Avir At Coronado
Inspection history, citations, penalties and survey trends for this long-term care facility in Abilene, Texas.
- Location
- 1751 N 15th St, Abilene, Texas 79603
- CMS Provider Number
- 675746
- Inspections on file
- 54
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Avir At Coronado during CMS and state inspections, most recent first.
DON Served as Charge Nurse Over Census Limit: The facility failed to ensure the DON did not serve as charge nurse when the average daily occupancy was over 60 residents. The DON reported working nights as a CNA and nurse to fill open shifts and said this caused her to fall behind on monitoring nurse assessments and updating care plans. The RCN and ADMN both acknowledged staffing shortages and turnover had led to the DON working on the floor, even though the DON should not have served as charge nurse when census exceeded 60.
Visible Ostomy and Urinary Drainage Bags Left Uncovered: The facility failed to maintain dignity for residents with ostomies and urinary catheters when a resident with an ileostomy was seen in the hallway with the bag exposed, a resident with a urinary catheter had the drainage bag repeatedly left uncovered in bed and in a chair despite an order for a privacy bag, and a resident with a colostomy and indwelling catheter was brought into the dining room with the colostomy bag exposed and more than 3/4 full while the urinary bag was also uncovered. Staff did not cover the bags or empty them before the resident was in the dining room, and the DON later removed the resident and emptied the colostomy bag.
Failure to Respond to Resident Council Grievances: The facility did not provide verbal or written responses to Resident Council grievances about nursing, dietary, housekeeping, and daily living concerns. The council reported issues such as unchanging bed linens, noisy and disrespectful housekeeping, loud staff conversations, meal and tray concerns, labeling personal items, and resident care concerns, but the facility did not consistently document a representative response or rationale.
Unsafe Room Conditions and Lack of Hot Water: Multiple resident rooms had sinks with no hot water, and several mattresses had cracked or peeling nonpermeable covers. A resident and family member reported discomfort and ongoing concerns, and staff including the ADMN and Maintenance Director acknowledged awareness of the hot water issue and the damaged mattresses.
Incomplete Care Plans for Mental Health, Smoking, and Tube/Catheter Care: The facility failed to maintain comprehensive person-centered care plans for several residents. A resident with anxiety and major depressive disorder had no care plan for those diagnoses, a cognitively intact resident who smoked had no smoking care plan, and residents with a G-tube and Foley catheter had no related care plan focus, goals, or interventions despite active orders and ongoing device care needs.
A facility failed to provide refried beans with a regular diet lunch for 21 of 73 residents reviewed. During kitchen observation, staff ran out of refried beans and only the last 4 trays received rice, while 17 trays went out without the menu item. The DM and Dietician stated rice was not an appropriate nutritional substitute, and the substitution log was blank.
Kitchen sanitation and food storage deficiencies: The kitchen floors, mixer stand, food thickener container, convection oven, stove, shelf above the stove, refrigerator shelf, and resident plate stand were observed to be soiled with dirt, food crumbs, dust, grease, and baked-on food. The DM stated the kitchen should be clean after every meal, and the ADMN stated it was his expectation for the kitchen to be clean. A kitchen sanitization policy was requested but not provided.
Inaccurate MDS Assessment Coding: The facility failed to accurately code an admission MDS for a resident with dysphagia, nontraumatic cerebral hemorrhage, severe cognitive impairment, and a gastrostomy tube. The MDS documented weight loss and eating assistance that did not match the resident’s record, and the MDS coordinator acknowledged the documentation error.
Failure to secure Foley tubing and document urine output for a resident with an indwelling catheter. The resident had neuromuscular bladder dysfunction and a UTI history, but the catheter tubing was observed leaking and not secured to the leg, the catheter bag was not covered with a privacy bag, and urine output was not documented on several shifts. The DON and LPN confirmed staff were expected to secure the tubing, use a privacy bag, and document output on the MAR.
A resident with CHF, AFib, and HTN returned from the hospital after treatment for sepsis and a UTI, but the facility did not document a readmission assessment or vital signs for several days. Staff interviews showed confusion about who was responsible for completing the assessment and obtaining vital signs, while the DON said she expected the assessment and daily vital signs to be done and was falling behind on monitoring compliance.
Failure to employ a full-time licensed SW was identified in a facility with 188 beds. The SSD reported she had a social work degree and prior NY licensure but was not licensed in TX and was working toward reciprocity while performing SW duties remotely for the facility. The VP of HR was unfamiliar with TX licensure rules, and the ADMN stated he expected a licensed full-time SW but no other SW was in the building to provide services.
Surveyors found a medication cart left unlocked and unattended near the nurse's station, containing various OTC medications, medical supplies, and personal items such as a butter knife and nail clippers. Staff interviews confirmed the cart should have been locked and monitored, and facility policy required all medications and biologicals to be stored securely in locked compartments.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions. Review of documentation showed incomplete planning and insufficient detail to ensure comprehensive care.
A care plan was not developed within 7 days of the comprehensive assessment and was not prepared, reviewed, or revised by a team of health professionals as required.
The facility was found deficient in food safety and hygiene practices, including improper thawing of ground meat, inadequate hand hygiene by the cook, and failure to label and store food items correctly. These actions could lead to contamination and foodborne illnesses among residents.
Two residents received Seroquel without proper consent at a facility. One resident with schizoaffective disorder was given increased dosages without consent, and another with neurocognitive disorder received the medication over several months without documented consent. Staff interviews revealed confusion and lack of clear policy on obtaining consent for antipsychotic medications.
The facility failed to develop comprehensive care plans with measurable objectives for six residents, affecting areas such as resisting care, visual function, pain, and cognitive loss. This deficiency could impact residents' needs and preferences.
The facility failed to implement its policy on food storage, leading to improper temperature logging and expired goods in residents' personal refrigerators. Observations showed that several residents' refrigerators lacked temperature logs or thermometers, and interviews revealed that staff did not consistently check these appliances. This oversight could risk foodborne illnesses.
A resident in a LTC facility experienced a safety risk due to a broken toilet that was not promptly repaired. Despite the resident's intact cognition and independence in toileting, the cracked and unstable toilet base posed a fall risk. The maintenance director was aware but absent due to an injury, and the administrator was unaware of the issue due to a lack of communication and oversight of the electronic repair request system.
