Avir At Kerrville
Inspection history, citations, penalties and survey trends for this long-term care facility in Kerrville, Texas.
- Location
- 1555 Bandera Hwy, Kerrville, Texas 78028
- CMS Provider Number
- 745050
- Inspections on file
- 19
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Avir At Kerrville during CMS and state inspections, most recent first.
A resident with dementia and bipolar disorder, but intact cognition per BIMS, had a substantial balance in a facility-managed trust fund that included funds transferred from a prior placement. Beginning shortly after admission, the resident repeatedly requested a lump-sum withdrawal to replace damaged clothing and purchase personal items, but over several months received only a partial payment while the remainder was delayed. The BOM, who was new to the role, cited high staff turnover, limited monthly petty cash from corporate, and the ADM’s delay in obtaining approval to cash petty cash checks as reasons for not honoring the resident’s full request, despite acknowledging the resident’s right to access his funds. This resulted in prolonged, unjustified restriction of the resident’s access to his own money, contrary to resident rights and facility policy.
A resident with Alzheimer’s disease, severe cognitive impairment, osteoporosis with pathological fracture, and anxiety, who required partial/moderate assistance with transfers, was the subject of an allegation that staff blew cigarette smoke toward her and her family in a designated smoking area. An Incident Investigation Worksheet showed the allegation was reported to the state, but there was no Provider Investigation Report 3613-A in the facility’s records or in the state’s TULIP system, and no evidence that a thorough investigation was completed or submitted within the required timeframe. Nursing notes only documented that the resident and family denied the incident, and interviews confirmed that no additional investigation documentation could be found, despite facility policy requiring all allegations of abuse, neglect, exploitation, or mistreatment to be thoroughly investigated and reported within five days.
A resident with a history of traumatic brain injury, Parkinson’s disease, and significant upper extremity limitations, who was cognitively intact and dependent on staff for ADLs, did not receive scheduled showers as outlined in the care plan. Records showed only three showers provided over nearly a month despite a plan for thrice‑weekly showers. The resident reported feeling dirty and helpless and communicated that staff took a long time to answer call lights. A CNA confirmed the resident’s total dependence for ADLs and acknowledged the limited number of showers, while an LVN and the night charge nurse indicated they were unaware the showers were not being completed, citing limited night staffing and lack of recent review of CNA task completion. The new DON was unfamiliar with specific shower schedules but recognized that residents unable to perform ADLs should receive hygiene assistance per facility policy.
Surveyors observed an unattended lunch tray with uncovered leftover food placed on furniture in the middle of a hallway, with no staff present nearby. The ADON confirmed the tray contained food left by a resident and acknowledged that leaving an open tray unattended was not appropriate, especially for confused residents who might have different food texture needs. The DON stated it was not acceptable for staff to leave leftover meal trays on hallway furniture, indicated that trays should be returned to the kitchen once residents finish eating in their rooms, and noted there was no specific facility policy on meal trays, despite the expectation to maintain a safe environment.
A resident with intact cognition and diagnoses including heart failure, COPD, and an anxiety disorder had an order for diazepam twice daily for anxiety, reflected in the care plan and MAR. Over multiple days, 11 scheduled doses were not administered because the medication was documented as unavailable. A medication aide and an LVN who worked during part of this period could not recall whether they notified a charge nurse, pharmacy, physician, or DON, and there was no documentation that staff attempted to obtain the drug from the emergency kit or contacted the prescriber or pharmacy. The DON, who was not employed at the time, confirmed the absence of such documentation, despite facility policy requiring contact with the prescriber or physician when there are concerns about medication administration.
Surveyors identified that a medication cart on the 400 hall was left unlocked and unattended during a medication pass. An LVN later acknowledged forgetting to lock the cart when leaving to see residents and confirmed that carts are supposed to remain locked to prevent unauthorized access to medications. The DON also stated that nurses are expected to always lock medication carts. Review of the facility’s “Administering Medications” policy showed that medication carts must be kept closed and locked when out of sight, with no medications on top and all outward sides inaccessible, which was not followed in this instance.
Surveyors found that kitchen staff failed to follow facility policy for food storage and labeling when an expired package of hamburger buns remained on a cooking table past its best-used-by date and a tray of Jello in a refrigerator was not labeled or dated. The kitchen manager acknowledged that both the expired buns and unlabeled Jello should have been discarded or properly labeled and dated per the facility’s food receiving and storage policy, which requires all refrigerated and frozen foods to be covered, labeled, and dated with a use-by date.
The facility did not employ a qualified full-time social worker despite having more than 120 beds, leaving the position vacant for several months after the prior social worker resigned. Review of the staff roster showed no social worker, and HR confirmed there was no full- or part-time social worker during that period. An RN acting as interim ADON reported attending care plan meetings without anyone assigned to perform social work duties. A part-time LSW later stated that before his start, no one was maintaining social work responsibilities and that he was addressing uncompleted reports and residents’ discharge needs once he began.
A resident with chronic pain and drug-induced polyneuropathy had active orders and a care plan for both scheduled and PRN analgesics, including pregabalin, tramadol, acetaminophen, and methocarbamol, and reported taking scheduled neuropathic pain medications with additional PRN doses several times per week. However, the quarterly MDS assessment documented that the resident had not received a scheduled pain regimen and had not received or been offered PRN pain medications in the look-back period. The MDS nurse, who was usually responsible for MDS completion but had been on leave and did not complete this assessment, later reviewed the section on pain management and acknowledged that the information recorded there was inaccurate.
The facility failed to maintain complete and accurate clinical records for multiple residents. A resident with a right thigh lymphatic ulcer had numerous ordered wound care treatments with no documentation on the TAR and no corresponding progress notes, and the diagnoses of lymphatic ulcer and lymphedema were not added to the diagnosis list despite repeated documentation in wound and MD notes. Another resident with a PEG tube and severe malnutrition had several scheduled enteral feedings with either blank MAR entries or exemption codes without supporting progress notes. A third resident receiving IV imipenem-cilastatin for a UTI had multiple scheduled IV doses with missing documentation and no progress notes to verify administration. A fourth resident with COPD and malnutrition had weekly and one-time ordered weights that were not documented on required dates, despite care plan and MD orders to monitor and evaluate weight.
A resident with a documented right thigh wound and MRSA infection had an active wound care plan, multiple wound-related progress notes, and ongoing treatment orders, including daily cleansing of a right medial/distal thigh lymphatic ulcer. Despite this, the Quarterly MDS, including Section M completed by an LPN, recorded that the resident had no skin ulcers, wounds, or skin problems. The wound was directly observed during survey, and the resident confirmed twice-daily wound care. Staff interviews revealed that the LPN believed the wound should have been coded as an open ulcer, the DON was unfamiliar with MDS accuracy implications, and the administrator acknowledged that inaccurate MDS documentation could affect care planning, contrary to facility policies requiring accurate, comprehensive assessments and documentation.
A resident with a right thigh wound related to lymphedema and a history of cerebral infarction and MRSA did not consistently receive ordered wound care. On one occasion, an LPN failed to perform the ordered wound treatment and documented an exception of the resident sleeping without follow-up or supporting progress notes. On later dates, another LPN documented completion of evening wound care, but the wound nurse observed the same dressing from the prior day still in place the following mornings, indicating the treatments were not actually done. These actions conflicted with the resident’s wound care orders, the care plan, and facility policies requiring accurate documentation of treatments and refusals.
Surveyors found that required daily nurse staffing and census information was not posted in a prominent location on one of the reviewed days. The ADMIN reported that the posting was usually placed outside the DON’s office and was typically the DON’s responsibility, but no current document was present. When a staffing document was produced, it was dated months earlier and did not break down staff numbers and hours by shift as required. The DON, recently hired, stated she was unsure who had previously been responsible for posting the information or when it was last posted, although a nursing schedule was kept at the nurses’ station. Facility policy required detailed, shift-specific staffing data to be posted within two hours of each shift’s start.
