Avir At Bandera

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure dietary staff consistently used hair and beard restraints in accordance with professional food safety standards and the facility’s own policies. During multiple observations in the kitchen, one dietary aide was seen wearing a beard restraint that covered his beard but did not cover his mustache, leaving the top lip exposed. Later, the same aide adjusted the beard restraint to cover his mustache, but in doing so pulled it off his chin, leaving his beard exposed while he prepared meal trays. Another dietary aide was observed entering and walking through the kitchen from the back door to the dining room door without any hair restraint, only putting on a hair restraint after entering the kitchen and then failing to apply a beard restraint despite having visible mustache and beard growth on the chin and jaw line. This aide then handled clean dishes and separated washed silverware without a beard restraint. He was later observed assisting at the kitchen door by providing a carafe of juice while his mustache and beard growth on the sides of his face and chin remained uncovered. During the same lunch service, the first dietary aide continued to assist with tray preparation and lunch service with his mustache not covered by the beard restraint. Interviews with dietary staff, the dietary manager, the DON, and the administrator confirmed that hair nets and beard restraints were required to be worn at all times in the kitchen and that beard restraints should cover all facial hair, even minimal chin hair. Staff and leadership consistently stated that failure to wear proper hair restraints could allow hair to get into food, cause cross contamination, and potentially make residents sick or cause foodborne illness. Review of facility policies on Food Safety and Sanitation, Employee Hygiene for Food Safety, and Personal Hygiene and Health Reporting, as well as the FDA Food Code provisions on hair restraints, showed that employees were required to wear hair restraints and beard covers to prevent hair from contacting exposed food, equipment, utensils, and food service areas, which was not followed by the observed dietary staff.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to immediately report an allegation of abuse to the Administrator and to required external authorities, including the State Survey Agency, as required by regulation and facility policy. A female resident with diagnoses including pneumonia, UTI, and dementia with moderate cognitive impairment (BIMS score 12/15) reported to therapy staff that she had been touched in a sexual manner. Her care plan, initiated and revised in early February, documented behavior problems related to delusions and statements that someone had been in her room touching her inappropriately, and included interventions such as use of two caregivers, female caregivers only, and anticipating and meeting her needs. On the day of the allegation, therapy staff informed the DON that the resident had stated she had been touched in a sexual manner. The DON interviewed the resident, who responded vaguely to questions about when and where she had been touched, saying "here and there," and refused to identify who had done it, stating she was not going to tell. Despite this, the DON did not report the allegation to the Administrator on the day it was received. The Administrator was not informed until the following day during the morning meeting, which was more than two hours after the allegation was made. The Administrator acknowledged that the allegation had been reported to the DON on one day and that she herself was not notified until the next day. She further stated that, after consultation with corporate staff, it was determined the allegation was not reportable and it was not reported to HHSC, despite the facility’s written policy requiring that all suspected abuse be reported immediately (defined as within two hours for allegations involving abuse) to the Administrator and to state agencies according to HHSC reporting guidelines. The facility’s failure to report the resident’s allegation of sexual misconduct by a CNA to HHSC constituted noncompliance with both regulatory requirements and the facility’s own ANE reporting policy.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to ensure that a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections (UTIs). The resident, an older female with a history of recurrent UTIs, obstructive and reflux uropathy, and chronic bladder spasms, began experiencing increased bladder spasms and dysuria over several days. Despite her increased requests for pain and bladder spasm medications, staff did not identify these as potential symptoms of a UTI or a change in condition, nor did they notify the nurse practitioner or physician for further assessment or order a urinalysis during this period. The resident's medical records showed a pattern of increased administration of pain and antispasmodic medications, and both family members and staff noted that her pain and discomfort were significantly worse than usual in the days leading up to her hospitalization. Family members reported the resident's increased pain and suspected a UTI to nursing staff multiple times, but no action was taken to escalate care or notify the medical provider. Nursing staff interviewed after the incident acknowledged that increased pain and use of PRN medications should have prompted further assessment and notification of the medical provider, especially given the resident's history of UTIs and catheter use. The resident eventually became lethargic and unresponsive, prompting emergency services to be called. Upon hospital admission, she was diagnosed with septic shock due to a UTI, and a suprapubic catheter was surgically placed. Interviews with staff and family confirmed that the signs and symptoms of a UTI and change in condition were present but not recognized or acted upon in a timely manner, resulting in a significant adverse event for the resident.

