident. The residents involved were an elderly male with no documented diagnoses, an elderly female with a diagnosis of altered mental status, and another elderly female with multiple diagnoses including hypotension, repeated falls, dementia, and acute respiratory failure. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), the Director of Nursing (DON), and the Administrator (ADM), revealed that the facility's policy required daily skilled notes in residents' EMRs, with a minimum of every 24 hours for Medicare residents. The staff acknowledged that the absence of documentation could lead to errors in care and treatment, as it would prevent nurses from knowing the residents' status and potentially result in missed care. The facility's Charting and Documentation Policy emphasized the importance of documenting all services provided, progress toward care plan goals, and any changes in the residents' conditions to facilitate communication among the interdisciplinary team.
Inadequate Infection Control and PPE Use in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, which resulted in inadequate protection against the transmission of communicable diseases and infections for several residents. Specifically, the facility did not ensure that personal protective equipment (PPE) was worn during high-contact resident care activities for residents with medical devices or wounds. Observations revealed that staff did not wear appropriate PPE, such as gowns and gloves, when providing care to residents with indwelling catheters, wound vacs, and other medical devices. Additionally, the facility did not have proper signage on resident doors to indicate the need for PPE during high-contact care. This lack of signage contributed to the staff's failure to adhere to Enhanced Barrier Precautions (EBP), which are critical for preventing the spread of infections. Interviews with staff and residents confirmed that PPE was not consistently used, and there were no isolation carts or PPE caddies available in the facility. The facility also failed to provide adequate education and training to staff on infection control procedures related to EBP. Interviews with various staff members, including the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), revealed a lack of awareness and training on EBP. The facility's infection control policy and guidelines were not effectively implemented, leading to potential risks of infection for residents with wounds and medical devices.
Incomplete Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to meet their medical and nursing needs. For one resident, the care plan did not include necessary interventions for Negative Pressure Wound Therapy (NPWT) to treat a stage 4 pressure ulcer. This resident, a female with a history of chronic pain, neuromuscular dysfunction of the bladder, paraplegia, and type 2 diabetes, was observed with a functioning wound vac machine at her bedside, but her care plan lacked specific instructions for the care and maintenance of the NPWT. Another resident's care plan was incomplete, failing to address her Activities of Daily Living (ADL) status, indwelling urinary catheter, stage 4 pressure ulcer, communication deficit, and CPAP usage. This resident, who had a history of aphasia, cerebrovascular accident, and chronic lung disease, was observed with a urinary catheter and tube feeding formula at her bedside. Despite these needs, her care plan did not reflect the necessary interventions to address her medical conditions and support her care. Interviews with facility staff revealed a lack of clarity and responsibility regarding the development and maintenance of care plans. The MDS Nurse, who was responsible for care plans, was on vacation, and the social worker, who scheduled care plan meetings, did not initiate nursing care plans. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) expressed expectations for comprehensive care plans but acknowledged gaps in their completion. The facility's policy required comprehensive care plans to be developed within a specific timeframe and to include measurable objectives, but these requirements were not met for the residents in question.
Failure in Resident Nail Care and Hygiene
Penalty
Summary
The facility failed to provide necessary services for maintaining good nutrition, grooming, and personal and oral hygiene for three residents, specifically in the area of nail care. Residents were observed with long, dirty, and jagged fingernails, which were not addressed despite their care plans indicating the need for assistance with personal hygiene. Resident #1, a male with severe cognitive impairment, had fingernails that were an inch past the nail bed, discolored, and with a brown substance underneath. Resident #2, a female with intact cognition but requiring extensive assistance, had nails extending more than half an inch past the nail bed with similar debris. Resident #3, a female with major depressive disorder, also had unkempt nails with a dark substance underneath. Interviews with staff, including a CNA and the DON, revealed that nail care was supposed to be a shared responsibility among staff, but it was not being adequately monitored or executed. The CNA acknowledged the presence of long nails and the potential adverse outcomes, while the DON admitted to not paying attention to residents' nails and stated that nail care had been assigned to one CNA. The facility lacked a specific policy addressing nail care, which contributed to the oversight and failure to maintain proper hygiene for the residents.
