Avir At Grand Saline
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Saline, Texas.
- Location
- 1638 Vz Cr 1803, Grand Saline, Texas 75140
- CMS Provider Number
- 675878
- Inspections on file
- 22
- Latest survey
- March 22, 2026
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Avir At Grand Saline during CMS and state inspections, most recent first.
The facility failed to ensure safe food handling by not consistently monitoring and documenting cooking and holding temperatures, and by lacking effective dietary oversight. Review of temperature logs showed many missing or incomplete entries for multiple meals, and on numerous days no logs were available at all, despite written standards specifying required internal cooking and holding temperatures. A complaint alleged that a resident was served raw chicken, and a family member reported that chicken had been served undercooked. The new DM acknowledged that she had not verified that cooks were completing temperature logs and had not trained a newly hired cook on the logging process. The cook stated he was unaware of the temperature log, did not document temperatures, and knew only the poultry temperature requirement, not other food or holding standards. These actions and inactions conflicted with the facility’s own dietary policies and job descriptions, which required temperature control, recordkeeping, and investigation of food quality complaints.
A resident with severe cognitive impairment and a Wanderguard bracelet exited the facility unsupervised after staff failed to conduct a proper census check when a door alarm sounded. The resident was not discovered missing until contacted by police, who found him over a mile away. Staff had received training and had protocols in place, but these were not followed at the time of the incident.
The facility did not consistently develop or implement baseline care plans within 48 hours of admission for three residents with complex medical needs. In some cases, care plans were incomplete, lacked required signatures, or were not made available to nursing staff, resulting in inadequate documentation and communication about residents' immediate care needs.
A resident with diabetes and her responsible party were not informed in advance about changes to her insulin dosing and blood glucose monitoring orders after re-admission. The nurse practitioner altered the orders without documented notification to the resident or her representative, and the responsible party only learned of the changes after questioning staff. Facility staff confirmed that notification should have occurred, but it was missed in this case.
A resident with multiple chronic conditions and moderate cognitive impairment, along with her representative, was not informed of or included in the development or review of her person-centered care plan. There was no documentation of invitations to care plan meetings or provision of care plan summaries, and the representative confirmed she was not consulted or given a copy of the care plan, contrary to facility policy.
A comprehensive MDS assessment was not completed within the required 14-day timeframe for a newly admitted resident with multiple complex medical conditions. Key sections of the assessment remained incomplete, and the MDS Coordinator acknowledged the delay, citing inexperience and workload as contributing factors.
A resident with severe cognitive impairment and multiple medical conditions was admitted, but the facility did not complete a comprehensive, person-centered care plan within the required 21-day period. Staff interviews revealed that the MDS Coordinator, DON, and ADON shared responsibility for care planning, but due to new staff and organizational challenges, the care plan was not developed on time as required by policy and federal regulations.
The facility did not report to the state agency an allegation of physical abuse made by a resident against two CNAs, nor did it report a serious injury involving a subdural hematoma following an unwitnessed fall by another resident. In both cases, the required notifications were not made despite facility policy and regulatory requirements.
A resident at risk for pressure injuries developed a DTI to the right heel after staff failed to consistently perform required skin assessments and follow the care plan, particularly during a period without a treatment nurse. Nursing staff did not regularly inspect the resident's skin, and the injury was only identified after it had developed, despite facility policy and care plan directives.
Staff failed to perform proper hand hygiene between glove changes and after handling contaminated materials during incontinent care for two residents. In both cases, CNAs did not follow hand hygiene protocols as outlined in facility policy, despite having received training. Interviews revealed inconsistent understanding of hand hygiene requirements among staff and leadership.
The facility's kitchen failed to maintain sanitary conditions, with a scoop left in a flour bin, raw cabbage stored on the floor, and several food items unlabeled or undated. The dietary manager acknowledged the issues, noting that new staff were still learning procedures. These actions violated facility policy and FDA guidelines, potentially risking foodborne illness for residents.
A long-term care facility failed to maintain an effective infection control program, as staff did not adhere to Enhanced Barrier Precautions (EBP) and proper PPE disposal protocols. An LVN did not wear a gown while administering medication to a resident with a gastrostomy tube, and rooms of residents on contact isolation lacked bio-hazard containers for PPE disposal. These lapses in infection control practices could increase the risk of cross-contamination and disease spread.
