Avir At Heritage Oaks
Inspection history, citations, penalties and survey trends for this long-term care facility in Lubbock, Texas.
- Location
- 5301 University Ave, Lubbock, Texas 79413
- CMS Provider Number
- 675346
- Inspections on file
- 39
- Latest survey
- May 6, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Avir At Heritage Oaks during CMS and state inspections, most recent first.
RN Coverage Not Maintained: The facility failed to provide RN services for at least 8 consecutive hours per day on 2 days reviewed. RN time punches showed no RN hours, and the ADM, DON, and staffing coordinator confirmed there was no RN coverage when the scheduled RN called off sick and no replacement was found. The facility policy stated an RN provides services at least 8 hours every 24 hours, 7 days a week.
Cell Phone Use During Resident Care: CNAs were observed and reported using personal cell phones while providing care, including showers, in resident rooms, at nurses’ stations, in hallways, and while supervising smoking times. Nine confidential residents said the behavior made them feel ignored, embarrassed, and that their privacy was violated. The DON and ADM stated residents should receive privacy and full attention during care, and the facility policy required staff to treat residents with kindness, respect, dignity, privacy, and confidentiality.
Missing Informed Consent for Psychotropic Medications: Five residents received psychotropic meds, including antidepressants and antianxiety agents, without signed consent forms in the chart. The residents included individuals with intact cognition as well as residents with dementia or severe cognitive impairment. The DON stated the consents had not been signed, and the ADM said she was unaware the forms were missing until the day of the interview. The facility’s psychotropic medication policy did not address medication consents, and no informed consent policy was provided.
Incomplete DNR Documentation: The facility failed to ensure DNR forms were completed correctly for three residents. One resident's DNR lacked required physician and resident signature details, another was missing a witness signature, and a third was missing a dated physician signature. The SW and ADM stated the forms were not valid if not filled out correctly and that there was no system for monitoring DNR accuracy.
Inadequate Shower Function and Hot Water Temperatures: The facility failed to maintain a functioning shower in the Magnolia unit and failed to keep shower and room sink water temperatures within the expected range. A resident reported delayed showers and inconsistent warm water, while staff confirmed residents were using showers on another hall because the Magnolia shower was out of service and water pressure was poor. Observations and log review showed repeated low hot water readings in Magnolia rooms and showers, and the Wildflower shower also measured below the facility's temperature range.
A facility failed to make grievance/complaint information available to 9 of 9 residents reviewed. Residents stated they did not know they could file anonymously, where to get a grievance form, who to give it to, what happened after filing, or that they had a right to a written decision. Observations showed the prominent postings did not include grievance instructions, and the ADM stated the grievance procedure and anonymous filing process were not being discussed in Resident Council.
Meals were not consistently palatable, attractive, or served at an appetizing temperature for several residents. Residents reported cold food, bland taste, and poor texture, including mechanical meals that were not warm and a resident who said he had almost choked on a mechanical diet item. Surveyors observed sample tray items that were cold, mushy, chunky, tough, or had no flavor.
Kitchen Food Storage and Sanitation Deficiencies: Surveyors observed unlabeled food items without use-by dates in the walk-in freezer and refrigerator, an uncovered garbage can next to the food prep table, a cook not properly wearing a hair restraint, and dirty black residue under the pot and pan sink/draining area. The cook, DM, and ADM each acknowledged the labeling, dating, sanitation, and hair restraint issues during interview.
Improper Dumpster Waste Disposal: The dumpster area behind dietary was observed with one dumpster about 3/4 full, another dumpster door left open, and bags of garbage on the ground around both dumpsters. The DM, MS, and ADM gave differing accounts of who was responsible for the area, and the MS stated he had not yet reviewed the waste disposal policy. The facility policy required waste to be properly contained with lids or otherwise covered and disposal areas kept sanitary and free from pests.
Failure to follow infection control practices during resident care was observed for two residents. One CNA provided foley catheter care to a resident with an indwelling catheter and EBP orders but did not change gloves, perform hand hygiene, or use the required PPE during dirty-to-clean tasks. Another CNA provided incontinence care to a resident with severe cognitive impairment and total incontinence, then handled a clean brief with dirty gloves without changing gloves or sanitizing hands, contrary to facility policy and staff expectations.