A facility failed to store medications securely, as a resident's personal refrigerator contained a prescription hydrocortisone cream without a physician's order. The resident could not apply the cream themselves, suggesting it was left for staff convenience. Staff interviews confirmed that medications should not be in resident rooms, and the DON noted the oversight could lead to improper administration. The facility's policy mandates locked storage for medications, which was not followed.
A facility failed to ensure proper use of PPE during catheter care for a resident on enhanced barrier precautions. The CNA did not wear a gown while performing care, contrary to facility policy requiring full PPE, including a gown, gloves, and mask. Interviews with staff confirmed the deficiency in infection control practices.
Two residents in a facility experienced unsanitary conditions due to cockroach infestations and clogged air conditioner units. Despite complaints from a resident's family and reports to staff, the issues persisted. The facility's pest control measures were inadequate, as documented in the Pest Control Logbook, and the Administrator acknowledged the ongoing problem.
A facility failed to report an alleged abuse incident involving a resident within the required timeframe. A family member reported that a CNA placed her elbow on the resident's thigh, causing discomfort, and provided a video of the incident. Despite the evidence, the facility did not report the incident to the state agency, citing a lack of intent to harm. The resident had multiple diagnoses and was dependent on assistance for mobility.
A facility failed to investigate an alleged abuse incident involving a resident and a CNA. A family member reported the incident, including a video, but the facility did not conduct a thorough investigation or suspend the CNA. The resident, who had multiple medical conditions and was dependent on assistance, was allegedly leaned on by the CNA, causing concern. The facility's response was limited to reassigning the CNA and providing education, without a formal investigation, contrary to their abuse prevention policy.
The facility failed to maintain an effective pest control program, resulting in cockroach infestations in common areas and the bathrooms of two residents. One resident, with multiple health conditions, reported seeing cockroaches in her bathroom, while another resident, also with significant health issues, experienced cockroaches in his bathroom and prosthetic legs. Despite a pest control contract, the problem persisted, with sightings documented since early 2023.
The facility failed to maintain an effective infection control program, resulting in COVID-19 exposure among residents. COVID-19 positive residents were not isolated from negative ones, and staff did not adhere to PPE protocols, increasing transmission risk. A COVID-19 positive resident left quarantine, exposing others. The facility's infection prevention policy was not properly implemented.
A resident with severe cognitive impairment eloped from the facility due to inadequate supervision and monitoring. The resident was missing for approximately six and a half hours before being located by law enforcement. Staff failed to verify the resident's location when his meal tray was left untouched, and the facility's policy on wandering and elopement was not effectively implemented.
A resident with severe cognitive impairment eloped from the facility and was found at a Salvation Army location. The incident was not reported to the State Survey Agency within the required timeframe, despite facility policies mandating such reporting. The administrator admitted to preparing the report but failing to send it due to distraction.
A resident with multiple medical conditions was discharged without proper notice or documentation after testing positive for illegal substances. The facility did not provide a written discharge notice, discharge summary, or medications, leading to the resident experiencing multiple health issues and emergency room visits.
A facility failed to develop a comprehensive person-centered care plan for a resident with severe cognitive impairment and a history of wandering. The care plan lacked specific interventions for supervision, despite the resident's identified need. Interviews with staff revealed awareness of the issue but incomplete and inaccurate care plans.
The facility failed to have sufficient nursing staff to ensure resident safety and well-being. Observations and interviews revealed that the facility was consistently understaffed, with only 3 LVNs and 4 CNAs scheduled for both day and night shifts for 78 residents. Record reviews showed that the facility did not meet the required direct care staff hours, and residents reported unmet needs and delays in care.
The facility failed to provide necessary care and services for two residents, leading to unmet requests for showers and transfers. One resident did not receive showers as per her care plan, while another was not transferred from bed to chair as requested. Staffing issues were acknowledged by the facility administrator.
DON Served as Charge Nurse When Census Exceeded 60
Penalty
Summary
The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 6 of 54 days reviewed for DON coverage. The DON worked as a charge nurse on 03/07/2026, 03/16/2026, 04/04/2026, 04/11/2026, 04/18/2026, and 04/19/2026, despite the facility policy stating the DNS may serve as charge nurse only when the average daily occupancy is 60 or fewer residents. During interviews, the DON stated she was falling behind on monitoring nurse assessments and care plan updates because she was working nights as a CNA and nurse to fill open shifts. The RCN stated the DON was getting behind on comprehensive care plans because leadership turnover and staffing shortages had required the DON to work on the floor as a nurse and CNA at times. The ADMN stated he knew the DON should not be working as a CNA or charge nurse when the facility had over 60 residents, but said it was better to have the shifts filled to perform resident care.
Visible Ostomy and Urinary Drainage Bags Left Uncovered
Penalty
Summary
The facility failed to treat residents with dignity and respect by leaving ostomy and urinary drainage equipment visible and, in one case, not emptied when residents were in common areas or their rooms. Resident #37, a cognitively intact male with a history of colon cancer and an ostomy, was observed walking in the hallway with his shirt raised so that his ileostomy bag was visible to staff and other residents. Resident #54, a cognitively intact female with a urinary catheter, had physician orders for a privacy bag for her urinary drainage bag while in bed, walking, or in a wheelchair. She was observed multiple times with the urinary catheter collection bag hanging on the side of the bed or attached to her chair without a privacy bag, making it visible to anyone passing by or in the room. Resident #67, a female with dementia, dehydration, constipation, and lower abdominal pain, had both a colostomy and an indwelling urinary catheter. She was observed in the dining room with her shirt not pulled down in the back, exposing a colostomy bag that appeared more than 3/4 full of liquid stool, while her urinary collection bag was about 1/2 full and not in a privacy bag. Staff assisted her into her wheelchair but did not cover the bag or take her to empty either collection bag at that time. Later, the DON removed her from the dining room, emptied the colostomy bag, and assisted her to change her shirt. The resident stated she did not like it when the colostomy bag was not covered and reported that when the bag was too full it caused pain and discomfort due to pulling on her skin.