A facility failed to ensure proper EBP training and implementation, as observed when an LVN did not don a gown while administering medication to a resident with a gastrostomy tube. Despite EBP signage and available PPE, the LVN only wore gloves, indicating a lack of training upon hire. Interviews confirmed that new hires were not trained on EBP, and observations showed other rooms with EBP signage lacked PPE supplies, highlighting systemic issues in infection control measures.
Failure to Monitor and Document Food Temperatures and Oversee Safe Food Handling
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the only kitchen reviewed. Surveyors’ record review of March 2026 food temperature logs showed that on multiple dates where logs were available, the facility did not document final internal cooking temperatures for breakfast, lunch, and dinner meals. For those same dates, required holding temperatures for breakfast and lunch had multiple blank or slashed entries, indicating that required temperature monitoring was not performed or recorded. On numerous additional dates in March 2026, there were no food temperature logs available at all, indicating that required temperature monitoring was not conducted or maintained on those days. The facility’s own temperature log form contained reference standards for safe food handling, including internal cooking temperatures and hot and cold holding parameters, but these standards were not consistently documented as being followed. A complaint investigation intake documented an allegation that the facility’s food was of poor quality and that a resident was served raw chicken on a specific date, which the resident did not eat. During dinner meal service observation and interview, a resident’s family member reported that kitchen staff had served chicken that was not fully cooked. The Dietary Manager (DM), who had been in her position for about one month and had previously worked as a cook for about one year, stated that cooks were responsible for obtaining and documenting food temperatures for all meals and that logs were kept on a clipboard in the kitchen. However, she acknowledged that several March 2026 food temperature logs were incomplete or not completed and that she could not confirm whether food temperatures were consistently taken. She also stated she was not aware that cooks were not completing the logs until the survey interview and that she had not followed up to ensure the logs were being completed. A cook who began working in the last week of February 2026 reported that he knew food temperatures were to be taken but said he was not instructed to document them and was unaware of the existence of a food temperature log. He stated that no one had shown or reviewed the temperature log with him, and while he knew poultry must reach 165°F, he could not identify required temperatures for other foods or the minimum holding temperatures for hot or cold items. The DM confirmed she had not trained or reviewed the food temperature log process with this cook and had assumed another cook had done so. The DM reported that she was notified on a specific date about residents’ complaints regarding uncooked chicken and received a picture showing chicken that was not fully cooked; she stated it was possible food temperatures were not taken that day and did not check the temperature log at that time. The cook initially denied but later admitted he was the cook who prepared the chicken on the date in question, stated he took the temperature but did not document it, and acknowledged that some chicken may not have been properly prepared. The DM’s job description and the facility’s Food Preparation and Service Policy both required oversight of dietary operations, investigation of food quality complaints, maintenance of dietary records, and adherence to specific cooking and holding temperatures, but the documented practices and interviews showed these requirements were not consistently implemented or monitored. The facility’s written Food Preparation and Service Policy, revised in November 2022, defined the temperature danger zone, identified potentially hazardous foods, and specified required internal cooking temperatures and holding parameters for various food items, including poultry and reheated foods. It also required that food thermometers be clean, sanitized, and calibrated, and that food and nutrition services staff monitor temperatures of foods held in steam tables throughout meal service. The policy further required that proper hot and cold temperatures be maintained during food distribution and service, and that foods held in the danger zone beyond specified time limits be discarded. Despite these detailed policy requirements, the lack of complete temperature logs, the absence of logs on multiple days, the DM’s lack of verification of staff practices, and the cook’s lack of training and knowledge about documentation and holding temperatures collectively demonstrate that the facility did not ensure that food was prepared and served in accordance with its own professional standards and safe food handling practices. The DM’s job description, signed earlier in the year, required her to evaluate and monitor all aspects of dietary operations, maintain high-quality food, plan and conduct training and in-service education for dietary personnel, investigate and resolve food quality and service complaints, and prepare routine reports and maintain all dietary records in accordance with policies and procedures. The cook job description required inspection of food and food preparation to maintain quality standards, temperature standards, and sanitation regulations. Interviews with the DM and the cook, combined with the incomplete and missing temperature logs and the complaint about undercooked chicken, show that these responsibilities were not fully carried out. The Administrator confirmed that the DM and the cook were both new and that the DM was responsible for training dietary staff and ensuring adherence to facility policies and procedures, but the evidence in the report shows that this oversight and training did not occur as required, contributing to the identified deficiency in food safety practices.