A cognitively intact male resident with paraplegia, dependent on staff for toileting and bathing, requested a shower during the night. A CNA, who reported being in the middle of rounds, undressed him in bed, partially attempted incontinence care, then left the room after he became verbally aggressive, without covering him, closing the door, or pulling the privacy curtain. The resident was later found by an LVN completely naked in bed with the door wide open, no privacy curtain in place, and soiled items on the bed, while his cognitively intact roommate was present. Facility leadership and policy indicated staff were expected to ensure residents were covered, safe, and afforded privacy before leaving the room, and acknowledged that this incident violated the resident’s dignity and privacy rights.
A cognitively intact male resident with paraplegia and other comorbidities was involved in an altercation with a maintenance staff member over access to an exterior door code. The staff member reported becoming frustrated after the resident repeatedly requested the code and threatened to tell others he had provided it, and admitted telling the resident to "get the fuck out of my face," which he recognized as verbal abuse by definition. Another cognitively intact male resident with a history of CVA and epilepsy corroborated that there was bickering about the door code and heard the staff member tell the resident to get out of his face, though he did not hear profanity and stated neither resident appeared upset. This incident reflects a failure to ensure a resident was free from verbal abuse.
A resident with quadriplegia, severe cognitive impairment, and a chronic coccyx pressure ulcer was admitted with an existing wound and later received a physician order for a low-pressure airflow mattress. The MDS identified pressure ulcer risk and triggered a CAA, and clinical notes documented wound progression, infection, and use of pressure-reducing devices, as well as ongoing wound care and repositioning efforts. However, the comprehensive care plan, even after revision, did not include the ordered pressure-relieving mattress as an intervention or provide guidance on its implementation or monitoring. Observations and interviews showed that the resident and family repeatedly reported concerns about the bed’s inflation, while CNAs and some nurses reported they had not been trained on the mechanics of the mattress and were unclear who was responsible for checking it. The MDS coordinator, ADONs, and DON all acknowledged that the low-pressure mattress should have been care planned and that existing systems for updating care plans did not ensure this intervention was added, resulting in a deficiency for failure to develop and revise a complete, measurable care plan based on the resident’s assessed needs and physician orders.
A resident was found to have cigarettes and a lighter stored in a bag on their walker in their room, contrary to the facility's smoking policy requiring all smoking supplies to be kept locked at the nurse's station and only accessed under staff supervision. Staff were unaware of the presence of these supplies, did not remove them, and did not report the incident, despite being trained on the policy. The facility's policy prohibits residents from keeping smoking articles except when directly supervised.
The facility failed to inform residents about their rights to file grievances, as 19 residents reported not having access to grievance forms or knowing the procedure. The grievance policy was not posted in prominent locations, and there was no option for anonymous submissions. The Administrator confirmed the lack of accessible grievance forms and the absence of discussions in Resident Council meetings.
The facility failed to maintain effective infection control due to inadequate hand hygiene practices by staff during resident care. Staff members, including CNAs and an LVN, did not adhere to the facility's handwashing protocols, washing hands for less than the required time and failing to follow proper procedures during peri and wound care. These actions could lead to the spread of infections among residents.
A resident with multiple medical conditions was observed with an uncovered urinary catheter drainage bag, compromising their dignity and privacy. Despite the facility's policy to use privacy bags, the resident's bag was visible through an open door on two occasions. Interviews with the DON, ADON, and ADM confirmed that nursing staff were responsible for ensuring privacy bags were used, as per facility policy.
A resident with respiratory conditions did not receive proper care as the facility failed to monitor and maintain oxygen equipment according to physician orders. The resident's oxygen humidification bottle was often empty, and the nasal cannula and tubing were not changed weekly, leading to discomfort and potential health risks. Despite facility policies and staff training, these deficiencies were observed, indicating a lapse in care.
A dietary aide failed to change gloves and wash hands during food preparation, despite leaving the prep table and engaging in various tasks, leading to a deficiency in food service safety. Interviews confirmed that the facility's policy required these actions to prevent cross-contamination.