Failure to Respond to Resident Council Grievances
Penalty
Summary
The facility failed to honor residents’ right to organize and participate in resident/family groups by not providing a verbal or written response to the Resident Council regarding grievances raised in multiple meetings. The report states that the facility did not consider the views of the resident group or act promptly upon grievances and recommendations concerning resident care and life in the facility, and did not demonstrate its response and rationale for its response for 12 of 15 confidential residents reviewed for meeting grievances. Record review showed the Resident Council submitted grievances related to nursing services, dietary services, housekeeping services, and other daily living concerns across several months. These included reports that bed sheets were not being changed for a month or more, housekeepers were noisy and disrespectful in the mornings, exterminator visits were requested more often, a shower room heater needed repair before winter, staff talked too loudly in the hallway, residents wanted boiled eggs instead of powdered eggs, more outside activities were requested, beds should be made daily with fresh sheets, nursing staff made negative remarks about other staff members, carts were being banged into walls, medication drawers were being slammed, laundry staff should label personal items, toast was not being served because bread was too soft or too hard, meal trays were left in the hallway overnight, a night nurse aide spent too much time with one resident and was loud, and nurse aides were not paying attention during shower chair transfers.
Unsafe Room Conditions and Lack of Hot Water
Penalty
Summary
The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for multiple resident rooms observed for environmental conditions. During observations, several resident room sinks on Hall 1 had hot water temperatures measured at 74.1 degrees F, 73.9 degrees F, 74.3 degrees F, and 74.1 degrees F. A family member of Resident #53 stated they had concerns about the facility not having hot water for residents and family members to wash their hands, and said the issue had been going on for a while. In a confidential group interview, 3 of 15 residents stated they had no hot water in their rooms and said the Maintenance Director was aware of the issue and it had not been fixed. The facility also failed to ensure that mattresses in several resident rooms had intact nonpermeable outer covers. During an observation and interview, Resident #72 stated his mattress was peeling and bothered him when he slept because he could feel the cracks; the mattress cover was observed cracked and peeling on the top half. In another room, a mattress was observed without sheets and with the protective nonpermeable outer cover cracked and peeled throughout the whole mattress, and Resident #26 was not present during the observation. Resident #27 and Resident #53 each stated their mattresses were peeling and uncomfortable because they could feel the cracks and peeling, and their mattresses were observed with cracked and peeling protective covers. Staff interviews confirmed awareness of the conditions. A housekeeper stated some mattresses had cracks and were peeling and that management was likely aware, and said she used disinfect spray to sanitize the mattresses. The ADMN stated mattresses were being replaced as needed but only four could be ordered per month, and said residents should have mattresses that were not cracked or peeling and were comfortable. The Maintenance Director stated he was aware of the hot water problem on Hall 1, had called a repair company, and was waiting for corporate approval for repairs. The ADMN later stated he was aware of hot water issues in multiple halls and that the facility was waiting for upper management approval before repairs could be made.
Incomplete Care Plans for Mental Health, Smoking, and Tube/Catheter Care
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and time frames for 4 of 18 residents reviewed. Resident #2 had diagnoses including dementia, schizoaffective disorder, bipolar disorder, major depressive disorder, and anxiety disorder, and the quarterly MDS showed severe cognitive impairment with active diagnoses of anxiety and depression. The care plan dated 11/01/2025 did not include a care plan addressing Major Depressive Disorder or Anxiety Disorder, and the DON acknowledged that such care plans should have been present but were not. Resident #3 was cognitively intact and stated that he smoked cigarettes and had no issues with the smoking process. His care plan, last revised 1/20/26, did not address smoking. During interview and record review, the ADMN and DON confirmed that he smoked and that there should have been a specific care plan for smoking, but none was present. The DON stated she had assessed him for safe smoking and that there had been no negative outcome, but the smoking status was still not included in the care plan. Resident #4 had diagnoses including neurogenic bladder, dysphagia, and nontraumatic cerebral hemorrhage, and the admission MDS showed severe cognitive impairment. She had a gastrostomy tube since admission, and physician orders included monitoring and assessing the unused gastrostomy tube and flushing it every 12 hours with 30 mL of fluid as needed. The comprehensive care plan did not include any focus, goal, or interventions related to flushing the gastrostomy tube. Resident #33 had diagnoses including neuromuscular dysfunction of bladder and UTI, was cognitively intact, had an indwelling catheter, and had orders to change the Foley catheter as needed and monitor urinary output every shift, but the comprehensive care plan did not include any focus, goal, or interventions related to Foley catheter care.
Missed Menu Item and Improper Food Substitution
Penalty
Summary
The facility failed to provide each resident with a nourishing, well-balanced diet to meet daily nutritional and special dietary needs for 21 of 73 residents reviewed for food and nutrition services. On the posted menu for a regular diet, lunch included soft tacos, refried beans, tortilla soup, and brownie. During observation of food preparation and service in the kitchen, the facility did not have enough refried beans or a comparable substitute, resulting in 21 residents not receiving refried beans. After 17 residents were served trays without refried beans, the Dietary Manager provided rice to the last 4 trays/residents. In interviews, the Dietary Manager said there were 53 residents on a regular diet and that she would try to identify the residents who did not receive refried beans and give them rice. The Dietician stated that rice was not an appropriate substitute for refried beans and would not have approved that substitution, and that when the kitchen runs out of food, a nutritional equivalent substitute should be provided. The substitution log for April 2026 was blank, and the Dietary Manager said she had not filled it out yet. The Dietary Manager and Administrator stated they did not know why the facility ran out of refried beans, and the Dietary Manager said she was not sure whether rice was a comparable nutritional substitute and should have called the Dietician before making the substitution.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During an initial tour, the floors throughout the kitchen were observed to be soiled with dirt and food crumbs, especially around the baseboards. The stand that the mixer was on was also soiled with dirt and food crumbs, and there was a pile of food thickener or flour underneath the stand. The plastic container holding the food thickener had spilled dried food and dust on the outside, and a plastic scoop was lying on top of the container. Additional observations showed the convection oven and stove had dried baked-on food on the inside and grease and dust on the outside. Extra oven shelves stored on top of the convection oven were covered with old baked food and grease. The shelf above the stove was soiled with food crumbs and dust, the bottom shelf of the refrigerator had food crumbs, and the stand holding residents' plates was soiled with food crumbs. The Dietary Manager stated it was her expectation for the kitchen to be clean after every meal, and the Administrator stated it was his expectation for the kitchen to be clean. A policy regarding kitchen sanitization was requested but not provided by the time of exit.