Two residents with PRN opioid orders for pain management were found to be missing one dose each of Tramadol and Hydrocodone from their narcotic blister packs, with the punched-out tablets not reconciled on the narcotic count sheets and MARs showing no administration on the date in question. Nursing documentation by an RN indicated it was unknown whether the PRN doses were actually given, and a medication aide later stated she could not remember if she administered the narcotics and admitted she did not document or reconcile the controlled medications during her shift. A prior shift narcotic count between an LVN and an RN had been correct, but the incoming medication aide took control of the cart without performing a narcotic count, and a subsequent LVN refused cart transfer when the discrepancies were discovered, demonstrating a failure to maintain accurate controlled drug records and reconciliation for these two residents.
A resident with intact cognition and surgical aftercare and gastrointestinal diagnoses brought a blister pack of diazepam (valium) into the facility after an outside urology visit and gave it to an unknown nurse. Later, the ADON found this controlled medication in a medication cart and discarded it into a biological waste box in the locked DON office, rather than placing it in the required double-locked narcotic storage and completing a narcotic sheet. During surveyor observation, the narcotic blister pack was found in the waste box with other medications and without any resident medication sheet, while all other narcotics in the locked cabinet were reconciled. Interviews with an LVN, pharmacist, administrator, and DON confirmed that controlled substances awaiting destruction must be stored under a two-lock system with corresponding documentation, and that this process was not followed in this case, contrary to the facility’s controlled substances policy.
A resident with advanced dementia was administered Donepezil 10 mg twice daily instead of the prescribed once daily dose for approximately two weeks, resulting in a worsening mental status. The error was not identified until a family member raised concerns about insurance coverage, leading to a review that confirmed the medication had been given at double the intended frequency.
Staff failed to consistently document wound care treatments as ordered for several residents with complex medical needs, resulting in incomplete treatment administration records. Interviews indicated that documentation lapses were due to workload and inconsistent record-keeping, with facility policy requiring all care to be recorded in the medical record.
A resident with advanced dementia received twice the prescribed daily dose of donepezil, resulting in worsening confusion and hospitalization. The facility did not report the significant medication error and injury to state authorities within the required timeframe, failing to follow its own policies and regulatory requirements.
The facility did not ensure its activities program was led by a qualified professional, as the current Activity Director lacked required training, certification, and experience. Interviews and record reviews confirmed that the individual in this role was not enrolled in any training and had no prior experience, affecting all residents reviewed.
A resident with morbid obesity, metabolic encephalopathy, and total dependence for several ADLs did not have a comprehensive, person-centered care plan that addressed required ADL assistance, cardiac diet interventions, or a weight management program. The care plan lacked measurable objectives, specific interventions, and did not reflect physician orders or the resident's actual care needs, due in part to incomplete documentation, staff role confusion, and technical issues with the electronic medical record system.
A newly hired RN, lacking her own EMR login, documented an assessment for a resident using an LVN's profile, resulting in inaccurate and incomplete medical records. The RN was shadowing the LVN and was allowed to use the LVN's credentials, but the LVN was unaware of the documentation being entered. Facility policy requires that only licensed personnel document under their own credentials, and this incident led to improper attribution of a resident's medical record entry.
A resident with chronic venous insufficiency did not receive wound care and compression therapy as ordered by the physician. Instead of applying TED hose as directed, staff left discontinued unna boot dressings on the resident's legs for over 30 days, which were observed to be dirty and unchanged. Staff interviews revealed a lack of communication and documentation regarding the change in orders, and the resident reported never being offered the TED hose.
Surveyors found that the kitchen's produce refrigerator contained three boxes of produce, including salad lettuce, shredded lettuce, and diced green cabbage, all stored past their labeled best by dates and still available for serving. The Food Service Manager confirmed the produce was not safe to serve and acknowledged responsibility for daily review and disposal of expired items, in accordance with facility policy.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors during their review of facility practices.
The facility did not maintain all equipment in safe working order, as evidenced by a commercial dishwasher with a malfunctioning temperature gauge and a resident bed left without a mattress for an extended period. Staff were aware of both issues, but appropriate maintenance and timely corrective actions were not documented or completed.
Surveyors found that in several rooms, call light cords in resident bathrooms were wrapped around metal bars, making them unreachable from the floor and preventing activation of the call system when pulled. The DON stated this was done to prevent slips, but acknowledged it could create a safety risk. Facility policy required accessible call systems, but the observed setup did not comply.
A resident with severe cognitive impairment and aphasia was slapped in the face by another cognitively impaired resident. The incident was witnessed by an LVN, who separated the residents and notified facility management and responsible parties. However, the event was not reported to the State Survey Agency as required, due to the belief by the DON and Administrator that there was no willful intent. No corresponding report was found in the state incident portal.
A resident with venous insufficiency and peripheral vascular disease was observed with continuous unna boot compression dressings on both legs, which were not documented in the MDS or skin assessment. The dressings were found to be discolored, dirty, and in direct contact with the floor over consecutive days. Interviews confirmed the omission in documentation, contrary to facility policy requiring accurate and comprehensive assessments.
A resident admitted with a traumatic subdural hemorrhage and cognitive communication deficit did not have a comprehensive baseline care plan developed within 48 hours of admission. The only documented care area was code status, omitting essential information such as allergies, fall risk, and therapy needs, as confirmed by interviews with the MDS nurse and DON.
A resident with a history of upper arm fracture and moderate cognitive impairment did not receive a physician-ordered house shake supplement with breakfast, as required for her therapeutic diet. Observations showed the kitchen lacked house shakes, and the supplement was missing from the resident's tray. Staff interviews revealed confusion over responsibility for providing the supplement, and the RD was unaware it was not being given.
A resident with multiple medical conditions was given amlodipine for hypertension without consistent documentation of blood pressure readings as required by physician orders. Despite staff claims that blood pressure was checked before administration, records did not reflect this, and the facility's policy to verify vital signs prior to medication administration was not followed.
A medication cart on the 200 hall was found unlocked and unattended near the activities room, with an LVN stating she thought it was locked when she walked away. The DON confirmed that facility policy requires medication carts to be locked when not in use, and staff interviews acknowledged the lapse in securing the cart.
Staff failed to perform proper hand hygiene between glove changes while providing indwelling catheter care to a resident with benign prostatic hyperplasia. Despite changing gloves during the procedure, hand hygiene was not performed as required by facility policy, a lapse confirmed by both the CNAs involved and the DON during interviews.
Staff failed to follow infection control protocols by not sanitizing a blood pressure cuff between use on two residents and by not performing hand hygiene between feeding three residents. Both the MA and LVN involved had received training and were assessed as competent in infection control practices, but did not adhere to facility policy during the observed care activities.
The facility did not ensure complete and accurate documentation of pain assessments, PRN pain medication administration, and weekly skin assessments for two residents. One resident with severe cognitive impairment had pain assessments recorded as '0' despite staff observing pain behaviors and administering Tylenol, which was not documented on the MAR. Both residents had missing weekly skin assessment documentation in the EMR, even though staff indicated assessments may have been performed. Facility policies required thorough documentation, but these procedures were not consistently followed.
The facility did not post up-to-date nurse staffing and census information for four consecutive days, as required by policy. Observations showed that the posted document was outdated and missing shift-specific care details. Staff interviews confirmed the lapse was due to printer issues and changes in facility ownership, which disrupted access to necessary resources for posting.
A nurse initiated CPR on a resident with a documented DNR order after finding the resident unresponsive, without first checking the code status binder or being aware of the resident's advance directive. Despite attempts by other staff to communicate the DNR status, CPR was performed, causing the resident pain. The resident's DNR status was clearly documented in multiple records, but facility protocols for verifying code status prior to emergency intervention were not followed.
A medication aide left a laptop displaying PHI unattended and unlocked on a medication cart, allowing several staff members to pass by the exposed information for several minutes before it was secured by the DON. Interviews confirmed the computer should have been locked, and facility policy prohibits leaving secured applications unattended.
A resident with multiple chronic conditions and mild cognitive impairment had several complaints made on their behalf regarding care, staff responsiveness, and communication. These grievances, submitted through texts, emails, and verbal reports to the DON and previous Administrator, were not documented or processed according to the facility's grievance policy. The facility failed to initiate the required grievance process, resulting in the resident's concerns not being formally addressed.
The facility did not report suspected violations of abuse, neglect, or exploitation to the state agency within the required timeframe for two residents. In one instance, CPR was performed on a resident with a DNR order, and in another, multiple allegations of neglect communicated by a resident's representative were not reported. Staff interviews and record reviews confirmed that these incidents were not recognized or reported as required by facility policy.