Two CNAs failed to perform proper hand hygiene during incontinence care for residents with cognitive impairments and incontinence issues, risking infection spread. One CNA did not wash hands between glove changes or before leaving a resident's room, while another did not wash hands before, during, or after care, handling clean items with dirty gloves. Interviews revealed a lack of awareness about infection control roles and recent training, despite facility policies emphasizing hand hygiene.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 2 of 30 days reviewed for RN coverage. Record review of RN time punches provided by the facility showed no RN hours for 4/24/2026 and 4/25/2026, and the facility failed to maintain RN coverage of eight hours on those dates. During interviews on 5/06/2026, the ADM stated there was no RN coverage for those two days and explained that the staffing coordinator and the DON were responsible for scheduling RN coverage. The DON stated the RN scheduled for that weekend called off sick and a replacement could not be found, and that agency was used for LVN nurses only, not RN coverage. The staffing coordinator stated she did not look for a replacement and believed the DON would do so because the RN had called in to the DON. The facility policy titled, Staffing, Sufficient and Competent Nursing, revised 08/22, stated that a registered nurse provides services at least eight hours every 24 hours, seven days a week.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and care in a manner that promotes quality of life and recognizes each resident’s individuality for 9 confidential residents. The deficiency was based on resident interviews and record review showing that CNAs were using personal cell phones while providing care, including assisting with showers, performing care in resident rooms, and supervising residents during supervised smoking times. Residents stated staff texted and talked on their phones while walking in hallways, at nurses’ stations, and while performing care in their rooms, and they reported that this occurred on every shift and often in the facility. The residents also stated they did not know the names of the CNAs involved. The 9 confidential residents stated the cell phone use made them feel ignored, not a priority, embarrassed, and concerned that a CNA could make a mistake because of distraction. They also stated their privacy was violated. During interviews, the DON and ADM stated residents should receive privacy and full attention during care, and both stated staff were trained on privacy, resident rights, dignity, and cell phone usage. The record review included the facility policy titled Resident Rights, dated February 2021, which stated employees shall treat all residents with kindness, respect, and dignity and that residents have the right to a dignified existence, to be treated with respect, kindness, and dignity, and to privacy and confidentiality.
Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that five residents were fully informed and had signed informed consent for psychotropic medications before those medications were administered. Residents #30, #32, #93, #127, and #130 were each receiving antidepressant and/or antianxiety medications, and record review showed no signed consent documents in their electronic medical records for the ordered psychotropic drugs. Resident #30 was admitted with diagnoses including cerebral infarction and depression, had a BIMS score of 13, and was receiving duloxetine and mirtazapine. Resident #32 had dementia, depression, and anxiety, had a BIMS score of 03, and was receiving Paxil. Resident #93 had cerebral infarction, depression, and anxiety, had a BIMS score of 05, and was receiving buspirone and citalopram. Resident #127 was admitted with depression and anxiety, had no completed MDS assessment in the record reviewed, and was receiving duloxetine. Resident #130 was admitted with depression and anxiety, had a BIMS score of 14, and was receiving clonazepam, escitalopram, and Wellbutrin XL. During interview, the DON stated the consents had not been signed and that nursing staff were responsible for obtaining consent when the order was received. The ADM stated she was not aware the consents were not signed until the day of the interview and that staff had been trained to obtain consent when medication was ordered. The facility’s psychotropic medication policy did not include information related to medication consents, and no informed consent policy was provided when requested.
Incomplete DNR Documentation
Penalty
Summary
The facility failed to ensure that advance directive and DNR documentation was completed accurately for 3 of 6 residents reviewed for advance directives. Resident #1 had a DNR order on the face sheet, physician order summary, and care plan, but the DNR form was incomplete because the resident's signature was not dated, the physician did not print his name after signing, the physician's signature was not dated, and the physician's license number was missing. Resident #5 also had DNR status documented on the face sheet, physician order summary, and care plan, but the DNR form was missing a witness signature. Resident #6 had DNR status documented on the face sheet, physician order summary, and care plan, but the DNR form was missing the physician's dated signature. During interviews, the SW and ADM stated the DNRs were not valid if not filled out correctly and verified the missing information for Residents #1, #5, and #6. They stated there was no system for monitoring DNRs for accuracy, and the ADM identified human error as the reason the forms were incomplete.