Inaccurate MDS Assessment Coding
Penalty
Summary
The facility failed to accurately assess Resident #4’s status on the admission MDS. Resident #4 was a [AGE]-year-old female admitted with diagnoses including dysphagia and nontraumatic cerebral hemorrhage. The admission MDS, dated 03/14/2026 and reviewed on 04/24/2026, documented a BIMS score of 00 indicating severe cognitive impairment, a gastrostomy tube since admission, and a weight loss of 5% or more in the last month or 10% or more in the last 6 months. The MDS also coded Eating as partial to moderate assistance for bringing food and liquid to the mouth and swallowing once the meal was placed before the resident. Record review showed a physician order dated 04/23/2026 with a start date of 4/21/2026 to monitor and assess a non-used gastrostomy tube and flush it every 12 hours with 30 milliliters of fluid as needed. The resident’s regular diet was Mechanical Soft texture with Regular consistency. The comprehensive care plan for Resident #33 reviewed on 04/24/2026 reflected no focus, goal, or interventions related to weight loss or gastrostomy tube feedings. During interview, the MDS coordinator stated she was responsible for MDS assessments and acknowledged she made a mistake in the documentation and had coded the assessment incorrectly for weight loss. The DON stated her expectation was for the MDS assessment to be completed in a timely manner and accurately.
Failure to Secure Foley Tubing and Document Urine Output
Penalty
Summary
The facility failed to ensure appropriate catheter care and urinary output monitoring for a resident with an indwelling urinary catheter and diagnoses including neuromuscular dysfunction of the bladder and UTI. The resident’s record showed she was cognitively intact, had an indwelling catheter, and was always incontinent of bowel movement. Physician orders included changing the indwelling urinary catheter as needed and monitoring urinary output every shift, but the MAR did not document urine output on several day shifts in April 2026, and the care plan did not include a focus, goal, or interventions related to Foley catheter care. During observation, the resident’s catheter tubing was found leaking into a brief and was not secured to her leg with a securement device. The catheter was changed, but the nurse who performed the change did not place a securement device on the tubing. On a later observation, the resident’s catheter bag was not covered with a privacy bag and there was no tape securing the catheter to her leg. The resident stated she had pain when moved and that the catheter had been replaced because it was hurting her. She also stated she wanted a privacy bag so her family would not see her urine when they visited. Interviews with the DON and LVN A confirmed that nurses were expected to secure catheter tubing to the resident’s leg and ensure a privacy bag was in place. The DON also stated urine output should be documented on the MAR when a resident had an indwelling urinary catheter. LVN A stated she did not secure the catheter because she forgot while being observed, that the catheter bag should have had a privacy bag, and that if outputs were not documented then she could not prove the bag had been emptied. The facility policy stated catheter tubing should remain secured with a leg strap, daily output should be maintained, and documentation should include catheter care provided and assessment data.
Incomplete Readmission Assessment and Missing Vital Signs Documentation
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for one resident after hospitalization and readmission. Resident #54, a cognitively intact female with diagnoses including diastolic CHF, atrial fibrillation, and HTN, returned to the facility from the hospital after treatment for sepsis and a UTI. Record review showed no evidence that a readmission assessment was completed and no vital signs were documented for several days after the resident returned, despite the facility policy requiring a readmission assessment, medication reconciliation, infection screening, provider notification, and care plan update within 4 hours of return. Progress notes showed the resident arrived back at the facility from the hospital, and later that same day she was transported again after staff called 911 when she became nonresponsive. During interviews, an LVN stated the admitting nurse was responsible for obtaining vital signs and completing the readmission assessment, and that daily vital signs for three days were intended to reduce rehospitalization risk. Another LVN stated she had not taken vital signs because there was no order for blood pressure or pulse, while the DON stated she expected the nurse to complete the assessment and daily vital signs but was falling behind on monitoring whether nurses were completing those assessments. The MD stated he expected nurses to perform assessments on admission or readmission but did not expect continued vital signs unless ordered.
Failure to Employ a Full-Time Licensed Social Worker
Penalty
Summary
The facility failed to employ a qualified social worker on a full-time basis in a building with a licensed capacity of 188 resident beds. During interview, the SSD stated she had a master's degree in social work from Puerto Rico and had been licensed in New York, but she was not licensed in Texas at the time of the survey and was working to obtain reciprocity. She stated she had been performing social work duties for the facility since December 2025, but she did not come to the facility and all communication was by phone or virtually. During interviews, the VP of HR stated she was unfamiliar with Texas regulations for a social worker and needed to review them before answering questions about licensure requirements. The ADMN stated his expectation was to have a full-time social worker that was licensed, but the SSD was still working on transferring her license to Texas. He stated no other social worker was in the building to perform social work duties, although the SSD had corporate oversight. Record review showed the Social Services job description dated 12/12/2025 listed licensure as preferred, the Social Services Director job posting listed licensure as required, and the facility policy stated not all medically-related social services are provided by a qualified social worker, but the facility is responsible for ensuring residents receive these services.