The facility did not investigate or report allegations of abuse, neglect, or exploitation for two residents, including an incident where a resident with a DNR order received CPR and multiple complaints from a resident's representative about inadequate care. Despite receiving these allegations, staff did not initiate investigations or submit required reports to the state agency, as confirmed by record reviews and staff interviews.
Staff failed to keep medication and treatment carts locked and attended, leaving them unsecured in a hallway where multiple staff members passed by. Both a medication aide and an LVN left their respective carts unattended and unlocked, contrary to facility policy requiring all drugs and biologicals to be stored securely with access limited to authorized personnel.
Surveyors found that the facility did not follow food safety standards in a resident snack pantry refrigerator, where multiple containers of expired, unlabeled, or spoiled food were accessible. Staff were unaware of proper labeling and monitoring practices, and the FSM was not initially aware of his responsibility for this area. The facility's own policy for date marking and food safety checks was not being followed, resulting in unsafe food storage conditions.
The facility did not ensure proper infection control in the laundry department, as clean blankets were stored with soiled infectious laundry and laundry aides handled soiled items with only gloves and without full PPE. Staff had not received specific training on handling infectious laundry, and clean and soiled linens were not kept separate as required by facility policy. The DON and Administrator acknowledged these failures placed individuals at risk for cross-contamination.
A resident with leukemia and cellulitis did not receive prescribed wound care on two consecutive days due to an LVN forgetting the task. The resident's care plan required daily wound care, which was not administered, leading to a lapse in treatment. The resident reported the missed care and expressed concern over the lack of explanation. Interviews with staff confirmed the oversight, emphasizing the need to follow MD orders for proper healing.
The facility failed to complete initial comprehensive assessments for four residents within the required 14-day period after admission. These residents, with various health conditions, did not receive timely evaluations of their needs and preferences. Interviews revealed a lack of clarity and communication among staff regarding the responsibility for completing and signing the MDS assessments, leading to delays and non-compliance with federal regulations.
Two residents in a LTC facility had inaccuracies in their initial comprehensive assessments. One resident was incorrectly coded as having an indwelling catheter, while another's fall history was inaccurately documented, missing a fracture related to a fall. These errors were identified through record reviews and staff interviews, with the Regional MDS Coordinator acknowledging the mistakes. Despite the inaccuracies, staff believed the errors did not impact the residents' care.
The facility failed to implement comprehensive care plans for four residents, omitting critical details such as full code status and fall risk interventions. Despite residents having a history of falls and requiring assistance, their care plans lacked specific objectives and timeframes. Interviews with staff revealed inconsistencies in the care planning process and uncertainty about responsibility for reviewing care plans.
A facility failed to develop comprehensive care plans for three residents, resulting in multiple falls and injuries. One resident, admitted with a broken neck, experienced several falls, including one causing a subdural hemorrhage. Despite being high fall risks, the residents lacked documented interventions to prevent falls. Staffing issues, including the absence of an MDS Coordinator, contributed to the deficiency, leaving staff uninformed about necessary care interventions.
A resident with a history of falls and multiple diagnoses experienced five falls in a facility due to inadequate supervision and lack of a comprehensive care plan. Despite being identified as a high fall risk, interventions were not documented, and staff were unaware of fall prevention measures. The facility's electronic records were not updated, and the DON was overwhelmed with duties, impacting the implementation of fall prevention strategies.
Failure to Provide Resident Timely Access to Personal Trust Fund Monies
Penalty
Summary
The facility failed to honor a resident’s right to manage and access his personal funds deposited with the facility. The resident was admitted with diagnoses including unspecified dementia with behavioral disturbance and bipolar disorder, but a recent MDS showed a BIMS score of 15, indicating no cognitive impairment. His care plan identified a risk for low self-esteem and included encouraging his participation in decision-making. The resident’s trust fund account was opened in September 2025, and a large deposit of $6,320 from a previous facility was made in January 2026, bringing his balance to $3,965.39 as of April 21, 2026. The resident reported that since at least October 2025 he had repeatedly requested a lump-sum withdrawal (initially $600) to purchase clothing and silk pillowcases after some of his clothes were damaged in the facility’s laundry, but he received only $150 in February and no further funds despite his ongoing requests. The Business Office Manager (BOM) confirmed that the resident had requested funds, including a $350 request in early 2026, and acknowledged that the resident was owed $375 at the time of the survey. The BOM stated he was new to the position, was still learning his role, and that high staff turnover, including changes in the Administrator (ADM), contributed to delays in providing funds. He explained that he received only $300 in petty cash monthly from corporate, which he used to disburse residents’ trust funds, and that he told the resident he could not provide the full requested lump sum due to petty cash limitations. The BOM reported discussing splitting the withdrawal with regional support and that the new ADM was waiting for corporate approval to cash petty cash checks, resulting in continued delay. The ADM acknowledged that the resident had a right to access his funds and that the resident had been requesting money since at least the end of February, but no additional funds were provided. This pattern of delayed and incomplete disbursement of the resident’s own money, despite his clear, repeated requests and adequate account balance, constituted the failure to properly manage and provide access to his personal funds as required by facility policy and resident rights regulations.
Failure to Thoroughly Investigate and Document Abuse Allegation Involving Cigarette Smoke
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document an allegation of abuse involving one resident. The resident was an elderly female with Alzheimer’s disease, severe cognitive impairment as evidenced by a BIMS score of 5/15, osteoporosis with pathological fracture, and anxiety, who required partial to moderate assistance with transfers. An Incident Investigation Worksheet dated 02/19/2026 showed that the administrator reported to Texas HHSC an allegation that staff members blew cigarette smoke in the direction of the resident and her family while they were in the designated smoking area. However, there was no corresponding Provider Investigation Report 3613-A in the facility’s records for this allegation. Further record review of the Texas Unified Licensure Information Portal (TULIP) showed no report of the allegation, and there was no evidence that a Provider Investigation Report 3613-A had been submitted to Texas HHSC within five days. A nursing progress note by an LVN on 02/19/2026 documented that the resident and her family denied that staff blew cigarette smoke in front of the resident, but there was no additional documentation of a thorough investigation. During interviews, the LVN stated she no longer worked at the facility and could not recall which CNAs smoked, only that she interviewed the resident and family and they denied the allegation. The current administrator, who began working after the date of the incident, reported he could not locate any investigation report 3613-A in paper or electronic records and confirmed there was no evidence the prior administrator completed or submitted the required investigation report, despite facility policy stating that all allegations are thoroughly investigated and that a follow-up investigation report is to be provided within five days.
Failure to Provide Scheduled Showers and Hygiene Assistance for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for activities of daily living received scheduled showers to maintain grooming and personal hygiene. The resident, admitted with a history of traumatic brain injury, Parkinson’s disease, and lack of coordination, had a quarterly MDS showing a BIMS score of 15, indicating no cognitive impairment, and was dependent on one to two staff for all ADLs except eating. His care plan identified a self-care deficit for bathing, dressing, and feeding, with interventions to evaluate his ability to perform ADLs and provide assistance as needed. Review of his shower plan of care for March and April showed he received showers only on three dates within nearly a 30‑day period. On observation, he was in bed with extremely limited upper extremity range of motion, able to move his hands but with restricted bilateral upper extremity movement, and he communicated via his phone that he had not received a shower since mid‑April and felt dirty, wanted a shower, and felt helpless. Staff interviews confirmed that the resident was totally dependent for all ADLs, including showers, and was scheduled to receive showers three times weekly on the night shift. A CNA stated the resident often complained about not receiving showers and that day‑shift staff would sometimes try to fit him into their shower schedule; she acknowledged that records showed only three showers in almost 30 days and described this as unacceptable. An LVN reported she was unaware the resident was missing scheduled showers and believed his shower schedule had been changed so that only male CNAs on night shift would provide showers due to his inappropriate behaviors toward female staff. The night charge nurse stated there was usually only one CNA and one nurse covering the resident’s hall at night, making it difficult to complete all tasks, including showers, and admitted he had not recently reviewed CNAs’ electronic plans of care to ensure showers were completed. The newly appointed DON stated she did not yet know residents’ shower schedules but acknowledged that a resident who wanted showers and did not receive them could feel bad and experience low self‑esteem. Facility policy required that residents unable to carry out ADLs independently receive necessary services to maintain grooming and personal hygiene, including assistance with bathing.
