Avir At Azalea Heights
Inspection history, citations, penalties and survey trends for this long-term care facility in Tyler, Texas.
- Location
- 3505 Old Jacksonville Rd, Tyler, Texas 75701
- CMS Provider Number
- 675289
- Inspections on file
- 28
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Avir At Azalea Heights during CMS and state inspections, most recent first.
A cognitively intact female resident with Guillain-Barre Syndrome, depression, muscle weakness, and dependence on staff for toileting received incontinent care from two CNAs while her roommate was present in the room, and the privacy curtain was not pulled at any time. The resident’s care plan documented a self-care deficit and need for assisted incontinent care, and facility policies on perineal care and resident rights required staff to provide privacy, including use of doors, curtains, and blinds. In post-incident interviews, both CNAs acknowledged that privacy should have been provided during the care and recognized that doing so is part of respecting resident rights and dignity, while the DON and Administrator confirmed their expectation that staff follow these privacy practices.
A CNA provided incontinent care to a resident with assistance from another CNA and failed to perform hand hygiene between multiple glove changes during perineal and brief care, only using alcohol-based hand rub before entering and after exiting the room. The CNA acknowledged that hand hygiene should occur between glove changes but cited the location of hand sanitizer dispensers in the hallway and uncertainty about portable sanitizer as reasons for noncompliance. The DON and Administrator both described expectations that staff perform hand hygiene before and after care and in conjunction with glove use, and the facility’s hand hygiene policy required hand hygiene immediately before resident contact and after glove removal, which was not followed during the observed care.
A resident with severe cognitive impairment and a history of falls was not provided with the required bed bolsters as outlined in her care plan. Instead, a CNA used a different positioning device, and the bed was left in a high position. The resident was later found on the floor with injuries, including a fractured femur, after falling from bed. Staff interviews confirmed knowledge of the care plan requirements, but the prescribed interventions were not followed.
The facility's kitchen operations were found to be unsanitary, with issues such as empty paper towel dispensers, improper storage of food items, and inadequate sanitizing procedures. Logs for sanitizing were pre-filled inaccurately, and the ice machine had black debris. An opened juice container was not labeled with the open date, violating food safety standards.
A facility failed to document a resident's enteral feeding orders in the EHR, resulting in a lack of recorded administration of liquid nutrition for four days. The oversight occurred when an LVN did not enter the order after receiving a verbal report from an agency nurse, despite the facility's policy requiring accurate documentation during admissions.
The facility failed to provide necessary hygiene services for two residents, one of whom did not receive a bath for five days after admission, and another who did not receive a bath or shower for four weeks. Documentation inconsistencies and staff interviews highlighted a lack of adherence to proper hygiene protocols.
The facility failed to ensure adequate supervision for a resident with dementia who had a history of elopement. The resident was admitted without proper assessment, leading to an elopement incident the following day. Staff were unaware of her elopement history, and the admission assessment was inaccurately completed.
A resident with multiple diagnoses, including Alzheimer's and anxiety disorder, was prescribed Lorazepam. The facility failed to consistently document monitoring for adverse side effects of the medication, particularly during changes in dosage. Interviews with staff revealed awareness of the importance of monitoring, but documentation was inconsistent. The DON acknowledged the lapse and stated there was no specific system in place for consistent monitoring prior to 4/19/24.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
Surveyors identified a failure to provide personal privacy during incontinent care for 1 of 7 residents reviewed. The resident was an adult female with Guillain-Barre Syndrome, anxiety, major depressive disorder, muscle weakness, and a need for assistance with personal care. Her MDS showed she was cognitively intact with a BIMS score of 15, usually understood and was understood by others, and was dependent on staff for toileting. Her care plan, revised 1/3/26, documented a self-care deficit related to impaired physical mobility and called for incontinent care with one-person staff assist. On 4/29/26 at 1:16 p.m., CNA A, with assistance from CNA B, provided incontinent care to the resident while her roommate was lying in bed with eyes closed. During this care, the CNAs did not pull the privacy curtain at any time. In interviews, CNA B acknowledged that the privacy curtain should have been pulled and admitted the resident had not been provided privacy, stating she forgot to ensure the curtain was pulled and recognizing privacy was needed so no one could watch and so the resident was covered. CNA A stated that during incontinent care the door should be shut or the privacy curtain pulled and believed the curtain had been shut during this care, and identified resident rights as the reason for providing privacy. The DON and Administrator both stated their expectation that staff provide privacy during personal care by closing the door, pulling the privacy curtain, and closing the blinds, consistent with the facility’s Perineal Care procedure and Resident Rights policy, which require providing privacy and treating residents with dignity and respect, including privacy and confidentiality.