Unattended and Unlocked Medication Cart with Accessible Drugs and Items
Penalty
Summary
During a medication storage inspection, surveyors observed that medication cart #1 was left unlocked and unattended outside the nurse's station, with residents and staff in close proximity and out of staff eyesight. The cart had unlocked drawers facing outward and contained various items including a butter knife, nail clippers, mouth wash, an unopened petrolatum dressing, glucometers, lancets, lab draw kits with needles, hand sanitizer, zinc oxide creams, moisture barrier creams, and several over-the-counter (OTC) medications such as Milk of Magnesia, cough suppressant, fish oil, gas relief tablets, B-Vitamins, Colace, Vitamin D, acid reducers, melatonin, and senna tablets. AA batteries were also found in one of the drawers. The cart was identified as previously used for isolation during COVID-19 but was no longer in use for that purpose. Interviews with the DON, LVN, and ADMN confirmed that the cart should have been locked when not in use and that staff were responsible for monitoring and securing it. The DON acknowledged that residents could have accessed the medications and items on the cart, potentially leading to harm. The ADMN stated that the responsibility for ensuring medication carts are locked ultimately rested with him and that the failure to secure the cart was due to staff being too busy to lock it after use. Facility policy reviewed by surveyors required all medications and biologicals to be stored in locked compartments, with access limited to authorized personnel.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover all assessed needs or provide clear, measurable interventions.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. The survey revealed improper thawing of ground meat, which was placed in a dish with running water but not fully submerged, leaving approximately 30% of the meat exposed. This method of thawing does not comply with the facility's policy, which requires meat to be thawed in a refrigerator or completely submerged under running water at a temperature of 70°F or below. Additionally, the facility did not ensure proper hand hygiene during food preparation. The cook was observed donning gloves without washing hands and handling food items without performing hand hygiene between glove changes. This practice contradicts the facility's hand hygiene policy, which mandates handwashing before donning and after doffing gloves to prevent cross-contamination and the spread of bacteria. The facility also failed to properly label and store food items. Several food items were found without proper labeling, including bags of food that were not sealed and expired items that were not disposed of. The dietary manager and dietician confirmed that food should be labeled with a description and date, and stored at least six inches off the floor. The lack of proper labeling and storage could lead to the wrong food being served, potentially causing allergic reactions or foodborne illnesses among residents.
Failure to Obtain Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed and provided consent for the administration of antipsychotic medication, specifically Seroquel (quetiapine), for two residents. Resident #29, who has a diagnosis of schizoaffective disorder, bipolar type, was administered Seroquel without a signed consent from either the resident or their representative. The medication was given at an increased dosage without obtaining the necessary consent, and there was no evidence that the side effects were communicated to the resident's representative. Attempts to contact the representative for consent were unsuccessful. Resident #44, diagnosed with neurocognitive disorder with Lewy bodies and major depressive disorder, also received Seroquel without a signed consent. The medication was administered multiple times over several months without documented consent from the resident or their representative. The facility's staff, including the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), acknowledged the oversight and the lack of a proper process for obtaining consent for antipsychotic medications. Interviews with facility staff revealed that there was confusion and a lack of clear policy regarding obtaining consent for antipsychotic medications. The DON admitted to not being aware that verbal consents were inappropriate for such medications, and the Clinical Care Nurse (CCN) mentioned that there were barriers to obtaining consents, such as unresponsive family members. The facility's policy, updated in July 2024, requires written consent for psychotropic medications, but this was not adhered to in these cases.
Deficient Care Plans Lacking Measurable Objectives
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for six residents, which included measurable objectives and time frames to meet their highest practicable physical, mental, and psychosocial well-being. The care plans for these residents lacked specific, measurable objectives for various issues such as resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks. This deficiency was identified during interviews and record reviews, highlighting the absence of clear, actionable goals in the care plans. For Resident #23, the care plan did not define measurable objectives for problems related to resisting care, visual function, oral hygiene, pain, mobility, cognitive loss, and daily tasks. Similarly, Resident #26's care plan lacked measurable objectives for issues concerning psychotropic drug use, psychosocial well-being, pain, mood, behaviors, activities of daily living, and daily tasks. Resident #36's care plan also failed to address mobility and daily tasks, as well as visual function and communication, which were triggered on the MDS. The care plans for Residents #39, #53, and #62 were similarly deficient. Resident #39's care plan did not include measurable objectives for visual function, self-care deficits, decreased cognition, and daily tasks, nor did it address dental care and communication. Resident #53's care plan lacked measurable objectives for daily tasks, pain, ADL function, and impaired cognition. Lastly, Resident #62's care plan did not define measurable objectives for self-care related to mobility, impaired cognition, and daily tasks. These failures could affect residents and place them at risk for not having their needs and preferences met.
Failure to Implement Food Storage Policy
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought to residents by family and other visitors, which is essential for ensuring safe and sanitary storage, handling, and consumption. Specifically, the facility did not maintain proper temperature logs for personal refrigerators of five residents, which could lead to foodborne illnesses. Observations revealed that Resident #17's refrigerator contained expired goods and lacked a temperature log, while Resident #43's refrigerator was missing a thermometer and a temperature log. Additionally, Residents #22, #5, and #49 had incomplete temperature logs for February 2025. Interviews with staff indicated that night shift staff were responsible for checking the residents' personal refrigerators, but this was not consistently done. The Administrator (ADMN) expected that refrigerator temperatures should be checked weekly and recorded, but acknowledged that staff did not perform thorough checks during their rounds. The facility's policy required that refrigerators maintain proper temperatures, be equipped with thermometers, and have temperatures recorded weekly. However, these procedures were not followed, leading to the potential risk of residents consuming spoiled food.
Facility Fails to Maintain Safe Environment Due to Broken Toilet
Penalty
Summary
The facility failed to maintain a safe and comfortable environment for a resident by not ensuring that the resident's toilet was free from cracks and securely attached to the floor. The resident, who was cognitively intact and used a wheelchair, expressed concerns about the broken toilet, fearing a fall. Observations confirmed that the toilet base was cracked and moved when pressed, posing a risk to the resident's safety. Despite the resident's complaint and a repair request made by a staff member, the issue remained unresolved. The maintenance director (MD) was aware of the problem but had been on leave due to an injury, which contributed to the delay in addressing the issue. The administrator (ADMN) was unaware of the broken toilet and did not check the electronic system for repair requests, leading to a communication breakdown. The facility's admission agreement emphasized the residents' right to safe and clean conditions, which was not upheld in this instance.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments and allowed unauthorized access to medication for one resident. During an observation, a bottle of prescription hydrocortisone cream was found in a resident's personal refrigerator, which was not locked. The resident did not have a physician's order for the hydrocortisone cream, and it was noted that the resident was unable to apply the cream themselves. This indicates that the cream was likely left in the room for staff convenience, contrary to the facility's policy. Interviews with staff, including an LVN and the DON, confirmed that prescription medications should not be left in resident rooms and that the presence of the cream in the resident's refrigerator was a failure in following proper procedures. The DON acknowledged that the oversight could lead to improper medication administration and attributed the failure to staff not being thorough in their checks. The facility's policy requires that drugs and biologicals be stored in locked compartments, accessible only to authorized personnel, which was not adhered to in this instance.