Unattended Uncovered Meal Tray Left in Hallway
Penalty
Summary
Surveyors identified a deficiency related to maintaining a safe, clean, comfortable, and homelike environment on the 400-hall. During observation, a lunch tray with leftover food from a resident meal was found placed on furniture in the middle of the 400-hallway, unattended and with the main lunch dish uncovered. The leftover food items included cornbread, squash, salad, and chocolate chip cookies. At the time of the observation, no staff were present on the 400-hallway and no residents were observed wandering in the area. In an interview, the ADON confirmed that the tray contained leftover food from a resident on the 400-hall and acknowledged that the open, unattended tray was not appropriate, noting that some confused residents with different food textures might eat the leftover food and experience choking. In a separate interview, the DON stated it was not acceptable for staff to place lunch trays with leftover food unattended on hallway furniture, citing concerns that confused residents might eat the food and develop infection or choking. The DON also stated that staff should have returned all lunch trays to the kitchen immediately after residents finished eating in their rooms and reported that the facility did not have a policy related to meal trays, while affirming the facility’s responsibility to maintain a safe environment for residents.
Failure to Ensure Availability and Administration of Ordered Diazepam
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administering of medications for a resident prescribed diazepam for anxiety. The resident, an older adult female with acute on chronic diastolic heart failure, COPD, and an anxiety disorder, had an admission MDS showing intact cognition (BIMS 15/15) and a care plan identifying the use of psychotropic medication (diazepam) with an intervention to administer medications as ordered and review effectiveness. A physician’s order dated 12/12/2025 directed diazepam 2 mg orally twice daily for anxiety, later changed on 12/16/2025 to diazepam 5 mg, ½ tablet twice daily. The MAR for December 2025 showed the diazepam scheduled at 7:30 AM and 7:30 PM, but the resident did not receive 11 scheduled doses over 7 days, with administration notes documenting the medication as unavailable on each of those dates. Staff interviews revealed that the medication aide who worked on two of the days could not recall whether she notified a charge nurse about the unavailability of diazepam, although she stated her usual practice was to report missing medications to the charge nurse so they could obtain the drug from the emergency kit or contact the pharmacy, physician, or DON. The LVN who worked those same days also could not recall whether she contacted the pharmacy, physician, or DON when the medication was unavailable, though she described that her general practice would be to attempt to obtain the medication from the emergency kit or contact appropriate parties if it was not available. The current DON, who was not employed at the facility at the time of the missed doses, stated there was no nursing documentation indicating attempts to obtain the medication from the emergency kit or to contact the physician, pharmacy, prior DON, or medical director, and acknowledged that nurses should contact physicians rather than only documenting “Meds Unavailable.” Facility policy on administering medications required contacting the prescriber or physician when there were concerns about medication administration, but the record contained no evidence that such contact occurred regarding the unavailable diazepam doses.
Unlocked and Unattended Medication Cart on 400 Hall
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were stored in locked compartments in accordance with professional standards and facility policy for one of three medication carts reviewed. On 04/23/2026 at 9:12 a.m., the 400-hall nursing cart was observed unlocked and unattended. At 9:18 a.m., an LVN assigned to that cart confirmed it had been left unlocked and unattended, stating she had forgotten to lock it when she left to see some residents and acknowledged it was her mistake. The LVN stated that nursing carts should be locked at all times to prevent someone from taking any medication, and the DON later confirmed that facility nurses are expected to always lock medication carts to prevent someone from taking medications. Record review of the facility’s policy titled “Administering Medications,” revised 04/2019, showed that during medication administration the medication cart must be kept closed and locked when out of sight of the medication nurse or aide, may be kept in the doorway of the resident’s room with open drawers facing inward and all other sides closed, must have no medications kept on top of the cart, must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. The observed unlocked and unattended 400-hall nursing cart was not in compliance with this policy.
Failure to Discard Expired Food and Label Refrigerated Items
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service practices when, during a kitchen observation, they found one packet containing 15 hamburger buns sitting on the cooking table with a label indicating a “best used by” date of 04/22/2026, which had passed as of the observation on 04/23/2026, and the buns had not been discarded. In a separate observation of a refrigerator labeled C-1, surveyors found a tray of Jello that was stored without any label or date. The kitchen manager confirmed during interview that the hamburger buns had expired and should have been discarded by kitchen staff to prevent possible use and food-borne illness, and also confirmed that the Jello should have been labeled and dated according to facility policy. Review of the facility’s “Food Receiving and Storage” policy, revised 11/2022, showed that all foods stored in the refrigerator or freezer are required to be covered, labeled, and dated with a use-by date, and that refrigerated foods must be labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded, which was not followed in these instances. These failures occurred in the one kitchen reviewed for storage, preparation, and sanitation and could place residents who received meals and/or snacks from the kitchen at risk for food-borne illnesses, as stated in the report.
Failure to Maintain Required Full-Time Social Worker Coverage
Penalty
Summary
The facility failed to employ a qualified full-time social worker despite having a licensed capacity of 130 beds, exceeding the 120-bed threshold that requires a full-time social worker. Review of the SSA Facility Summary Report showed the facility’s licensed capacity and license expiration date, and review of the staff roster provided on 3/17/2026 revealed no staff member with the position title of social worker. Human Resources reported that the last full-time social worker resigned in mid-December 2025 and that there was no social worker on a full- or part-time basis from that time until 3/16/2026. During this period without a social worker, RN A, who had been acting as interim ADON, stated she attended care plan meetings but that no one had been assigned to perform the social worker duties in those meetings. A licensed social worker interviewed on 3/18/2026 reported he began working part-time on 3/16/2026 and confirmed that prior to that date no one was maintaining the social worker’s responsibilities, and he was then working on uncompleted reports and residents’ discharge needs. He stated that not having a social worker could result in residents’ discharge needs not being met or unidentified admission, discharge, or social barriers affecting their care. The interim Administrator confirmed he had just started on 3/16/2026 and that the facility only had a part-time social worker at that time.
Inaccurate MDS Pain Management Assessment for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the resident’s pain management status. The quarterly MDS submitted on 1/1/2026 for Resident #1 documented in section J0100 that the resident had not received a scheduled pain medication regimen and had not received or been offered PRN pain medications in the prior five days. This documentation conflicted with the resident’s medical record, which showed active physician orders for multiple scheduled and PRN pain medications, including acetaminophen PRN, methocarbamol scheduled at bedside and PRN, pregabalin three times daily for drug-induced polyneuropathy, and tramadol at bedtime for pain. The resident’s care plan also identified acute pain and osteoporosis, with an intervention to give analgesics PRN for pain. Resident #1 was a female with diagnoses including unspecified pain and drug-induced polyneuropathy, and her quarterly MDS reflected a BIMS score of 14, indicating intact cognition. In an interview, she reported having neuropathy, taking Lyrica (pregabalin) and tramadol on a scheduled basis three times a day, and using additional PRN doses several times a week, stating that this regimen had been consistent for several years and effectively controlled her pain. The MDS nurse stated she was primarily responsible for MDS completion but had been out on leave and did not complete the 1/1/2026 MDS for this resident. After reviewing section J0100, she acknowledged that it contained inaccurate information and stated that the MDS should be completed accurately in accordance with the facility’s comprehensive assessment policy and for accurate reimbursement and evaluation of residents’ long-term needs.