Failure to Perform Hand Hygiene Between Glove Changes During Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene practices during incontinent care. During an observation on 4/29/26, CNA A and CNA B used alcohol-based hand rub from a dispenser outside a resident’s room, performed hand hygiene, and donned clean gloves before beginning care. Once inside the room, CNA A moved the resident’s bed, removed her gloves, and repeatedly failed to perform hand hygiene between subsequent glove changes while providing perineal and incontinent care. Specifically, CNA A opened the resident’s brief and cleansed the pelvic and vaginal area, then removed gloves without hand hygiene; later, after the resident was rolled to her side and the bottom area and soiled brief were cleaned and removed, CNA A again removed gloves without hand hygiene. CNA A continued care by handling a clean brief and chuck pad, repeatedly changing gloves without performing hand hygiene until after exiting the room and disposing of trash. In interviews, CNA A stated that hand hygiene should be performed prior to and after providing care and between glove changes, and acknowledged she did not perform hand hygiene between glove changes during the observed care. She attributed this to the placement of hand sanitizer dispensers in the hallway outside resident rooms and uncertainty about the location of small bottles of hand sanitizer within the facility. The DON stated she expected staff to perform hand hygiene before entering a room, before donning gloves, after removing gloves, during care, and when exiting a room, and the Administrator similarly stated expectations for hand hygiene before and after care, eating, using the restroom, and with glove use. Review of the facility’s Handwashing/Hand Hygiene policy, updated 1/2025, indicated that hand hygiene is considered the primary means to prevent the spread of healthcare-associated infections, that hand hygiene products are to be readily accessible, and that hand hygiene is indicated immediately before touching a resident, after contact with blood, body fluids, or contaminated surfaces, after touching a resident or the resident’s environment, and immediately after glove removal. The observed practice by CNA A did not align with these stated expectations and policy requirements.
Failure to Implement Fall Prevention Interventions Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, total dependence for activities of daily living, and a history of falls was not provided with the required safety interventions as outlined in her care plan. The resident, who had diagnoses including anoxic brain damage, convulsions, aphasia, and pseudobulbar affect, was care planned to have bolsters on her bed to minimize the risk of rolling out and for the bed to be kept at an appropriate height when unattended. On the day of the incident, the resident was returned to bed by a CNA who used a black wedge positioning device instead of the prescribed bolsters, which were found stored in front of the closet rather than on the bed. The incident was discovered when a nurse heard a loud thud and found the resident on the floor beside her bed, with a laceration to her face and a right leg injury. The bed was observed to be in a higher position, typically used for mechanical lift transfers, and there were no bolsters or wedge cushions on or around the bed at the time. The resident was subsequently diagnosed with a fractured right femur and required hospitalization and surgery. Interviews with staff revealed that the CNA was aware of the care plan requirements but did not use the bolsters, instead opting for a different device that was not part of the resident's care plan. Further review indicated that the CNA did not provide a clear reason for not using the prescribed bolsters, stating only that she used what was present on the bed that morning. The facility's documentation confirmed that all staff had access to the resident's care plan and Kardex, which specified the need for bolsters and bed positioning. The failure to implement these interventions as planned directly led to the resident's fall and subsequent injury.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. The paper towel dispensers at the hand wash sink and employee restroom were found to be empty, which could hinder proper hand hygiene. Additionally, a scoop was improperly stored inside a bulk flour bin, and the utensil drawer was soiled with food debris and dried liquid. Opened bags of brown sugar and potato chips were not properly sealed, which could compromise food safety. The facility's three-compartment sink was not sanitizing properly, and the logs for the sink and dish machine were pre-filled with results for meals that had not yet occurred. This indicates a lack of proper monitoring and documentation of sanitizing conditions. The ice machine in the dining area was found to have copious amounts of black debris on the ice chute, despite being cleaned by a vendor recently. The maintenance supervisor noted that the kitchen staff were supposed to clean the machine regularly, but there was no documentation to support this. Furthermore, a reach-in cooler contained an opened container of nectar thick orange juice that was not labeled with the open date, contrary to the package instructions. These deficiencies in food storage, preparation, and sanitation could place residents at risk of foodborne illness, as the facility did not adhere to its own policies and professional standards for maintaining sanitary conditions.