Inadequate Shower Function and Hot Water Temperatures
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents, staff, and the public by not maintaining functioning showers and adequate hot water temperatures in resident rooms and shower areas. The deficiency involved 2 of 3 showers, identified as Magnolia and Wildflower, and 2 of 12 rooms. The Magnolia shower had been out of order for approximately 4 months, with an undated sign on the shower door stating, "DO NOT USE." During observation, the Magnolia shower had inconsistent water pressure and the handheld shower head only trickled water. Staff interviews confirmed the shower had been out of service since at least February 2026 and that residents were being directed to use another unit's shower instead. Resident and staff interviews described ongoing problems with shower access and water temperature. A resident stated the Magnolia shower had not been working for a while, showers were sometimes delayed, and the water was not always warm because other residents had used the same shower. CNA and LVN interviews confirmed residents on Magnolia were using showers on another hall and that hot water had been an issue throughout the facility. The DON stated the importance of hot water and a functioning shower was for residents to be comfortable, clean, and to decrease infection risk. The ADM stated the hot water concerns had started the prior week and that the facility had approved repair of the tankless water heater. Record review showed repeated water temperature readings below the facility's stated range for resident rooms and shower areas. In Magnolia unit rooms, documented hot water temperatures included readings such as 93.6 F, 92.4 F, 86.2 F, 83.4 F, 89.6 F, 83.7 F, and 90.3 F. In the Magnolia shower, documented temperatures included 95.1 F, 99.6 F, 93.8 F, 95.4 F, and 93.7 F, and later observation showed 70.4 F. In the Wildflower shower, observation showed 95.3 F. A confidential resident council interview included 9 residents stating the water did not get hot enough during showers. Facility policy stated water heaters serving resident rooms, bathrooms, common areas, and tub/shower areas were to be set to no more than 110-115 F or the maximum allowable temperature per state regulation, and maintenance staff were responsible for checking and recording water temperatures.
Grievance Procedure Information Not Made Available to Residents
Penalty
Summary
The facility failed to make information on how to file a grievance or complaint available to residents for 9 of 9 confidential residents reviewed for grievances. During interviews, all 9 residents stated they did not know they could file a grievance anonymously, that the grievance procedure had never been discussed in Resident Council, and that they had not seen a posting of the grievance procedure in prominent locations. The residents also stated they did not know where to obtain a grievance form, who to submit it to, what happened after a grievance was filed, or that they had the right to receive a written decision once the grievance was resolved. Observation of prominent postings showed the facility did not include instructions regarding the grievance procedure with the postings. The ADM stated she was the grievance officer and that grievance forms were available on a shelf by the piano, but she did not know there were no forms available there. She stated the Activities Director completed grievance forms during monthly Resident Council meetings when concerns were voiced, and staff also completed forms for some face-to-face complaints. The ADM stated grievances were assigned to the appropriate department, addressed with the complainant, resolved, and documented on the grievance form, which was then reviewed and kept in a notebook for 3 plus years. The ADM also stated she was responsible for staff training on the grievance process and agreed the availability of grievance forms, the grievance procedure, and the process for submitting an anonymous grievance should be explained at admission and continually discussed in monthly Resident Council meetings.
Meals Served Cold and Poor in Texture and Flavor
Penalty
Summary
Food and drink were not provided in a palatable, attractive, and safe appetizing temperature for five residents, including Residents #8, #60, #99, #101, and one confidential resident. Several residents voiced concerns that meals were cold, lacked flavor, or had poor texture. Resident #99 said some foods were not really good and had no flavor or taste. Resident #101 reported that mechanical meals were not even warm and said he had almost choked once about a month earlier. The confidential resident stated that eggs were very cold in the mornings, lunch tasted like old food, and the meat was particularly poor. Resident #60 said the food did not look or taste good, was sometimes cold, and that the meat served at lunch was tough. Resident #8 stated that the food was bland, cold most of the time, and that spaghetti was sometimes not drained enough and vegetables were not drained well.
Kitchen Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During a kitchen tour, surveyors observed an uncovered garbage can next to the food prepping table, a cook not properly wearing a hair restraint to cover the mustache area, and dirty black food residues under the pot and pan sink/draining area. These observations were made in the facility kitchen that was reviewed for food safety. Surveyors also observed food items in the walk-in freezer and walk-in refrigerator that were not labeled and did not have use-by dates. In the walk-in freezer, items that resembled chicken breasts, hashbrowns, breast sticks, and sausages were stored in clear plastic bags with no labels or use-by dates. In the walk-in refrigerator, items that resembled lettuce, sausages, tortillas, and ground beef were also stored in clear plastic bags with no labels or use-by dates. During interviews, the cook stated he was responsible for labeling and dating food items but had forgotten to do so because he was busy with other kitchen tasks, and he acknowledged he had been trained on labeling, dating, and kitchen sanitation policies. The DM stated she was responsible for monitoring labeling and dating of food items and also acknowledged that the uncovered garbage can, improper hair restraint use, and dirty residue under the pot and pan draining area were not in compliance with facility expectations. The ADM stated kitchen staff were responsible for dating and labeling food items, that the garbage can should have been covered when not in use, and that the dirty residue needed to be cleaned.