Resident Elopement Due to Inadequate Supervision and Alarm Response
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple psychiatric diagnoses, who was wearing a Wanderguard bracelet, was able to leave the facility unsupervised. The resident was last seen by staff in the morning, and although the front door alarm sounded, the charge nurse assumed it was triggered by other residents accompanied by family members and did not conduct a facility-wide check to account for all residents with Wanderguard devices. The resident was not discovered missing until the local police contacted the facility after finding him approximately 1.3 miles away. The resident's care plan had previously identified a risk for wandering, and a Wanderguard had been placed after a prior incident where the resident was found outside the facility. Despite this, staff did not follow procedures to verify the whereabouts of all residents at risk when the door alarm was activated. Interviews with staff revealed that although they had received training on elopement procedures and the use of a binder listing residents with Wanderguards, the protocol was not followed at the time of the incident. The charge nurse did not initiate a sweep or census check to ensure all at-risk residents were present after the alarm sounded. The facility's failure to provide adequate supervision and to respond appropriately to the door alarm resulted in the resident leaving the premises undetected for approximately one hour. The resident was eventually located by law enforcement and returned to the facility without injury. The incident demonstrated a lapse in the implementation of established elopement prevention protocols, specifically in monitoring and accounting for residents identified as being at risk for wandering or elopement.
Failure to Develop and Implement Timely Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for three residents, as required by policy. For one resident with Alzheimer's disease, dementia, aortic stenosis, and osteoporosis, the electronic baseline care plan was completed but lacked signatures from the resident, the resident's representative, and the staff who developed the plan. The document was not properly signed or made available to the nursing staff, and the process for obtaining signatures was inconsistently followed. Another resident with a principal diagnosis of COPD, emphysema, dementia, and diabetes mellitus did not have their baseline care plan updated to address the principal diagnosis or the identified risks for hypoglycemia and hyperglycemia. The care plan was a revision of a previous stay's plan and did not include goals or interventions for the current admission's primary health concerns. Additionally, there was no documentation that the resident or their representative had been informed or included in the care planning process. A third resident with multiple diagnoses, including cerebral atherosclerosis, major depression, diabetes, and dysphagia, had an incomplete and undated baseline care plan in the electronic record, and the signed paper copy was not scanned into the electronic health record. As a result, the baseline care plan was not accessible to nursing staff and could not be updated to reflect changing needs. The facility's process for managing baseline care plans was inconsistent, leading to incomplete documentation and lack of communication among staff regarding residents' immediate care needs.
Failure to Notify Resident and Representative of Changes in Insulin Orders
Penalty
Summary
The facility failed to inform a resident with diabetes mellitus and her responsible party in advance about changes made to her physician orders regarding insulin dosing and blood glucose monitoring. Upon re-admission from the hospital, the resident's orders were changed by the nurse practitioner from a sliding scale insulin regimen with blood glucose checks four times daily to a reduced frequency of two times daily and discontinuation of the sliding scale insulin. There was no documented evidence that either the resident or her responsible party was notified of these changes, as required by facility policy and regulatory standards. The responsible party only became aware of the changes several days after admission when the resident reported not receiving her insulin shots. Upon inquiry, the responsible party learned of the order changes from nursing staff and subsequently had the original orders reinstated after discussing with the nurse practitioner. Interviews with staff, including the charge nurse and DON, confirmed that notification of such changes is expected practice, but in this instance, the notification was missed. Facility policy also requires prompt notification of residents and their representatives regarding changes in care or treatment.
Failure to Include Resident and Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and her representative were informed of and included in the development and implementation of a person-centered care plan. Record review showed that during the resident's stay, there was no documentation indicating that either the resident or her representative had been invited to participate in care planning meetings, had been consulted about the care plan, or had received a copy of the care plan. The resident, who had a history of COPD, emphysema, dementia, and diabetes mellitus, was moderately cognitively impaired and ambulatory with a walker. Despite these needs, there was no evidence in the medical record of any communication or invitation to the care planning process for the resident or her representative. Interviews with the resident's representative confirmed that she was not consulted or included in the care planning process, was never asked to attend a care plan meeting, and was not provided with a copy of the care plan. The DON, who was not employed at the facility during the resident's stay, was unable to find any documentation of care plan meetings or invitations for the resident or her representative. Facility policy required that residents and/or their representatives be provided with a written summary of the baseline care plan and be informed of their right to participate in care planning, but this was not followed in this case.