Failure to Document Enteral Feeding Orders
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards for a resident who was admitted with multiple diagnoses, including dysphagia and a gastrostomy tube for enteral feeding. Upon review, it was found that the order for enteral feedings from the hospital was not documented in the resident's physician's orders at the facility. Additionally, there was no documentation of the administration of liquid nutrition for four consecutive days after the resident's admission, despite observations confirming that the resident was receiving the nutrition. Interviews revealed that the failure to document the enteral feeding order was due to an oversight by LVN B, who did not enter the order into the electronic health records (EHR) after receiving a verbal report from an agency nurse. The Director of Clinical Operations Nurse confirmed that LVN B completed the new admission form but missed entering the feeding order, although all other admission orders were entered correctly. The facility's policy requires nurses to document assessments and orders accurately, especially during admissions, but this was not adhered to in this case.
Failure to Provide Necessary Hygiene Services
Penalty
Summary
The facility failed to provide necessary services to maintain acceptable grooming and personal hygiene for two residents. Resident #1 did not receive a bath until five days after his admission, despite being dependent on staff for all activities of daily living (ADLs) including bathing. His family member observed that he remained in the same clothes for the first four days and did not appear to have received a shower. Documentation confirmed that Resident #1 did not receive a shower or bath from the date of admission until five days later. Resident #2, who required substantial assistance for bathing due to paraplegia and other medical conditions, did not receive a bath or shower for four weeks. During interviews, Resident #2 reported not receiving a shower or bed bath and noted that staff seemed unwilling to go through the process of providing a shower. Observations confirmed that Resident #2 had greasy hair and a faint body odor. Documentation inconsistencies were found, with some CNAs denying they had provided the documented care, and one CNA admitting to sharing login information with agency staff for documentation purposes. Interviews with staff, including CNAs and the Director of Nursing (DON), emphasized the importance of regular bathing for hygiene and skin health. However, the facility's policy and procedure on activities of daily living did not specifically address ensuring dependent residents received regular showers or baths. This lack of adherence to proper hygiene protocols placed residents at risk for poor personal hygiene and potential skin infections.
Failure to Prevent Elopement of Resident with Dementia
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for a resident with a history of elopement. Resident #3, who had diagnoses including dementia, was admitted without a proper assessment of her elopement risk. The facility did not have a secure unit or a wander guard system and would not have accepted her had they known about her history of elopement. On the day following her admission, Resident #3 eloped from the facility, triggering an alarm that led to staff intervention to bring her back safely. The incident revealed that the facility's admission process did not capture critical information about Resident #3's elopement history, which was known to her family but not documented in the admission paperwork. Interviews with various staff members, including the admissions coordinator, DON, and social worker, confirmed that they were unaware of Resident #3's elopement history. The admission assessment was also inaccurately completed, marking Resident #3 as not physically able to leave the building on her own, which was incorrect. The facility's policy did not explicitly state that residents with a history of elopement would not be accepted, leading to a significant oversight in Resident #3's case.
Failure to Monitor Adverse Side Effects of Lorazepam
Penalty
Summary
The facility failed to ensure that Resident #1's drug regimen was free from unnecessary psychotropic drugs and that the resident was consistently and adequately monitored for adverse side effects of Lorazepam. Resident #1, who had multiple diagnoses including Alzheimer's disease, anxiety disorder, and major depressive disorder, was prescribed Lorazepam for anxiety. The medication orders for Lorazepam were changed multiple times between 4/1/24 and 4/18/24, but the monitoring for antianxiety side effects was not consistently documented during this period. Specifically, there were gaps in the documentation of side effects monitoring on the MAR and in the nursing progress notes, particularly from 4/11/24 to 4/19/24. This lack of consistent monitoring could have led to the resident experiencing adverse effects without timely intervention. Interviews with the nursing staff and the ADON revealed that they were aware of the importance of monitoring but failed to document it consistently. The DON acknowledged the lapse in monitoring and documentation, stating that there was no specific system in place to ensure consistent monitoring of psychotropic medications prior to 4/19/24. A facility policy and procedure regarding the monitoring of residents on psychotropic medications was requested but not received.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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