Removal Plan

• Resident was being treated for pain/discomfort with PRN medications prescribed to treat chronic pain/bladder spasms and was being monitored by licensed nurse. Resident was sent to hospital for evaluation & treatment.
• Regional Nurse provided in-service to DNS/Admin/Admin in-training/ADNS regarding process for ensuring changes in conditions are identified and reported to the medical provider, notification of PCP of abnormal labs, implementation of orders as provided, and documentation in the EHR of notification of change in condition to MD/NP/PA as well as any prescribed orders and notification to Resident's family or representative.
• Nurse conducting a proper assessment and documenting in the Electronic Health Record (E.H.R.).
• Notifying medical provider of the change in condition (increased pain).
• Adhering to physician's orders and recommendations.
• Communicating pertinent information regarding the status of resident's condition to ensure the well-being of residents during the nurse/shift change report.
• Documentation of the resident's status and delivery of care provided according to the plan of care.
• If the nurse is unable to reach the medical provider, they will place a call to Medical Director to ensure timely notification to the Medical Doctor, Nurse Practitioner, or Physician's assistant (MD/NP/PA).
• Nurses should conduct on-going monitoring of resident related to the change in condition and to ensure that the nurse is communicating the resident's status during change of shift and to ensure proper follow up and necessary interventions are in place and properly documenting findings, interventions and response to care provided within the Electronic Health Record (E.H.R).
• Nurses will conduct on-going monitoring of residents and specifically monitor residents with bowel/bladder issues, and indwelling catheters to identify and recognize sign/symptoms of UTI: such as flank discomfort, urinary frequency, discomfort upon urination, increased confusion, changes in mental status, changes in urine odor, color, amount of urine and hematuria.
• Nurse/Interdisciplinary team (IDT) to review the plan of care and/or updating the plan of care accordingly.
• Abuse and Neglect (ANE) - Identifying Prevention and Reporting.
• Administrator and Director of Nursing conducted an AdHoc Quality Assurance Performance Improvement (QAPI) meeting with the Medical Director to review plan of removal/immediate corrective action plan implemented.
• Director of Nursing/Assistant Director of Nursing conducted 100% audit/assessment/evaluation of all current/active residents, including those with bladder and bowel issues, incontinence and indwelling catheters, to identify any signs or symptoms of a change in condition and validated that the medical provider has reported to the PCP for physician's review and to ensure appropriate plan of care is in place.
• Director of Nursing/Assistant Director of Nursing conducted an audit of all residents to identify any changes in conditions to ensure proper notification of the Medical Doctor (MD) and family representatives and to ensure appropriate interventions were in place.
• Director of Nursing/Assistant Director of Nursing conducted in-service training to all licensed nurses prior to the nurse working his/her next scheduled shift; comprehension verified through follow up questions.
• Director of Nursing/Assistant Director of Nursing will conduct rounds to identify any resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented within the electronic health record.
• Director of Nursing/Assistant Director of Nursing will conduct random audits of documentation of progress notes, Medication Administration Record (MARS) (pain meds) as well as staff interviews to identify any signs and symptoms of a resident with a change in condition and will ensure appropriate documentation, notifications and appropriate interventions are in place and documented within the electronic health record.
• Director of Nursing/Assistant Director of Nursing will conduct random interviews with the nursing team members to identify competency/comprehension of identifying signs and symptoms of a urinary tract infection, increased pain, and other signs of a change in condition as well as the process for reporting the identified change in condition to the license nurse, the process for the nurse to conduct an assessment, will ensure appropriate documentation, MD and family notifications as well as ensuring appropriate interventions are in place and documented within the electronic health record.
• The facility will conduct a Quality Assurance Performance Improvement (QAPI) meeting to review the status and compliance notification to Medical Doctor, Nurse practitioner, or physician's assistant (MD/NP/PA) ensuring appropriate intervention and orders are implemented as ordered and appropriate documentation is noted within the Electronic Health Record (E.H.R.).
• Director of Nursing/Designee will ensure all licensed nursing staff will be educated to include nurses on leave/agency/Part time staff (PRN staff) - Nurses will be in serviced prior to working their next shift.
• DNS/Designee will ensure administrative nursing staff in the community will provide in-service/education prior to team members working their assigned shift. The trainings will also be conducted with new hires.