Incomplete and Missing Clinical Documentation for Treatments, Tube Feeds, IV Antibiotics, and Weights
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, readily accessible, and systematically organized clinical records for multiple residents, as required by professional standards. For one cognitively intact female resident with a right medial thigh lymphatic ulcer present on admission, the Treatment Administration Records (TARs) for January and February showed multiple blanks where daily and bedtime wound care orders were scheduled. Specifically, there were no documented wound treatments on numerous ordered dates and times, and progress notes did not reflect that wound care was performed on those dates. The facility’s wound care policy required documentation of the date wound care was given, the initials of the person performing the care, and notation of refusals, but this information was missing for several ordered treatments. Interviews with the wound care nurse, ADON, DON, and administrator confirmed that a blank on the record was interpreted as care not done or not documented, and one nurse acknowledged she believed she may have missed at least one scheduled wound care treatment during a busy period. The same resident’s diagnosis list was also incomplete. Multiple wound-related documents, including a wound NP note, wound assessment reports, and a physician progress note, identified the right medial thigh wound as a lymphatic ulcer associated with lymphedema. However, the resident’s Medical Diagnosis tab did not list lymphatic ulcer or lymphedema as diagnoses. The DON stated that diagnoses should be added when new issues arise or persist and acknowledged that lymphedema should have been part of this resident’s diagnosis list. The administrator similarly stated that not having a diagnosis listed might impact a resident’s treatment. For a second female resident with metabolic encephalopathy, protein-calorie malnutrition, dysphagia, and a PEG tube, the Medication Administration Records for January and February showed blanks on several days when continuous enteral feeding at a specified rate was ordered. On some dates, an exemption code of “Other / See Progress Notes” was used, but corresponding progress notes did not consistently document that tube feeding was provided or explain the exemption. On other dates, there were no entries at all for the scheduled tube feeding, and progress notes did not document that the feeding was given. The DON reported she closely monitored this resident’s tube feeding and believed no feedings were missed, but acknowledged that staff may not have charted when the feed was already running at the scheduled time and stated her expectation that staff still document the administration. For a third male resident with a history of intracerebral hemorrhage and UTIs, the Medication Administration Records for an IV imipenem-cilastatin order scheduled four times daily showed missing documentation at specific 5:30 p.m. doses on three separate dates. One of these times was coded as “Other / See Progress Notes,” but there were no corresponding progress notes documenting the IV antibiotic administration at that time, and the other two times were left blank with no entries. The facility’s medication administration and medication error policies defined medications as to be administered as ordered and identified omissions as medication errors, but the clinical record did not show that the ordered IV doses were given or refused, nor did it provide explanatory documentation. For a fourth cognitively intact female resident with COPD, anxiety disorder, and protein-calorie malnutrition, the record showed failures in weight documentation. The care plan included interventions to monitor and evaluate the resident’s weight, and a physician order required weekly weights. However, the weekly weight was not documented for one of three weeks in the specified period, and a separate order to obtain a weight on a specific date was entered and confirmed but not documented as completed in the record. Additionally, the resident’s weight was not documented on two dates as required by the care plan and physician order. The Order Summary Report did not reflect current active orders regarding weight monitoring, and the clinical record lacked the required weight entries on the ordered dates.
Inaccurate MDS Coding of Existing Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s Minimum Data Set (MDS) assessment accurately reflected the presence of an existing wound. The resident, a female with diagnoses including cerebral infarction, rash and other nonspecific skin eruption, and MRSA infection, was admitted with a right thigh wound. Her Quarterly MDS assessment, dated 12/23/2025 and signed complete on 01/12/2026, documented that she was cognitively intact with a BIMS score of 15, used a wheelchair, was dependent for bed mobility and transfers, and was at risk for pressure ulcers. However, Section M – Skin Conditions, completed by an LPN on 01/01/2026, indicated that she had no skin ulcers, wounds, or skin problems. Contrary to the MDS coding, multiple clinical records showed the resident had an ongoing right medial/distal thigh wound. The care plan included a focus on wound management with an intervention to provide wound care per treatment order initiated on 11/04/2025. A nurse practitioner progress note dated 12/04/2025 referenced a right lower extremity thigh wound with MRSA. A skin issues progress note documented an abscess on the right medial thigh, and wound care orders on the Treatment Administration Record throughout January directed cleansing of a right distal thigh wound for a spider bite and later for lymphedema, with ongoing treatments and no discontinue date for some orders. A specialized skin and wound note dated 01/02/2026 described a pre-existing right medial thigh ulcer characterized as a lymphatic ulcer, and a wound assessment report dated 01/28/2026 identified the right medial thigh wound as a lymphatic ulcer acquired on 12/03/2025. Surveyor observations and staff interviews further confirmed the presence of the wound and the inaccuracy of the MDS. On 02/06/2026, an LPN was observed performing wound care on a small wound on the resident’s right inner thigh, and the resident reported that staff performed wound care twice daily and that treatments had not been missed. The LPN wound nurse stated the resident had been admitted with the thigh wound, initially thought to be lymphatic. The LPN who completed Section M of the MDS did not recall the resident but stated she believed the wound should have been coded as an open ulcer and that she would normally refer to the RAI manual if a wound did not fit standard options. The DON reported being unfamiliar with MDS assessments or how assessment accuracy could impact care, while the administrator acknowledged that inaccurate MDS wound documentation could affect care planning because MDS entries trigger care plan development. Facility policies required comprehensive assessments per the RAI Manual and complete, accurate documentation, but the resident’s wound was not coded on the Quarterly MDS despite extensive documentation of its presence and treatment.
Missed and Falsely Documented Wound Care Treatments for Thigh Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care treatment according to physician orders, the resident’s comprehensive care plan, and professional standards of practice for one resident. The resident was an adult female with diagnoses including cerebral infarction, rash and nonspecific skin eruption, and MRSA infection. A quarterly MDS showed she was cognitively intact with a BIMS score of 15, used a wheelchair, was dependent for bed mobility and transfers, and was at risk for pressure ulcers but had no documented skin ulcers at that time. Her care plan included a focus on wound management with an intervention to provide wound care per treatment order. Physician orders and treatment records showed that the resident had an order to cleanse a right distal thigh wound related to lymphedema. An order for once-daily wound cleansing was active in January, and a new order for wound care at bedtime, and later twice daily due to drainage, was active from late January onward. On one January date, the Treatment Administration Record reflected that the wound care was not completed and an exception code of "Sleeping" was entered and signed by an LPN. There was no corresponding progress note documenting the missed treatment, any resident refusal, or other explanation on that date. During interview, the LPN later acknowledged she believed she might have missed one of the resident’s scheduled wound care treatments while assisting on the floor and being behind on medications, and she described the resident as not allowing wound care after a certain evening time. In early February, the Treatment Administration Record showed that another LPN documented completion of the resident’s bedtime wound care on two evening shifts. However, the wound care nurse reported that on the mornings following those shifts she observed the same bandage she had applied the prior day still in place, indicating the ordered evening wound care had not been performed despite being charted as completed. She stated she had noticed evening wound care being missed a few times and had not yet reported these findings. On observation, the resident’s wound was small and located on the right inner thigh, with the dressing dated the previous day. The resident reported that staff were performing wound care twice a day and denied any concerns or awareness of missed treatments. The wound care NP stated the wound was not progressing well and there was concern for possible infection, and she was not aware of missed treatments because the wound was always dressed when she assessed it. The DON and the administrator both stated that sleeping was not an acceptable reason to omit wound care without follow-up, and facility policies on wound care and charting required accurate documentation of treatments, refusals, and related resident information, which was not done in these instances.
Failure to Post Required Daily Nurse Staffing and Census Information
Penalty
Summary
The deficiency involves the facility’s failure to post required daily nurse staffing and census information in a prominent location for at least one of three days reviewed. On 02/04/2026, during an afternoon tour, surveyors were unable to locate any document displaying the daily census and nurse staffing information. Later that day, the Administrator stated that the daily census and nurse staffing posting was usually placed in a clear display holder outside the DON’s office and that it was typically the DON’s responsibility to post the document. The Administrator explained that, in the absence of the posting, residents and visitors could ask to view the nurse staffing schedule kept at the nurses’ station. When asked to provide the staffing posting, the Administrator produced a document labeled with the facility name and dated 12/19/2025. This document listed, by staff type (RNs, LVNs, CNAs, medication aides, and staff training), the number of staff, hours scheduled, and total hours worked, as well as the total hours worked for the day and the daily census; however, it did not break down the information by shift as required. The Administrator acknowledged the document was probably not completed correctly. In a subsequent interview, the DON, who had been in her role for just over one month, reported she did not know who had previously been responsible for posting the daily census and nurse staffing document or when it was last posted, though she confirmed that the nursing schedule was always available at the nurses’ station. Review of the facility’s policy "Posting Direct Care Daily Staffing Numbers" showed that the facility was required to post, within two hours of the beginning of each shift, detailed nurse staffing data by shift, including staff type, category, and actual time worked, in a prominent, accessible location.