Failure to Secure Medication Carts and Store Medications Properly
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, as observed with two of the six medication carts. On the morning of December 17, 2024, medication carts #2 and #3 were found unlocked and unattended near the nurses' station, with their drawers facing outward. This occurred while the RN was down the hall, and the carts were not visible from the middle of the hallway. Additionally, an unopened bag containing medication bottles was found sitting on a treatment cart, further indicating improper storage practices. Interviews with the RN and the DON confirmed awareness of the requirement for medication carts to be locked and for delivered medications to be stored promptly. The facility's policy on the delivery, receipt, and storage of medication specifies that only authorized staff should have access to medication storage areas, and that medications should be unpackaged and stored properly upon delivery. The failure to adhere to these protocols allowed unauthorized access to medications, posing a potential risk to residents and staff.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that four residents were free from the use of physical restraints, specifically wheelchair seat belt restraints, which were not documented or assessed as required. The residents involved had various medical conditions, including cerebral palsy, aphasia, epilepsy, and quadriplegia, which necessitated the use of wheelchairs. However, there was no documentation of trunk restraints in their medical records, and no assessments or consents for the use of seat belts were present. The care plans for these residents did not include any problems or interventions related to seatbelt use, and physician orders for the use of seat belts were present without corresponding assessments or consents. Observations revealed that the residents were using seat belts and, in one case, a shoulder strap, while in their wheelchairs. Interviews with the residents and their representatives indicated that the seat belts were perceived as safety devices to prevent sliding or falling out of the wheelchairs. The Director of Nursing (DON) stated that the facility did not have a restraint policy because they did not consider the seat belts as restraints but as safety devices. The physician involved was not aware of the specific type of seat belts used but believed they were necessary for the residents' safety due to their medical conditions. Despite the intention to use seat belts for safety, the lack of proper documentation, assessment, and consent constitutes a deficiency in ensuring residents are free from physical restraints unless medically necessary and properly documented.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a reported rate of 6.72 percent due to two errors out of 32 opportunities. The errors involved two residents, one with a diagnosis of vitamin deficiencies and moderate cognitive impairment, and another with hypertension and no cognitive impairment. The first resident did not receive Vitamin D 100 mg as ordered, and the second resident did not receive Terazosin 1 mg as prescribed. These medications were not available during the medication administration process. The medication aide (MA A) responsible for administering the medications stated that medications are typically reordered when there are only five days of supply left. However, due to being off for two days and running behind schedule, MA A did not check or restock the medication cart before the medication pass. The Director of Nursing (DON) confirmed that the expectation is for medications to be administered as ordered and for any unavailability to be reported to the charge nurse and herself. The facility's medication administration policy requires medications to be delivered within one hour before or after the scheduled time.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that Resident #48's drug regimen was free from unnecessary medications. Despite the resident's comprehensive assessment indicating no mood indicators, hallucinations, delusions, or other behavioral symptoms, the resident was prescribed multiple psychotropic medications, including Quetiapine, Sertraline, Trazodone, and Hydroxyzine. The facility did not document the necessity of these medications to treat specific conditions as diagnosed and documented in the clinical record. Additionally, the facility did not monitor Resident #48 for side effects or the effectiveness of the prescribed psychotropic medications. The MAR for April 2024 showed that the resident received the medications as ordered, but there was no documentation of side effect monitoring for the antidepressants or antianxiety medications. The MAR also lacked documentation of behavior monitoring related to the use of these medications. The pharmacist had recommended adding behavior and side effect monitoring for the medications, but this recommendation was not followed up within the expected timeframe. Interviews with the DON revealed that the facility's policy required monitoring for side effects and behaviors for all residents on psychotropic medications. However, this policy was not adhered to in the case of Resident #48. The DON acknowledged that not following up on pharmacy recommendations could lead to adverse outcomes. The facility's policy on psychotropic medication use emphasized the importance of monitoring for efficacy and adverse consequences, but this was not implemented for Resident #48.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing data, including the total number and actual hours worked by registered nurses, licensed practical or vocational nurses, and certified nurse aides, for several consecutive days. Specifically, the staffing log was not updated for the dates 04/06/24, 04/07/24, 04/08/24, and 04/09/24. An observation on 04/09/24 revealed that the staffing information posted was outdated, showing data from 04/05/24. The posted information did not include the total number and actual hours worked by the nursing staff, which is a requirement for transparency and accountability. Interviews conducted during the investigation revealed a lack of clarity and responsibility among staff regarding the posting of the staffing log. The CNA Scheduler, who was responsible for posting the information, did not work over the weekend and was unaware of the requirement to post actual hours worked. The Director of Nursing (DON) acknowledged that the staffing should have been posted daily and that department heads were responsible for posting the log in the absence of the CNA Scheduler. However, there was no policy in place to ensure compliance, and the oversight was attributed to a simple miss over the weekend, with no immediate negative outcomes reported.
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.
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