Penalty

No penalty information released

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

Summary

The facility failed to immediately notify a resident's nurse practitioner (NP) when there was a significant change in the resident's physical status. The resident, who had a history of urinary tract infections (UTIs) and required an indwelling catheter, began experiencing increased bladder spasms and dysuria over several days. Despite these symptoms and an increased need for pain and bladder spasm medications, there was no documentation or evidence that the NP was notified of the change in the resident's condition. Medical record reviews showed that the resident was administered oxybutynin chloride and phenazopyridine HCl multiple times over a period of days for bladder spasms and dysuria, indicating ongoing and possibly worsening symptoms. Interviews with nursing staff confirmed that the resident's increased pain and medication use should have prompted notification to the NP, as these could indicate complications such as catheter obstruction or a UTI. The NP also stated she would have expected to be notified and for a urinalysis to be conducted if the resident was experiencing increased pain. The resident herself reported experiencing excruciating pain for several days prior to being sent to the hospital, requiring frequent requests for pain medication. Facility policy required that the physician and resident representative be notified of changes in condition or symptoms suggestive of a UTI, but this was not followed. The failure to notify the NP of the resident's change in condition was confirmed through interviews, record review, and review of facility policy.

Penalty

Inspection fine: $132,990

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

Summary

The facility failed to develop and implement a comprehensive person-centered care plan for two residents, which could potentially place them at risk for psychosocial and physical harm. For one resident, the facility did not adequately address her wishes to discharge from the facility. Despite the resident's intact cognition and expressed desire to return home, the facility did not document discharge planning goals or interventions. Interviews revealed that the resident was frustrated with the lack of information regarding her discharge, and although she had improved with therapy, she had no family support or financial means to facilitate her transition back to the community. Another resident with an implanted defibrillator/pacemaker did not have a care plan that included specific interventions for the care and monitoring of his device. The resident was aware of the device's limitations and had a bedside monitor to communicate with his cardiologist. However, the care plan lacked details on the use, care, or monitoring of the device. Interviews with staff indicated a lack of awareness and specific instructions regarding the resident's pacemaker and monitoring device, which could lead to inadequate care and monitoring. The facility's care plan policy emphasizes the importance of developing a plan to maintain the resident's highest practicable well-being. However, the failure to include specific discharge planning for one resident and detailed care interventions for another resident's medical device indicates a gap in the facility's adherence to its policy. This deficiency highlights the need for comprehensive and individualized care plans to ensure residents' needs are met effectively.

Penalty

Inspection fine: $132,990

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

Summary

The facility failed to provide an ongoing program of activities tailored to the interests and needs of residents, particularly those in the memory care unit and those requiring in-room activities. For Resident #40, who is severely cognitively impaired with a BIMS score of 0, the facility did not provide an activities calendar or regular activities, as observed by CNA G. The CNA reported that activities were infrequent and not conducted daily, which could help mitigate anxious behaviors in the memory care unit. The lack of activities was corroborated by the absence of an activities calendar in the memory care unit. Additionally, the facility did not provide in-room activities for Residents #34 and #48, both of whom have complex medical conditions including CHF, Afib, and COPD, among others. The activity participation logs for these residents showed no data regarding in-room activity programs, and Resident #48's care plan lacked activity interventions. Interviews with the activity director and other staff revealed that in-room activities had not been initiated, and the activities calendar for March 2025 showed a significant lack of scheduled activities. The facility's policy requires an organized program of activities to meet residents' interests and well-being, which was not adhered to in this case.