Failure to Complete Timely Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a newly admitted resident within the required 14-day timeframe, as specified by the CMS Resident Assessment Instrument (RAI) User Manual. Record review showed that the resident, a male with multiple diagnoses including cerebral atherosclerosis, major depression, diabetes mellitus, anxiety, sleep apnea, atrial fibrillation, dysphagia, arthritis, ataxia, and a history of repeated falls, was admitted to the facility and had an incomplete admission MDS assessment. Key sections of the MDS, such as identification information, preferences, functional abilities, health conditions, special treatments, participation in assessment, and care area assessment summary, were not completed, and the assessment was not signed as completed by the required date. During an interview, the MDS Coordinator acknowledged the assessment was overdue and could not provide a reason for the delay. She stated she was still learning the process and had not completed the assessment within the regulatory timeframe. The facility's policy, based on the RAI Version 3.0 Manual, requires comprehensive assessments to be completed by the end of day 14 following admission, but this was not met for the resident in question.
Failure to Complete Comprehensive Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident within the required timeframe. Specifically, a female resident with diagnoses including Alzheimer's disease, dementia, aortic stenosis, and osteoporosis was admitted, and her records showed a severely impaired cognitive status with a BIMS score of 6. Despite these needs, a comprehensive care plan had not been completed within 21 days of admission, as required by both federal regulations and the facility's own policy. The MDS Coordinator confirmed that the comprehensive MDS assessment and subsequent care plan were not completed on time, attributing the delay to efforts to get caught up with new admissions. Interviews with facility staff, including the MDS Coordinator and the DON, revealed that responsibility for care plan development was shared among the MDS Coordinator, DON, and ADON. The DON and other key staff were new to the facility and acknowledged they were still organizing processes and were unaware that the resident's care plan was overdue. Review of the facility's policy and the CMS RAI Manual confirmed the requirement for care plan completion within 21 days of admission, which was not met in this case.
Failure to Timely Report Alleged Abuse and Serious Injury
Penalty
Summary
The facility failed to ensure timely reporting of alleged abuse and serious injury to the state agency as required by regulations. In one instance, a male resident with dementia and physical impairments reported to the DON that two CNAs were rough with him during care, including an allegation that one CNA struck him with a rolled-up rag and knocked a scab off his foot. Although the Administrator conducted an internal investigation and determined the accused CNAs were not present at the time of the alleged incident, the facility did not report the allegation to the state agency as required, since the Administrator believed reporting was unnecessary if the accused staff were not present. In a separate case, another male resident with dementia and a history of falls experienced an unwitnessed fall resulting in a head injury. The resident was found on the floor with a hematoma and was transported to the hospital, where he was diagnosed with a subdural hematoma. Despite the serious nature of the injury, the facility did not report the incident to the state agency. The DON, who was present at the time of the fall, confirmed that the Administrator was responsible for reporting such incidents, but the required report was not made. Review of the facility's own policy confirmed that all allegations of abuse, neglect, exploitation, or injuries of unknown source must be reported immediately to the Administrator and to authorities, with specific timelines based on the severity of the incident. The facility's failure to report both the abuse allegation and the serious injury was not in accordance with their policy or regulatory requirements.
Failure to Prevent Pressure Injury Due to Inconsistent Skin Assessments
Penalty
Summary
A deficiency occurred when a resident, who was at risk for pressure injuries due to conditions such as dementia, diabetes, incontinence, and limited mobility, developed a deep tissue injury (DTI) to her right heel. The resident's care plan required skin assessment and inspection every shift, with particular attention to the heels, but this was not consistently implemented. The facility's policy also required daily skin inspections during personal care and weekly risk assessments, but these were not reliably performed. Nursing staff interviews revealed that skin assessments were primarily the responsibility of the treatment nurse, and when the facility was without a treatment nurse, other nurses did not assume this responsibility. Several staff members, including RNs and LVNs, stated they had not recently assessed the resident's feet or performed skin assessments, despite the care plan's requirements. The DON confirmed that skin assessments should be performed on admission and weekly, and that if a care plan called for assessments every shift, this should be done, but was unaware of any such care plans being in place. Documentation showed that the resident had no skin issues noted in assessments prior to the discovery of the DTI. The injury was first identified by an RN who noticed a dark area with surrounding redness on the resident's right heel and subsequently notified the physician and responsible party. Observations at the hospital confirmed the presence of a DTI on the right heel. The facility's failure to ensure consistent skin assessments and adherence to the care plan led to the development of the pressure injury.