Improper Dumpster Waste Disposal
Penalty
Summary
The facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (#1 and #2). During observation on 05/04/2026 at 10:21 a.m., the dumpster area behind the dietary department was found with a commercial-size dumpster about 3/4 full of garbage, dumpster #2 left open, and bags of garbage on the floor around dumpsters #1 and #2. The report states the area was not kept clean and waste was not properly contained in the dumpsters with lids or otherwise covered. During interviews, the DM stated that everyone in the facility was responsible for keeping the dumpster area clean and closing the door, and that all staff members were responsible for monitoring the task. The MS stated he and his assistant were responsible for keeping the dumpster area clean and closing the door, but said the task was overlooked and that he had not yet come across the waste disposal policy. The ADM stated maintenance personnel were responsible for keeping the dumpster area clean and closing the door, with the MS monitoring the task, and also stated she did not know why the area was littered with garbage or why the door was not closed. Record review of the facility policy titled Sanitation, revised November 2022, stated garbage and refuse containers are to be in good condition, waste properly contained in dumpsters/compactors with lids or otherwise covered, and garbage disposal areas maintained to prevent pests.
Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 of 6 residents reviewed for infection control. During observation, CNA D provided foley catheter care to a resident with a history of cerebral infarction, obstructive and reflux uropathy, benign prostatic hyperplasia, moderate cognitive impairment, and an indwelling catheter. The resident had Enhanced Barrier Precautions ordered for high-contact care activities, including hygiene, incontinence care, and catheter care. CNA D washed her hands and put on gloves, but during the care she did not change gloves or perform hand hygiene when moving between dirty and clean tasks, and she also did not wear the appropriate PPE for EBP. During the same survey, CNA E provided incontinence care to another resident with dementia, muscle weakness, severe cognitive impairment, and total bowel and bladder incontinence. CNA E cleaned the resident’s buttocks, removed the soiled brief, and then grabbed a clean brief with dirty gloves and placed it on the resident without changing gloves or performing hand hygiene before touching the clean brief. The resident’s care plan identified incontinence care needs, and the facility policy for perineal care required discarding soiled gloves, sanitizing hands, and re-gloving before touching clean linens or an adult brief. The DON stated she was the infection preventionist and that staff are trained on hand hygiene, glove changes, and EBP quarterly, with infection control training done monthly. She stated staff are expected to follow all infection control policies, including wearing a gown, gloves, and mask for EBP, and that not following these practices could spread infection. The ADM also stated staff are expected to follow infection control training and use the appropriate PPE and hand hygiene protocols. The observations showed CNA D and CNA E did not follow those practices during the resident care events.
Failure to Maintain Resident Privacy and Dignity During Personal Care
Penalty
Summary
The deficiency involves a failure to ensure personal privacy and dignity for a cognitively intact male resident with chronic kidney disease, malignant neoplasm of the spinal cord, and paraplegia, who was dependent on staff for toileting hygiene and required substantial assistance for showers. According to his care plan, he required staff assistance with ADLs, including toilet and personal hygiene. On the night in question, the resident returned late from a pass and initially fell asleep after being put to bed. In the early morning hours, he used his call light and requested a shower from a CNA who reported she was in the middle of rounds and could not provide the shower at that time. During this interaction, the resident became verbally aggressive and used profanity toward the CNA. The CNA stated she placed him in bed, removed his bottoms, and attempted to complete incontinence care, but reported that he stopped cooperating and refused to turn, preventing her from completing his brief change. She told him she would step out and that someone else would finish his care, then left the room. The CNA acknowledged that the resident was left with only a shirt and half a brief on, and she was unsure whether the door was left open. She did not cover him with a sheet or otherwise ensure he was not exposed before leaving, and she did not return to the room or follow up on whether his care was completed, instead notifying her charge nurse that he had been cursing at her and that she had stepped out to let him calm down. Another nurse later received a call from the resident asking for help and went to his room, where she found the door wide open, the privacy curtain between the two roommates not pulled, and the resident completely naked on the bed with a soiled brief and dirty wipes present. The roommate, who was also cognitively intact and paraplegic, recalled that the CNA had undressed the resident in bed, left the door open, and then left, and that some time passed before another nurse came to finish the resident’s care. Facility leadership, including the LVN charge nurse, the administrator, and the DON, stated that staff were expected to ensure residents were safe, covered, and provided privacy before leaving a room, even when stepping out due to resident behavior, and acknowledged that leaving the resident exposed in bed with the door open and without privacy curtains constituted a violation of his dignity and privacy. The facility’s resident rights policy required employees to treat residents with kindness, respect, and dignity, and to protect their privacy and confidentiality.