Inadequate Use of PPE During Catheter Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the improper use of personal protective equipment (PPE) by a certified nursing assistant (CNA) during the care of a resident with a Foley catheter. The resident, a female with dementia, a disorder of the urinary system, and type 2 diabetes, was on enhanced barrier precautions due to her indwelling Foley catheter. During an observation, the CNA did not wear a gown while performing catheter care, despite the requirement for full PPE, including a gown, gloves, and mask, as per the facility's policy on enhanced barrier precautions. Interviews with the licensed vocational nurse (LVN) and the director of nursing (DON), who also serves as the infection preventionist, confirmed that the CNA should have worn a gown during the procedure to prevent the spread of bacteria. The facility's policy on enhanced barrier precautions mandates the use of targeted gown and gloves during high-contact resident care activities to reduce the transmission of multidrug-resistant organisms. The absence of PPE outside the resident's room and the CNA's failure to don the required gown during catheter care were identified as deficiencies in the facility's infection control practices.
Facility Fails to Maintain Sanitary Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for two residents, leading to a deficiency in maintaining sanitary conditions. Resident #3, a female with multiple health conditions including cerebral infarction and generalized anxiety disorder, was found to have a bathroom infested with cockroaches. Despite repeated complaints from her family member, the issue persisted, and an inspection revealed a large cockroach and several smaller ones in her bathroom. Additionally, the air conditioner unit in her room was clogged with a thick layer of lint, further contributing to an uncomfortable environment. Resident #8, a male with type 2 diabetes and a history of amputations, also experienced similar issues with cockroaches in his bathroom. He reported seeing roaches frequently, including one that emerged from his pants containing his prosthetic legs, which nearly caused him to fall. The air conditioner in his room was similarly clogged with lint and dirt, and the unit was inadequately secured to the window with tape. Despite his reports to various staff members, including the CNAs, nurses, and the Administrator, the problem remained unresolved. The facility's pest control measures were inadequate, as evidenced by the ongoing presence of cockroaches documented in the Pest Control Logbook since early 2023. The facility had a contract with a pest control company for monthly services, but the infestation persisted. The Administrator acknowledged the issue and stated that while the situation had improved since her arrival, it was still a concern. The Maintenance Supervisor confirmed awareness of the problem and the facility's reliance on professional pest control services, which had not been recently utilized beyond the regular monthly visits.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident within the required timeframe. A family member of the resident reported an incident where a CNA allegedly placed her elbow on the resident's thigh, causing discomfort. The family member provided a video of the incident to the facility's social worker, who then shared it with the Administrator and DON. Despite the evidence, the facility did not report the incident to the state agency as required. The resident involved was an elderly female with multiple diagnoses, including cerebral infarction, generalized anxiety disorder, cellulitis, and osteoarthritis of the knee. She was dependent on assistance for all bed mobility and had a moderate cognitive impairment. The incident was captured on video, showing the CNA sitting on the edge of the resident's bed and placing her elbow on the resident's thigh, which the resident found uncomfortable. Interviews with facility staff revealed that the incident was not reported because the family member did not believe the act was intentional and felt that training was appropriate. The Administrator and DON also did not report the incident, citing a lack of intent to harm. The facility's policy required all allegations of abuse to be reported immediately, but this protocol was not followed in this case.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to investigate an alleged abuse incident involving a resident and a Certified Nursing Assistant (CNA). A family member of the resident reported the alleged abuse to the facility's social worker, including a video showing the incident. Despite the report, the facility did not conduct a thorough investigation or suspend the CNA involved, as required by their abuse prevention policy. The Administrator and Director of Nursing (DON) viewed the video but did not consider the incident as intentional abuse, and thus did not report it as such. The resident involved was an elderly female with multiple medical conditions, including cerebral infarction, generalized anxiety disorder, cellulitis, and osteoarthritis of the knee. She was dependent on assistance for all bed mobility and had moderate cognitive impairment. The alleged abuse involved the CNA placing her elbow on the resident's sore leg, which was captured in the video provided by the family member. The facility's response was limited to reassigning the CNA to another resident and providing some education, without a formal investigation or suspension. Interviews with the facility staff, including the CNA, DON, and Administrator, revealed that the incident was not treated as an abuse allegation. The social worker, who first received the video, believed the movement was inappropriate and that the administration should have followed protocol by investigating the allegation and suspending the CNA if necessary. The facility's policy mandates that all allegations of abuse be thoroughly investigated and reported to the appropriate agencies, which was not done in this case.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in two common areas and in the bathrooms of two residents. Resident #3, a female with cerebral infarction, generalized anxiety disorder, cellulitis, and osteoarthritis of the knee, was reported by her family member to have cockroaches in her bathroom. The family member had observed roaches running across the floor and had resorted to using mothballs to address the issue, as the facility did not respond to her concerns. Resident #3 herself confirmed seeing cockroaches in her bathroom. Resident #8, a male with type 2 diabetes mellitus, acquired absence of both legs below the knee, generalized anxiety disorder, and a stage 3 pressure ulcer, also reported cockroaches in his bathroom. He described an incident where a cockroach emerged from his pants, which contained his prosthetic legs, causing him distress. Despite reporting the issue to various staff members, including CNAs, nurses, the DON, and the Administrator, the problem persisted. Observations confirmed the presence of cockroaches in Resident #8's bathroom. The facility's pest control measures were inadequate, as evidenced by the ongoing presence of cockroaches despite a contract with a pest control company for monthly services. The Maintenance Supervisor acknowledged the issue, noting that the facility was an older building with recurring pest problems. The Pest Control Logbook documented sightings of roaches since February 2023, with the most recent entry on the day of the investigation. The Administrator admitted awareness of the issue and stated that while the situation had improved since her arrival, it remained unresolved.