Unreconciled Missing Narcotics and Inadequate Controlled Drug Accounting
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, administering, and accounting of controlled drugs for two residents. For Resident #1, a female with a history including lumbar vertebra fracture, cellulitis, difficulty walking, and cognitive communication deficit, the care plan included a goal of pain management with opioid medications. Physician orders dated December 1, 2025, included Tramadol 50 mg every four hours PRN, and the December 2025 MAR showed no Tramadol administered on 12/23/25. Review of the resident’s Tramadol 50 mg narcotic blister pack revealed one tablet was punched out but not reconciled with the narcotic count sheet, and an Orders Administration Note authored by RN A on 12/23/25 at 5:53 AM documented that it was unknown whether the resident received the PRN Tramadol on that date. For Resident #2, a female with diagnoses including pulmonary embolism, urinary tract infection, and cognitive communication deficit, the care plan also included a goal of pain management with PRN Hydrocodone every six hours. Physician orders dated December 1, 2025, reflected Hydrocodone 10-325 mg PRN every six hours for pain. Review of Resident #2’s Hydrocodone 10-325 mg narcotic blister pack showed one tablet punched out that was not reconciled with the narcotic count sheet. An Orders Administration Note dated 12/23/25 at 5:53 AM by RN A similarly reflected that it was unknown whether the resident received the PRN Hydrocodone on that date. The facility’s internal investigation file documented that it was alleged that one Tramadol and one Norco were missing for these two residents and that reconciliation sheets were not completed. Staff interviews and documentation further described the actions and inactions that led to the discrepancy. A written statement by RN A on 12/23/25 confirmed there were two missing narcotics involving these residents. A written statement by MA B on 12/23/25 indicated that MA B could not remember whether the narcotics were given and admitted to not documenting or reconciling narcotic medications on 12/23/25. The Administrator’s timeline indicated that LVN C reconciled the narcotic count with RN A at the end of her shift, showing that the residents had received PRN narcotics on 12/22/25, but when MA B arrived later and took possession of the medication cart, she did so without reconciling the narcotic count with RN A. Later, during an attempted cart transfer, LVN D refused to accept the cart because two controlled substances for these residents were not accounted for. In a subsequent interview, MA B stated she did not count the narcotic medications because she was overwhelmed and distracted, noticed the missing medications at shift change, and maintained she did not administer the missing doses, while also acknowledging that the narcotic counts had not been reconciled. The facility’s policy on Drug Discrepancies/Diversion of Medications stated that all discrepancies, suspected loss, and/or diversion of medications are to be immediately investigated and reported, underscoring that the missing and unreconciled narcotics constituted a failure to maintain drug records in proper order and to account for all controlled drugs.
Improper Storage and Documentation of Controlled Substance Intended for Destruction
Penalty
Summary
The deficiency involves the facility’s failure to properly store a DEA-controlled substance (diazepam/valium) intended for destruction in accordance with its policy and professional standards. Surveyor observation of the medication carts and the medication/drug storage room showed that narcotic medications in the locked narcotic cabinet were reconciled and stored under a double-lock system in the DON’s office. However, a biological waste box in the same locked room contained multiple medications and one narcotic blister pack of diazepam 5 mg, prescribed as 1 tablet PRN 30 minutes prior to imaging for Resident #3, without an accompanying resident medication sheet. Record review showed no physician order or administration record for diazepam for this resident in December 2025. Staff interviews confirmed that this narcotic blister pack was not stored in the required double-locked container and lacked the required resident sheet. Resident #3 was an adult male with diagnoses including surgical aftercare on the digestive system, vertigo, and intestinal obstruction, with a BIMS score of 13 indicating no cognitive impairment and requiring only supervision for transfers and mobility. The resident reported bringing a urologist-prescribed blister pack medication into the facility around New Year and giving it to an unknown nurse, and did not recall the purpose of the medication or whether he received any doses. The ADON stated that the resident returned from pass with diazepam and gave it to an unknown nurse, and that she later found the medication in a medication cart and threw it into the biological waste box in the locked DON storage room instead of placing it in the double-locked narcotic container or completing a resident narcotic sheet. The LVN, pharmacist, administrator, and DON each confirmed that controlled substances scheduled for destruction were required to be stored in a two-lock system with a corresponding resident sheet, and that the facility’s practice in this instance did not follow those procedures. The facility’s Controlled Substances policy stated that controlled substances remaining after discontinuation or discharge are to be securely locked in an area with restricted access until destroyed.
Significant Medication Error: Double Dosing of Donepezil
Penalty
Summary
A deficiency occurred when a resident was administered Donepezil HCL Oral Tablet 10 mg twice daily for approximately two weeks, despite the physician's order specifying a dose of 10 mg once daily. This error was identified through observation, interview, and record review, which revealed that the medication was given at double the prescribed frequency from 11/14/2025 to 11/26/2025. The error was discovered after the resident's family reported insurance would not cover more than one tablet per day, prompting a review of the medication orders and administration records. The resident involved had a history of advanced dementia, metabolic encephalopathy, and muscle weakness, and was at risk for falls and nutritional problems. During the period of the medication error, the resident experienced a worsening mental status, as documented in a hospital report, which noted that the increase in Donepezil dosage coincided with the decline in mentation. The resident was alert only to person at the time of hospital evaluation, and no other sources of infection or acute illness were identified as contributing factors. Facility records showed that the medication order for Donepezil was incorrectly entered into the electronic medical record (EMR) as 10 mg twice daily, despite a dose warning indicating that this frequency exceeded the usual recommendation. The error persisted until it was recognized and the resident was subsequently sent to the hospital for evaluation. Interviews with staff confirmed that the error was not identified until after the family inquiry, and that the physician and pharmacy were notified only after the error was discovered.
Incomplete Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for six out of eight residents, specifically regarding the documentation of wound care treatments as ordered in the electronic medical record. For multiple residents, staff did not mark the completion of wound care treatments on specific dates, despite physician orders requiring daily or scheduled wound care. The treatment administration records (TARs) for these residents contained blanks where documentation of wound care should have been recorded, indicating either the care was not provided or not documented. Residents affected had various medical conditions, including cirrhosis of the liver, atherosclerosis with gangrene, spinal stenosis, and cerebral infarction. For example, one resident with a right-hand skin tear did not have wound care documented on three separate days, while another with an above-knee amputation and groin wounds had missing documentation on four days. Other residents with surgical wounds, scalp lesions, and staples also had incomplete wound care documentation on multiple dates as required by their treatment orders. Interviews with staff revealed that nurses sometimes found it difficult to document every treatment due to workload, and that blanks in the TAR could mean either the care was not completed or simply not recorded. The Assistant Director of Nursing acknowledged that blanks in the records signified wound care was not documented and noted that some staff had been disciplined for not completing electronic medical record entries. The facility's own policy requires that all treatments and services provided to residents be documented in the medical record to facilitate communication among the care team.
Failure to Timely Report Medication Error and Resulting Injury
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent neglect by not ensuring that all alleged violations involving neglect were reported immediately, as required. Specifically, a significant medication error occurred when a resident received twice the ordered daily dose of donepezil, a medication for dementia, which led to worsening confusion and necessitated hospitalization. The error was discovered after the resident exhibited a decline in mental status, but the incident was not reported to the appropriate state authorities (HHSC) within the required two-hour timeframe after discovery. The resident involved had a history of advanced dementia, metabolic encephalopathy, and muscle weakness, and was at risk for falls and harm as documented in her care plan. Medical records showed that the resident's donepezil dosage was increased in error, and the medication administration record included a warning that the frequency exceeded the usual daily dose. Despite these indicators and the resident's subsequent hospitalization for altered mental status, the facility did not report the medication error and resulting injury as required by policy and regulation.