Failure to Perform Proper Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper hand hygiene practices among staff during incontinent care for two residents. In one instance, a CNA performed multiple glove changes while providing care, including opening a wet brief, wiping the resident's vaginal area and bottom, applying lotion, and putting on a clean brief, but did not perform hand hygiene between glove changes. Although the CNA had previously been checked off on proper handwashing techniques, she stated that hand hygiene was not necessary between glove changes. In another instance, a CNA disposed of a dirty wipe after receiving it from another CNA during incontinent care, but did not change gloves or perform hand hygiene before handing over clean wipes and a clean brief. The CNA acknowledged the lapse, attributing it to nervousness. Interviews with the DON and Administrator revealed differing expectations regarding hand hygiene, with the DON expecting hand hygiene before care, between dirty and clean tasks, after care, and between glove changes, while the Administrator emphasized hand hygiene before and after glove use and when hands are visibly soiled. The facility's policy indicated that hand hygiene is the primary means to prevent the spread of healthcare-associated infections and outlined specific indications for hand hygiene.
Sanitation Deficiencies in Kitchen Food Storage and Labeling
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. A scoop was left inside a bulk flour bin in the dry pantry, which was later removed by the dietary manager (DM) who acknowledged that new kitchen staff had not yet learned all procedures. Additionally, a box of raw cabbage was improperly stored on the floor in front of a reach-in cooler, and several food items in the coolers were not labeled or dated, including a resealable bag of breadsticks, a large plastic container with an unknown orange-brown substance, and various nectar-thickened juices. The DM admitted to not knowing the contents of the plastic container and confirmed that thickened liquids should be dated when opened. The facility's policy on food storage, dated 12/01/11, requires that scoops be stored in a protected area near food containers, all items be stored at least six inches above the floor, and refrigerated foods be dated, labeled, and tightly sealed. The Food and Drug Administration Code, 2013, also mandates that food be stored in a clean, dry location, protected from contamination, and at least six inches above the floor. The facility's failure to adhere to these standards could place residents at risk of foodborne illness.
Inadequate Infection Control Practices in LTC Facility
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 staff. Specifically, LVN A did not wear the required gown while administering medication to a resident with a gastrostomy tube, despite the presence of signage indicating the need for Enhanced Barrier Precautions (EBP). LVN A admitted to forgetting to don a gown and acknowledged that she had not received training on EBP at the facility. Interviews with other staff, including LVN B and the Director of Nursing (DON), confirmed that the facility's policy required the use of gloves and gowns for residents with indwelling devices, such as feeding tubes, to prevent cross-contamination and the spread of infections. Additionally, the facility failed to provide appropriate containers for the disposal of contaminated PPE in the rooms of residents requiring contact isolation. Observations revealed that rooms of residents on contact isolation did not have lined bio-hazard containers for doffed PPE. Staff interviews indicated that PPE was improperly disposed of in regular trash cans or removed from the room in plastic bags. The DON confirmed that bio-hazard boxes should have been placed in the rooms for proper disposal of PPE, and it was the responsibility of medical services to ensure their presence. The facility's policies and CDC guidelines emphasize the importance of using PPE, including gloves and gowns, for high-contact resident care activities and proper disposal of PPE to contain pathogens. The lack of adherence to these protocols and the absence of necessary disposal containers highlight significant lapses in the facility's infection control practices, potentially increasing the risk of cross-contamination and the spread of communicable diseases among residents.
Deficiency in EBP Training and Implementation
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skill sets to provide safe and effective care, specifically in the context of Enhanced Barrier Precautions (EBP). This deficiency was observed when LVN A did not don a gown before administering medication to a resident with a gastrostomy tube, who was under EBP due to the presence of an indwelling device. Despite the presence of EBP signage and available personal protective equipment (PPE) at the resident's room, LVN A only wore gloves and neglected to wear a gown, which is a requirement for EBP to prevent cross-contamination and the spread of infections. Interviews with LVN A revealed that she was aware of the EBP requirements but admitted to forgetting to don a gown during the procedure. Further investigation showed that LVN A had not received any EBP training upon her hire at the facility, which was confirmed by the Director of Clinical Operations (DCO) and the Director of Nursing (DON). The lack of initial EBP training was a systemic issue, as the Business Office Manager (BOM) also confirmed that new hires were not trained or checked off on EBP, and the facility's new hire orientation and training checklists did not address EBP. Additionally, observations indicated that other rooms with EBP signage lacked PPE supplies at or near the entrances, suggesting a broader issue with the facility's implementation of EBP protocols. The facility's policy on EBP, which aligns with CDC guidelines, mandates the use of gowns and gloves for high-contact resident care activities, such as those involving feeding tubes. However, the absence of training and proper PPE setup compromised the facility's ability to adhere to these infection control measures.
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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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