Inadequate Infection Control and PPE Protocols Lead to COVID-19 Exposure
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, leading to the exposure and potential transmission of COVID-19 among residents. The deficiency was observed in the facility's inability to isolate COVID-19 positive residents from those who tested negative. Specifically, COVID-19 positive residents were cohorted with negative residents on the same unit, and in some cases, shared the same room. This failure to properly isolate residents was evident when a COVID-19 positive resident was placed in the same room as a COVID-19 negative resident, increasing the risk of transmission. Additionally, the facility did not ensure that staff adhered to proper personal protective equipment (PPE) protocols. Staff members were observed not changing PPE between interactions with COVID-19 positive and negative residents, and some staff did not wear the required PPE, such as goggles or face shields, when caring for residents. This lack of adherence to PPE protocols further contributed to the risk of spreading the virus within the facility. The facility also failed to enforce quarantine measures for COVID-19 positive residents. One resident, who was COVID-19 positive, was observed leaving their room without wearing a mask, interacting with other residents, and using shared facilities, thereby exposing multiple COVID-19 negative residents. The facility's infection prevention policy was not effectively implemented, as evidenced by the lack of individual room isolation and the improper use of PPE by staff, which contributed to the spread of COVID-19 among residents.
Removal Plan
- COVID negative residents will be temporarily moved to another hall. Residents will continue to be tested per policy. As residents of the secure unit recover, they will be relocated to the negative cohort secure unit. Residents will be moved back into the secured unit if they test positive or there are no longer COVID+ residents on the male secured unit. The negative residents, who have not tested positive, are separated on their own hall, residents are residing in separate rooms, staff was wearing masks and eye protection.
- Testing will occur every three days, until the facility had been COVID free.
- Administrator and Director of Nursing educated by Clinical Resource Nurse over COVID policy as it related to isolation protocol. PPE must be donned correctly before entering the patient area. PPE should be doffed when leaving an individual patient room or isolation unit if cohorting. PPE must remain in place and be worn correctly for the duration of work in contaminated areas and should not be adjusted during patient care. If cohorting, positive residents' gown and gloves should be changed following patient care. PPE includes NIOSH approved respirator, well-fitting face masks, gowns, gloves, eye protection.
- N95 masks may be worn for the duration of the shift when used solely for source control but should be changed when soiled or compromised. Other PPE should be changed when it becomes soiled.
- All staff will be educated prior to working their next shift. Any new or temporary staff will be educated prior to working their first shift.
- Administrator, Director of Nursing, Assistant Director of Nursing, and/or Designee will observe the secured unit to monitor for correct PPE usage and proper hand hygiene.
- Director of Nursing, Assistant Director of Nursing, and/or Designee will continue to test per protocol and will follow isolation guidelines per the facility policy.
- Ad hoc QAPI performed with Medical Director informing him of the IJ template for F880 and the facility's plan to remove immediacy.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents, resulting in a resident with severe cognitive impairment eloping from the facility. The resident, who had a history of wandering in unsafe places and was care planned for elopement risk, was last seen by staff at 2:00 PM and was missing for approximately six and a half hours before being located by law enforcement. The facility was unaware of the resident's absence until 8:00 PM, indicating a significant lapse in monitoring and supervision. Interviews with staff revealed that the resident was seen in various locations within the facility throughout the day, but there was no consistent monitoring to ensure his whereabouts. The resident's meal tray was left untouched in his room, and staff failed to verify his location when the tray was not eaten. The facility's policy on wandering and elopement was not effectively implemented, as staff did not monitor the doors or ensure that residents at risk for elopement were adequately supervised. The facility's documentation and interviews indicated that the resident was not safe to be out of the facility unsupervised. Despite this, the resident managed to exit the building and walk several miles to a local homeless shelter, crossing busy streets and railroad tracks. The facility's failure to monitor the resident and secure the exits led to the resident's elopement, posing a significant risk to his safety and well-being.
Removal Plan
- Resident was sent to the hospital for evaluation when he arrived back to the nursing facility, no new orders received. Resident was assessed upon returning from the hospital.
- Resident was reassessed for being an elopement risk and placed in the secured unit for safety.
- Medical Director notified of the incident.
- Resident head count performed throughout the center to ensure no other residents were identified as missing. No other residents noted missing.
- All doors verified in working order. No issues noted with the door functions. Additionally, the doors were checked for functionality with no concerns.
- Gates checked for functionality; No concerns, all gates are functioning properly.
- Mock elopement drills performed each shift.
- Signage present on doors that state, 'Attention visitors please do not allow anyone to exit the building with you that did not come in with you, help us keep our residents safe, any questions please contact a staff member, thank you.'
- All residents in house received an updated elopement assessment. Ensured all care plans match the updated elopement assessment and are person-centered.
- All staff educated: Wandering & Elopement/Missing Resident Policy (to include adequate supervision to prevent accidents or elopements and when delivering meal trays in either dining area or in residents rooms staff should ensure residents are located and aware of meal. Any meal tray picked up that is not eaten staff need to verify resident is located and aware meal tray is ready. Charge nurse will be notified immediately if resident is not observed and informed.
- Certified Nurses Aides, Certified Medication Aides, and Charge Nurses educated on the resident profile to inform them of the level of supervision, elopement risk, and educated over accuracy of documentation. The type and frequency of resident supervision may vary among residents as determined by the residents' assessed needs and the identified hazards in the environment.
- If resident is not observed during medication pass, meal times, and/or routine resident care rounds the charge nurse will be notified and the center will initiate a search for the resident immediately. The clinical staff will know to perform this action through education.
- Action items in the above plan of removal will be monitored for effectiveness daily, for 1 month and until deemed by QAPI committee that the facility is in substantial compliance. If any changes are needed, they will be brought to the QAPI committee and discussed for a plan action.
- Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy template and the facility's plan to lower the Immediate Jeopardy.