Unqualified Staff Directing Activities Program
Penalty
Summary
The facility failed to ensure that its activities program was directed by a qualified professional, as required. Record review and interviews revealed that the individual serving as Activity Director did not possess the necessary qualifications, training, or certification. The Activity Director had been in the position for 4-5 weeks, had no prior experience, was not an occupational therapist or occupational therapy assistant, and was not enrolled in any training program for the role. The HR Director confirmed that there was no proof of education or training in the personnel file, and the Administrator acknowledged that the Activity Director was not currently registered for any required training and that no one else at the facility met the qualifications for the position. The facility's job description for the Activity Coordinator did not specify required qualifications, and the policy on the activity program did not address the qualifications for the Activity Director. The Administrator and Activity Director both stated that the current Activity Director was initially hired as an assistant and was performing the role on a trial basis, with intentions to pursue certification in the future. As a result, 72 out of 72 residents reviewed were affected by the lack of a qualified professional directing the activities program.
Failure to Develop and Implement Comprehensive Person-Centered Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical needs. The resident, a male with morbid obesity, a BMI between 50.0-59.9, and metabolic encephalopathy, was admitted with significant impairments in mobility and required total dependence for several activities of daily living (ADLs) such as toileting, bathing, and lower body dressing. Despite these needs, the care plan lacked specific interventions for required ADL care and assistance, did not specify the number of staff needed for care, and failed to provide measurable objectives or timeframes for meeting the resident's needs. The care plan also included only placeholder information for bed mobility and did not address the resident's total dependence or the level of assistance required. Additionally, the care plan was incomplete regarding the resident's nutritional needs. Although there was a physician order for a cardiac diet and semaglutide for weight management, the care plan did not include interventions for the cardiac diet or a weight management program. There was no direction on ideal nutritional intake, weight goals, or monitoring strategies. Interviews with staff revealed that the resident was allowed to eat snacks in addition to the prescribed diet, and staff were expected to monitor and record food intake, but these practices were not reflected in the care plan. The MDS Coordinator acknowledged that the care plan was incomplete and lacked necessary details, attributing this to being new in the role and the absence of regular care plan meetings. Further contributing to the deficiency, the facility experienced issues with their electronic medical record system, which resulted in baseline care plans being opened by LVNs and required manual intervention to create comprehensive care plans. The DON and other staff confirmed that these technical issues, along with unclear responsibilities and lack of regular oversight, led to incomplete care plans. The facility's own policy required comprehensive, person-centered care plans with measurable objectives and timetables, but this was not achieved for the resident in question.
Inaccurate Medical Record Documentation Due to Improper EMR Access
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices, resulting in incomplete and inaccurate documentation for one resident. Specifically, a newly hired RN, who did not have her own login credentials for the electronic medical record (EMR) system, was allowed to document an assessment note for a resident using an LVN's profile. The progress note in question was electronically signed and time-stamped under the LVN's credentials, although the content was authored by the RN. The RN stated she was shadowing the LVN to learn the computer system and was permitted to use the LVN's profile, but the LVN was not present when the documentation was entered and was unaware that the RN was making entries in the medical record. The LVN later discovered the note and reported it to the Director of Nursing (DON). Interviews with facility staff revealed that the RN was new, had not been fully trained, and was not authorized to chart independently. The Assistant Director of Nursing (ADON) and DON both confirmed that documentation under another staff member's credentials was not permitted and constituted a violation of facility policy, which requires that entries in the medical record be objective, complete, accurate, and only recorded by licensed personnel under their own credentials. The resident involved was an elderly female with multiple diagnoses, including urinary retention, type 2 diabetes mellitus, and hypertension. The incident resulted in inaccurate attribution of documentation in the resident's permanent medical record.
Failure to Provide Wound Care and Follow Physician Orders for Compression Therapy
Penalty
Summary
A male resident with a history of venous insufficiency and peripheral vascular disease was admitted to the facility and had physician orders for TED hose to be applied daily for edema management, with documentation required if refused. Despite these orders, there was no evidence on the treatment administration record that the TED hose were applied, and staff interviews revealed that the resident was not offered the TED hose, nor were they present in his room. Instead, the resident continued to wear unna boot compression dressings, which had been discontinued by physician order, for over 30 days. The dressings were observed to be dirty, discolored, undated, and in direct contact with the floor, and had not been changed since their application. Staff interviews indicated a lack of communication and follow-through regarding the change in orders from unna boots to TED hose. The wound care nurse (WCN) was unaware that the resident still had the unna boots on, and the primary nurse did not ensure their removal. The nurse practitioner and DON were also unaware of the resident's continued use of the unna boots and the lack of TED hose application. The resident denied refusing the TED hose and stated that staff had not offered them. Facility policy did not provide guidance on discontinuing wound care orders, contributing to the failure to provide care in accordance with physician orders and the resident's care plan.
Expired Produce Stored in Kitchen Refrigerator
Penalty
Summary
Surveyors observed that the facility failed to store and manage food in accordance with professional standards for food service safety. During an inspection of the kitchen's produce refrigerator, three boxes containing a total of 60 pounds of produce (salad lettuce, shredded lettuce, and diced green cabbage) were found to be stored past their labeled 'best by' dates. The produce was still available for serving to residents at the time of the observation. The Food Service Manager (FSM) confirmed during an interview that the produce was beyond the best by date and acknowledged it was not safe to serve. The FSM stated that it was his responsibility to review the produce daily and discard any items past their best by date, as per facility policy. The facility's Food Receiving and Storage policy requires that refrigerated foods be labeled, dated, monitored, and either used by their use-by date, frozen, or discarded. The Administrator also confirmed the expectation that no foods should be kept past expiration or best by dates. The failure to follow these procedures resulted in the deficiency cited by surveyors.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation and review of facility practices, which revealed lapses in the protection and management of confidential resident information and medical documentation. No additional details regarding specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Safe and Functional Equipment
Penalty
Summary
The facility failed to ensure that all mechanical, electrical, and patient care equipment was maintained in safe operating condition. Specifically, the commercial electric dishwasher in the kitchen had a malfunctioning temperature gauge, which had been reading below the manufacturer's required minimum of 120°F for effective sanitization. Dietary staff and the Food Service Manager (FSM) were aware of the issue, and logs showed temperature readings ranging from 100°F to 120°F. Although a handheld thermometer showed the water temperature was sufficient, the built-in gauge had been malfunctioning since April, and there was no documented evidence of a maintenance technician's visit or a work order to address the problem. Additionally, one of two beds in an occupied resident room was found without a mattress for approximately a month following the passing of a hospice resident. Staff interviews revealed uncertainty about why a new mattress had not been placed on the bed, and the Director of Nursing (DON) acknowledged awareness of the risk posed by an exposed metal bed frame. The facility's equipment safety and maintenance policy required prompt reporting and addressing of equipment malfunctions, but these procedures were not effectively followed in these instances.
Inaccessible Call Light System in Resident Bathrooms
Penalty
Summary
The facility failed to ensure that a working call system was accessible in each resident's bathroom and bathing area for 11 out of 15 rooms reviewed. Observations revealed that in multiple rooms, the call light cords were wrapped around the metal assistance bars next to the toilets, making them unreachable from the floor and approximately two feet above the ground. When attempts were made to pull the call light cords from the floor, the system did not activate, as the tension was absorbed by the metal bar rather than triggering the call system. Further observations confirmed that the call system functioned only when the cords were pulled without obstruction. During an interview, the DON explained that the cords were wrapped around the bars to prevent residents from slipping on them, acknowledging that this practice could pose a safety risk by making the call system inaccessible in emergencies. The facility's policy required that each resident have a means to call staff for assistance from the bed, toileting/bathing facilities, and from the floor, but the observed practice did not comply with this policy. No incidents of falls with inability to use the call system were reported at the time of the survey.
Failure to Timely Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to ensure that all allegations of abuse, neglect, and misappropriation were reported immediately, but no later than two hours after the allegation was made, to the State Survey Agency. Specifically, an incident occurred in which a resident with severe cognitive impairment and aphasia was slapped in the face by another resident, who also had severe cognitive impairment. The incident was witnessed by an LVN, who immediately separated the residents and notified the Director of Nursing (DON), Administrator, physician, and both residents' responsible parties. Documentation in the progress notes confirmed the incident and the actions taken at the time. Despite these actions, the incident was not reported to the State Survey Agency as required by federal regulations. The DON and Administrator stated during interviews that they did not report the incident because they believed there was no willful intent from the resident who committed the act, citing the resident's BIMS score of 0 and lack of prior behavioral issues. A review of the Texas Unified Licensure Information Portal (TULIP) confirmed that no report corresponding to this incident was submitted. The facility's policy required investigation and reporting of any allegations within the federally mandated timeframes, which was not followed in this case.