Failure to Protect Resident From Verbal Abuse by Staff Member
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from abuse and/or neglect when a maintenance staff member (MM A) used profane language toward a resident. Resident #1, a cognitively intact male with chronic kidney disease, malignant neoplasm of the spinal cord, and paraplegia, was involved in an interaction with MM A related to the exterior door code. According to MM A’s interview, he had recently changed the exterior door codes and went outside to smoke when Resident #1 approached and repeatedly asked for the code. MM A stated he refused to provide the code due to facility policy, and Resident #1 continued to pressure him and said he would tell others that MM A had given him the code. MM A reported that he became frustrated and told Resident #1 to “get the fuck out of my face,” acknowledging he was irritated and believed, by definition, his statement constituted verbal abuse. Resident #1 later told surveyors he did not recall anything happening between him and MM A, stated they had always gotten along, and denied hearing MM A say anything to him, though he confirmed the DON had spoken to him about the incident. Resident #2, also cognitively intact with a history of cerebral infarct, hemiplegia, and epilepsy, reported overhearing bickering between Resident #1 and MM A about the door code. Resident #2 stated he heard Resident #1 say he would tell others that MM A gave him the code, and then heard MM A say “get out of my face,” without cursing or yelling. Resident #2 reported that both he and Resident #1 were laughing, did not feel upset, and he did not hear MM A use the word “fuck.” Despite differing accounts regarding the exact wording, the report identifies that MM A directed an inappropriate, potentially abusive statement toward Resident #1, constituting a failure to protect the resident from verbal abuse.
Failure to Include Ordered Pressure-Relieving Mattress in Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to develop and revise a comprehensive care plan to include a physician-ordered pressure-relieving mattress for a resident with a significant pressure ulcer. The resident, an older male with quadriplegia and severely impaired cognition, was admitted with a coccyx pressure ulcer that was present on admission and greater than three months in duration. The comprehensive MDS identified the resident as at risk for pressure ulcers, with a triggered CAA for pressure ulcers that should have been care planned, and documented the use of a pressure-reducing device for the bed. Physician orders included a pressure-reducing mattress to the bed with a start date in November and detailed wound care orders for an unstageable coccyx pressure ulcer. Despite these orders and the resident’s high-risk condition, the written care plan did not include the low-pressure airflow mattress as an intervention. Record review showed that the resident’s care plan, last revised in early January, contained a focus on wound management with goals for wound improvement and freedom from infection, and interventions such as administering antibiotics as prescribed, notifying the provider if there was no improvement, and providing wound care per treatment orders. Another care plan focus addressed the resident’s resistance to repositioning due to anxiety, with interventions including education about noncompliance and praise for appropriate behavior. However, the care plan lacked any reference to the ordered pressure-relieving mattress, did not provide clear guidance for staff on implementation or monitoring of the mattress, and did not outline expectations for pressure injury management related to the specialized bed. Progress notes over several months documented the presence and progression of the coccyx wound, including staging changes from Stage 2 to unstageable, wound measurements, infection, antibiotic use, and additional care such as turning/repositioning and pressure-reducing devices, but did not include progress notes specifically addressing the pressure-relieving mattress. Interviews and observations further demonstrated gaps in care planning and staff knowledge related to the low-pressure airflow mattress. On observation, the resident was seen lying on a low-pressure airflow mattress with the static button turned on, and the resident and a family representative reported repeated concerns that the bed was not properly inflated, with staff appearing unsure how to manage or check the bed. Multiple CNAs and an agency nurse reported they had not received instruction or individualized training on low-pressure airflow mattresses and were unclear about who was responsible for checking them. The MDS Coordinator, ADONs, and DON all stated that the low-pressure airflow mattress should have been care planned as an intervention, and acknowledged that it was not included in the resident’s care plan. Leadership interviews revealed confusion and inconsistency about who was responsible for ensuring such interventions were entered into care plans, especially after the facility no longer had a designated wound care nurse, and there was no specific policy for low-pressure airflow mattresses. The DON stated that the care plan should have reflected the implementation of the low-pressure airflow bed at admission and acknowledged that the omission could result in worsening wounds or increased infection, confirming that the ordered pressure-relieving mattress was not incorporated into the comprehensive care plan as required. The facility’s own staff described the care plan as the primary guide for all staff to know residents’ active issues, conditions, and required interventions, and recognized that missing interventions could place residents at risk for decline. Despite this, the system described for monitoring and updating care plans—baseline care plans within 48 hours, discussion in morning meetings, and quarterly or change-in-condition reviews—did not result in the inclusion of the low-pressure airflow mattress for this resident. The MDS Coordinator indicated that, historically, the wound care nurse would have ensured wound-related interventions were added to care plans, but after that role was vacated, no clear reassignment of those duties occurred. The DON and administrative staff acknowledged overall responsibility for ensuring interventions were included in care plans, yet they were unaware that this resident’s mattress intervention was missing until it was identified during the survey. This combination of incomplete care planning, lack of documented guidance on the mattress, and staff uncertainty about mattress operation and monitoring led to the cited deficiency for failure to develop and revise a comprehensive care plan consistent with the resident’s assessed needs and physician orders.