Penalty

Inspection fine: $132,990

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

Summary

The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Specifically, the facility did not take blood pressure measurements for Resident #37 before administering the blood pressure medication amlodipine, as ordered by the resident's physician. This oversight occurred on multiple occasions between March 1, 2025, and March 19, 2025, where the medication was administered without checking or documenting blood pressure vital signs, contrary to the physician's parameters. Additionally, the facility failed to monitor for signs and symptoms of heart failure in Residents #1, #34, and #79 while they were being treated with diuretic medications. These residents had diagnoses of heart failure and were at risk for complications such as chest pain, shortness of breath, fatigue, dizziness, poor endurance, and edema. Despite these risks, the facility did not adequately monitor the residents for these symptoms, which could lead to a decline in their health. Interviews with facility staff revealed a lack of consistent monitoring and documentation practices. The Director of Nursing (DON) acknowledged the potential adverse effects of not monitoring residents on diuretics, which could result in delayed treatment, physical and functional decline, and possible hospitalization or death. The facility's policies on medication administration and quality of care emphasize the importance of taking vital signs and ensuring treatment aligns with professional standards, yet these were not adhered to in the cases reviewed.

Penalty

Inspection fine: $132,990

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

Summary

The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain personal hygiene. Specifically, the resident, who was moderately cognitively impaired and required substantial assistance for showering, did not receive 4 out of 20 scheduled showers over a period of approximately six weeks. The resident's care plan indicated a need for assistance due to impaired mobility and other health conditions, and the facility's policy required showers to be scheduled at least twice weekly. The deficiency was identified through a review of the resident's records, which showed that the resident missed scheduled showers on four Saturdays. The Director of Nursing was unaware of the missed showers and could not provide documentation to confirm that the showers were given on those dates. The facility's policy emphasized the importance of adhering to the shower schedule based on resident preference, but the lack of documentation and missed showers indicated a failure to comply with this policy, potentially impacting the resident's hygiene and quality of life.

Penalty

No penalty information released

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

Summary

The facility failed to maintain accurate and complete clinical records for a resident with a history of chronic urinary tract infections (UTIs). The resident, who had multiple complex medical conditions including vascular dementia, aphasia, and hemiplegia, was under orders for regular urinalysis collection due to recurrent UTIs. The medication administration record (MAR) for January did not accurately reflect the status of urine sample collection on several days, with documentation inconsistencies such as marking the sample as administered when it was not collected, and leaving entries blank. Additionally, there was no documentation or rationale from a medical provider when the order for urine collection was canceled by the Director of Nursing (DON), and the reason for discontinuation was left blank in the records. Record reviews showed that the resident's MAR indicated refusals on some days, an 'administered' status on others, and a blank entry, while progress notes and lab reports confirmed that no urine sample was actually collected in January. Interviews with staff revealed that the resident was often uncooperative with urine collection, and staff would sometimes document the procedure as completed to prevent repeated attempts by other staff. The DON acknowledged that the rationale for discontinuing the monthly urinalysis order was not documented at the time, and that proper documentation protocols were not followed. The facility's own policy required that medical records be maintained in accordance with accepted professional standards, including accurate documentation of care and services provided. The lack of accurate documentation and failure to provide a provider's rationale for discontinuing a medical order resulted in incomplete clinical records for the resident, as evidenced by the discrepancies between the MAR, progress notes, and lab results.

Penalty

Inspection fine: $13,849

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

Summary

The facility failed to provide adequate supervision to prevent accidents for a resident identified as being at risk for elopement. The resident, who had severe cognitive impairment due to multiple sclerosis and dementia, was found lying in the grass beside his wheelchair on the opposite side of a two-lane road after eloping from the facility. This incident resulted in a laceration to his right eye and facial bruising. The resident had a history of exit-seeking behavior, as documented in his care plan and progress notes, which indicated multiple attempts to leave the facility unattended. The deficiency occurred when the resident managed to exit the facility through a hallway door, despite wearing a wander guard device. The alarm system was triggered, but the responsible RN prematurely silenced the alarm without confirming the whereabouts of all residents, contrary to the facility's elopement response policy. The RN acknowledged this failure, which led to the resident being outside in extreme heat conditions, posing a significant risk to his safety. Interviews with staff and family members revealed that the resident had been exhibiting exit-seeking behavior multiple times a day, and there were previous incidents where he attempted to leave the facility. Despite these known risks, the facility's response to the alarm was inadequate, as the RN did not follow the proper protocol to ensure the resident's safety. This lapse in supervision and failure to adhere to established procedures directly contributed to the resident's elopement and subsequent injury.