Failure to Report Elopement Incident
Penalty
Summary
The facility failed to report allegations of abuse and neglect to the State Survey Agency within the required timeframe following the elopement of a resident. The resident, who had severe cognitive impairment and was at high risk for elopement, was found missing from his room during a medication pass. The staff initiated a search and notified the administrator, Director of Nursing (DON), and law enforcement. The resident was eventually found at a Salvation Army location and returned to the facility without any immediate physical harm. However, the incident was not reported to the State Survey Agency as required by regulations and facility policy. Interviews with staff revealed that the Licensed Vocational Nurse (LVN) on duty discovered the resident missing and followed the facility's emergency procedures for a missing resident. The Social Worker (SW) and DON confirmed that elopement is a reportable incident and that the administrator, who is the Abuse/Neglect Coordinator, was responsible for reporting it. The administrator admitted to having prepared the report but failed to send it due to being distracted by other tasks. This lapse in reporting was acknowledged during the interview. The facility's policies on emergency procedures for missing residents and the abuse prevention program clearly state the requirements for reporting such incidents to the State Survey Agency. Despite these policies, the failure to report the elopement incident in a timely manner was identified, which could potentially affect the safety and well-being of other residents by delaying necessary investigations and interventions.
Failure to Provide Proper Discharge Notice and Documentation
Penalty
Summary
The facility failed to permit Resident #2 to remain in the facility and did not provide a written discharge notice or a discharge summary. Resident #2, a male with multiple medical conditions including Type II Diabetes Mellitus, Hypertension, and bilateral leg amputations, was informed by the social worker that he needed to find an alternate residence by 3:30 PM on the day of discharge. The facility did not provide any discharge paperwork or medications to Resident #2 at the time of discharge, which led to him experiencing multiple health issues and emergency room visits due to not having his medications. Resident #2 reported that he was told to leave the facility because he tested positive for illegal substances, specifically Delta-8, which he believed to be legalized marijuana. He stated that he did not feel he had a choice in taking the drug test and was told he had to leave the facility that day. The facility planned to discharge him to a local homeless shelter, which he refused because it was not a permanent place and he needed help with his medications. The resident expressed concerns about his safety and well-being after being discharged without proper arrangements. The facility's administrator confirmed that their policy had recently changed to immediate discharge for residents testing positive for illegal substances. However, Resident #2 had not signed any confirmation of this policy, and the facility did not follow their own policy of providing a 30-day written notice or ensuring the discharge was done correctly. The administrator admitted that the failure to provide a written discharge notice and proper documentation was due to following the corporate policy without ensuring compliance with the facility's established procedures.
Failure to Develop Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident with severe cognitive impairment, Alzheimer's disease, type 2 diabetes mellitus, hypertension, and Major Depressive Disorder. The care plan did not include specific interventions to address the resident's need for supervision for wandering, despite a history of wandering behaviors reported by the resident's family member. The resident's care plan included general approaches for behavioral symptoms, falls/safety risk, delirium, and cognitive loss but lacked detailed, measurable actions for supervision related to wandering. Interviews with facility staff revealed that the MDS Coordinator and the DON were aware of the resident's wandering behavior but did not include specific supervision interventions in the care plan. The MDS Coordinator noted that the resident's MDS was coded with no wandering because the behavior did not occur during the lookback period, and the DON acknowledged that the care plans were incomplete and not double-checked for accuracy. The DON also mentioned that the resident exhibited wandering issues but not elopement issues, which led to the omission of elopement interventions in the care plan. The facility's policy on comprehensive care plans requires that care plans describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. However, the care plan for this resident did not meet these standards, as it lacked person-centered interventions for supervision despite the resident's identified need. This deficiency was identified during a survey, and the facility's failure to address the resident's supervision needs placed the resident at risk for not receiving appropriate care and services.
Insufficient Nursing Staff
Penalty
Summary
The facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. On 04/09/2024, observations revealed that the facility had a census of 78 residents with only 3 LVNs and 4 CNAs scheduled for both day and night shifts. Unit 1 had 2 LVNs and 3 CNAs for 61 residents, while Unit 2, a secured unit, had 1 LVN and 1 CNA for 16 residents. The total hours scheduled to be worked during this 24-hour period equaled 168, which was insufficient according to the facility's assessment tool. Interviews with the ADMN confirmed that the facility was experiencing staffing issues, including agency staff canceling shifts and a no-call no-show incident on the morning of 04/09/2024, which left the facility short-staffed and unable to fill the shift at that time. Record reviews of timesheets from various dates in 2024 showed that the facility consistently failed to meet the required direct care staff hours based on their census and facility assessment. For example, on 02/20/2024, only 168.200 hours were worked by direct care staff, whereas 225.15 hours were needed. Interviews with residents further highlighted the impact of insufficient staffing. One resident reported not having had a shower in three weeks, while another resident expressed concerns about not being transferred out of bed as requested and experiencing delays in call light responses. The facility's assessment tool, last updated on 04/02/2024, indicated that the average HPPD was 2.85, but the facility failed to meet this standard, leading to unmet resident needs and compromised safety and well-being.
Failure to Provide Necessary Care and Services
Penalty
Summary
The facility failed to provide necessary care and services to ensure the highest practicable physical, mental, and psychosocial well-being for two residents. Resident #10, a [AGE] year-old female with multiple diagnoses including moderate cognitive impairment, chronic obstructive pulmonary disease, and heart failure, did not receive showers as per her request on several documented dates. Despite her care plan indicating a preference for showers on specific days and times, there was no evidence of assistance provided on multiple occasions. During an interview, Resident #10 confirmed she had not had a shower in three weeks and attributed this to the facility being short-staffed. Resident #12, a [AGE] year-old female with diagnoses including Parkinson's disease, breast cancer, and depression, was not transferred from bed to chair as per her request. Her care plan specified her preference to be transferred after breakfast on certain days, but she reported that staff often delayed or failed to assist her. During an observation, Resident #12 expressed frustration over the lack of timely assistance and mentioned that she had called the Ombudsman and requested a meeting with the administrator to review her care plan. She also noted that other residents would enter her room, and staff were slow to respond to her call light. The facility administrator acknowledged the staffing issues, stating that the facility used a summary tool to determine staffing ratios and had started contracting agency nurses and CNAs to help with staffing. However, the facility continued to face challenges with agency staff canceling shifts, making it difficult to maintain appropriate staffing levels. The facility's assessment tool and policy on resident rights emphasized the need for adequate staffing to ensure residents' well-being, but the facility was still understaffed, impacting the quality of care provided to the residents.
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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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