Failure to Enforce Smoking Policy and Control Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for one resident who was reviewed for smoking. According to the resident's care plan and the facility's smoking policy, all cigarettes and lighters were to be kept locked at the nurse's station, and residents were only permitted to smoke during scheduled times under staff supervision. However, during observation and interview, it was found that the resident kept cigarettes and a lighter in a black bag attached to his walker, which was stored in his room. The resident confirmed that he kept his smoking supplies in his room and was not told he could not do so. Staff interviews revealed that multiple staff members, including the DON, MA, ADM, and SW, were not aware that the resident had smoking supplies in his room. Although all staff reported being trained on the smoking policy, which prohibits residents from keeping smoking supplies in their rooms or on their person, the supplies were not removed when discovered, and the incident was not reported to supervisory staff. The resident was observed accessing his cigarettes and lighter from his walker and later smoking outside under staff supervision, with the blue smoking supply box present. The facility's policy, dated October 2022, clearly states that residents may not have or keep any smoking articles except when under direct supervision. Despite this, the resident was able to retain smoking supplies in his room, and staff did not enforce the policy or report the violation. The lack of adherence to the policy was confirmed through interviews and observations, with staff acknowledging the potential for residents to obtain smoking supplies from a nearby store and the inability to search residents' belongings.
Failure to Provide Grievance Information to Residents
Penalty
Summary
The facility failed to provide information to residents and their representatives on their rights related to filing grievances or concerns. This deficiency was identified during a Resident Council meeting where 19 out of 22 confidential residents reported they did not have access to the grievance form, were unaware of the option to file grievances anonymously, and had not seen the grievance procedure posted in prominent locations. The residents also expressed that the grievance procedure had never been discussed in Resident Council meetings, and they were unaware of how to acquire a grievance form, who to submit it to, and the process that follows once a grievance is filed. The facility's grievance policy, last updated in 2023, mandates that information on how to file a grievance should be made available to residents, family, and staff. However, observations revealed that the facility did not include instructions regarding the grievance procedure in any prominent postings, and grievance forms were not readily accessible. The Administrator, who is the grievance officer, stated that grievance forms were kept at the Nurses' Station and in the Administrator's office, and residents could not obtain a form without asking. Additionally, there was no procedure for submitting grievances anonymously, and the grievance process was not being discussed in Resident Council meetings.
Inadequate Hand Hygiene Practices in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple instances of staff not adhering to hand hygiene protocols during resident care. Specifically, CNA H did not follow proper handwashing procedures while providing peri care to a resident with multiple infections and an indwelling catheter. Despite wearing personal protective equipment (PPE), CNA H washed her hands for only 10 seconds, contrary to the facility's policy of 30-60 seconds, and failed to rinse the urinal before placing it back on the nightstand. LVN E also did not adhere to hand hygiene protocols while providing wound care to two residents. During wound care for a resident with a stage 4 pressure ulcer and a suprapubic catheter, LVN E washed her hands for only a few seconds at various points, instead of the required 20 seconds. Similarly, while attending to another resident with multiple pressure ulcers, LVN E repeatedly washed her hands for less than the required time and did not lather soap properly. CNA I, while providing peri care to a resident with cognitive impairment and incontinence, washed her hands for only nine seconds and failed to wash her hands after disposing of trash. These lapses in hand hygiene could potentially lead to the spread of infections among residents, as acknowledged by the staff during interviews. The facility's policies on hand hygiene, enhanced barrier precautions, and perineal care were not followed, contributing to the deficiency in infection control.
Failure to Maintain Resident Dignity with Uncovered Catheter Bag
Penalty
Summary
The facility failed to maintain the dignity and privacy of Resident #98, who was observed with an uncovered urinary catheter drainage bag on two separate occasions. The resident, a male with multiple medical conditions including osteomyelitis, pathological fracture, and neuromuscular dysfunction of the bladder, was found lying in bed with the room door open, exposing the urinary catheter drainage bag to view. The resident expressed that he was unaware of the option to have the drainage bag covered with a privacy bag and stated a preference for it. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Administrator (ADM) revealed that it was the facility's policy to provide privacy bags for urinary catheter drainage bags unless a resident specifically requested otherwise. The DON and ADM acknowledged that the responsibility for ensuring the use of privacy bags lay with the nursing staff, who were trained to monitor and provide catheter care. The facility's policy on dignity emphasized the importance of maintaining resident privacy and preventing practices that compromise dignity, such as failing to cover urinary catheter bags.
Failure to Maintain Oxygen Equipment for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, specifically in monitoring and maintaining oxygen equipment as per physician's orders. The resident, a male with a history of acute respiratory failure with hypoxia, pulmonary embolism, and other respiratory conditions, was observed with an empty oxygen humidification bottle and undated nasal cannula and oxygen tubing. The resident reported that the oxygen tubing and nasal cannula were not changed weekly as required, and the humidification bottle was often empty, causing discomfort. Interviews with the Director of Nursing (DON) and other staff revealed that the facility's policy required oxygen tubing to be changed weekly and humidification bottles to be monitored and refilled every shift. However, these procedures were not consistently followed, as evidenced by the lack of dates on the equipment and the resident's statements. The DON acknowledged that the failure to maintain the humidification bottle could lead to dryness and discomfort, and that not changing the tubing regularly could increase the risk of infection. The facility's policy on oxygen administration emphasized the importance of adhering to physician orders and maintaining equipment to prevent complications. Despite regular in-service training for staff, the deficiency in following these protocols was evident. The administration and nursing management were responsible for ensuring compliance, but the oversight led to a lapse in care for the resident, potentially compromising their respiratory health.
Failure in Hand Hygiene and Glove Use During Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, specifically in the area of hand hygiene and glove use, during the preparation of snack sandwiches. On the observed date, a dietary aide (DA A) was seen preparing sandwiches while wearing gloves. However, DA A did not change gloves or wash hands after leaving the prep table multiple times, touching various surfaces, and engaging in different tasks. These actions included walking to the dry storage room, opening a bag of potato chips, using a sharpie marker from a pocket, and interacting with other staff members, all without changing gloves or washing hands. Interviews with DA A, the dietary manager (DM), and the administrator (ADM) confirmed that the facility's policy required changing gloves and washing hands when leaving the prep table, changing tasks, or touching unsanitized items. Despite being trained on these procedures, DA A did not follow them, which was acknowledged as a problem by both the DM and ADM. The facility's policy on handwashing and glove use was reviewed, highlighting the need for proper hand hygiene to prevent cross-contamination during food preparation.
Inadequate Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper hand hygiene practices observed during incontinence care for two residents. A certified nursing assistant (CNA) providing care to a female resident with dementia, anxiety disorder, and hypertension did not perform hand hygiene between glove changes or before exiting the resident's room. This resident was always incontinent of bladder and bowel, requiring the use of briefs, and the CNA's failure to follow proper hand hygiene protocols during care posed a risk of infection and cross-contamination. Another CNA was observed providing incontinence care to a male resident with COPD, hypertension, atrial fibrillation, and cognitive communication deficit. The CNA did not perform hand hygiene before donning gloves, during care, or after completing the care. The CNA handled clean briefs and other items in the resident's room without changing gloves or washing hands, further increasing the risk of spreading infections. This resident also required the use of briefs due to incontinence, and the lack of proper hand hygiene during care was a significant lapse in infection control practices. Interviews with the CNAs revealed a lack of awareness about the infection preventionist and insufficient recent training on infection control. The facility's administration, including the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and an educator, were unaware of the staff's non-compliance with infection control protocols. The facility's policies on infection control and hand hygiene emphasized the importance of handwashing to prevent the spread of infections, but these were not adhered to during the observed incidents.
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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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