Inaccurate MDS Assessment and Documentation of Compression Dressings
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident with venous insufficiency and peripheral vascular disease. The annual MDS for this resident did not document the presence of continuous compression dressings, specifically unna boot dressings, which were observed on both legs during surveyor observations. The MDS indicated that no non-surgical dressings were applied, and the skin assessment did not note any alterations or the presence of dressings. Surveyors observed the resident wearing discolored and dirty dressings on both legs, extending from mid-foot to the knee, with the dressings in direct contact with the floor and not dated. These observations were made on consecutive days, and the condition of the dressings remained unchanged. Interviews with the MDS nurse and the Director of Nursing confirmed that the dressings should have been documented in the MDS and that nursing assessments are expected to accurately reflect the resident's status. Facility policy requires comprehensive assessments to be conducted and coordinated by a registered nurse with input from the interdisciplinary team.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a newly admitted resident. Record review showed that the only item addressed in the baseline care plan was the resident's full code status, with no documentation of other essential care areas such as allergies, fall risk, skin conditions, bowel and bladder needs, pain management, or nutrition. The resident in question was admitted with significant medical needs, including a traumatic subdural hemorrhage and a cognitive communication deficit, and was discharged to an acute care hospital after 10 days. Interviews with facility staff, including the MDS nurse and the DON, confirmed that the baseline care plan was insufficient and did not meet professional standards for person-centered care. The MDS nurse stated that the care plan should have included comprehensive information to guide care, and the DON acknowledged that the document was lacking critical details such as medications, transfer status, and therapy needs. The facility's care planning policy did not address baseline care planning for new admissions.
Failure to Provide Ordered Nutritional Supplement to Resident
Penalty
Summary
The facility failed to ensure that a resident with a nutritional problem received a therapeutic diet as ordered by the healthcare provider. Specifically, a female resident with a history of a right upper arm fracture and moderately impaired cognition was prescribed a regular diet with the addition of a house shake at breakfast and whole milk with dinner to support healing and optimal nutrition. Despite these orders, observations revealed that the kitchen did not have house shakes available, and the resident's breakfast tray did not include the required supplement. The resident confirmed she had not received the house shake at any point since admission. Interviews with staff indicated a lack of clarity regarding responsibility for providing the house shake, with dietary staff expected to include it on the tray and nursing staff expected to verify its presence. The registered dietitian confirmed the recommendation for the house shake and was unaware it had not been provided. The director of nursing also stated that dietary services should deliver the house shakes and that nursing should check for them before serving trays. The absence of the ordered nutritional supplement was confirmed through multiple observations and staff interviews.
Failure to Document Blood Pressure Prior to Antihypertensive Administration
Penalty
Summary
A resident with a history of epilepsy, aphasia, and nontraumatic intracerebral hemorrhage was prescribed amlodipine for hypertension, with physician orders specifying that the medication should be held if the diastolic blood pressure was less than 110 mmHg or the systolic blood pressure was less than 60 mmHg. The resident's care plan included interventions to obtain and record blood pressure readings under consistent conditions before administering antihypertensive medications. However, review of the Medication Administration Records for May and June showed that the resident received amlodipine 42 times without documentation of blood pressure readings at the time of administration. The Blood Pressure Vitals Record indicated that blood pressure was only recorded five times during this period, despite daily administration of the medication. Interviews with the Director of Nursing (DON) and a Licensed Vocational Nurse (LVN) revealed that the electronic health record may not have prompted staff to input blood pressure readings prior to medication administration. The LVN stated she checked the resident's blood pressure before giving the medication but could not provide evidence of this in the records. The facility's medication administration policy required verification of vital signs when necessary prior to administering medications, but this was not consistently documented or followed in this case.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
A medication cart assigned to the 200 hall was observed left unlocked and unattended near the entrance closest to the resident activities room. The cart was not secured at the time of observation, and staff interviews confirmed that the cart was under the responsibility of an LVN who had walked away, mistakenly believing it was locked. Another staff member subsequently locked the cart after noticing it was unsecured. The Director of Nursing (DON) confirmed that the facility's expectation is for medication carts to be locked when not in use to prevent unauthorized access. Review of the facility's policy on medication labeling and storage, revised in February 2023, specifies that all compartments containing medications and biologicals must be locked when not in use, and carts used to transport such items should not be left unattended if open or accessible. The failure to secure the medication cart was directly observed and acknowledged by staff, with the DON reiterating the importance of keeping medication carts locked to prevent unauthorized access.
Failure to Perform Hand Hygiene During Catheter Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during indwelling catheter care for a male resident with benign prostatic hyperplasia. During an observed care episode, two CNAs donned gowns and gloves before entering the resident's room. One CNA assisted the resident with transferring to bed and removing clothing, then initiated catheter care without changing gloves or performing hand hygiene. After cleansing the resident's thigh creases, the CNA disposed of soiled gloves but did not perform hand hygiene before donning new gloves. This process was repeated after cleansing the catheter tubing, with gloves changed but no hand hygiene performed between changes. Interviews with the involved CNAs and the DON confirmed that hand hygiene should have been performed between all glove changes, as per facility policy. The facility's standard precautions policy requires hand hygiene before and after resident contact and after removing gloves. The failure to follow these procedures was observed and acknowledged by staff, and the DON confirmed that not adhering to hand hygiene protocols could result in the spread of infection.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for five of seven residents reviewed. Specifically, a medication aide (MA) did not sanitize a wrist blood pressure cuff between use on two different residents, despite having received training and being assessed as satisfactory in infection control practices. The MA acknowledged forgetting to sanitize the equipment and recognized the risk of spreading germs. Both residents involved had diagnoses of hypertension and were receiving blood pressure monitoring and medication administration as part of their care. Additionally, a licensed vocational nurse (LVN) did not perform hand hygiene between feeding and assisting three different residents during breakfast. The LVN admitted to not washing or sanitizing her hands between residents, citing a desire to ensure timely feeding, and acknowledged awareness of infection control protocols. The LVN had previously been assessed as competent in hand hygiene and standard precautions. Facility policy required hand hygiene before and after resident contact and cleaning of reusable equipment between residents, but these protocols were not followed during the observed incidents.
Incomplete Documentation of Pain Management and Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, specifically in the areas of pain assessment, medication administration documentation, and weekly skin assessments. For one resident with severe cognitive impairment and multiple diagnoses including Alzheimer's disease and osteoporosis, pain assessments were documented as '0' on the Medication Administration Record (MAR) and Nursing Medication Administration Record (NMAR) during periods when staff interviews and progress notes indicated the resident exhibited signs of pain, such as grimacing and moaning. Despite staff acknowledging the resident's pain and administering Tylenol, the MAR entries for the administration of this PRN pain medication were left blank, and staff could not consistently recall or explain the lack of documentation. Additionally, the same resident's weekly skin assessments were not documented in the electronic medical record (EMR) for two of fourteen weeks, despite orders requiring weekly assessments. Staff interviews revealed confusion regarding the process for documenting skin assessments, with some nurses indicating that assessments may have been performed but not entered into the correct section of the EMR. The facility's management confirmed that if the MAR was checked as administered, it was assumed the assessment was done, but acknowledged that missing documentation in the assessment tab meant the findings were not recorded. A second resident, who was moderately cognitively impaired and at risk for pressure ulcers, also had missing documentation for weekly skin assessments for three weeks. While the MAR indicated that assessments were administered, there were no corresponding entries in the EMR assessment tab or progress notes for those weeks. Staff interviews suggested that assessments may have been completed but not documented, and management did not believe the lack of documentation impacted care, as they relied on the MAR check-off and the presence of a treatment nurse. Facility policies required comprehensive documentation of pain assessments, medication administration, and skin assessments, but these were not consistently followed.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the required daily nurse staffing information, including the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or vocational nurses, certified nurse aides, and the resident census for four consecutive days. Observations on one of these days revealed that the most recent posted document was dated several days prior and did not include information regarding care provided per shift. Interviews with staff, including the LPN and DON, confirmed that the document was not updated or posted as required, and that the DON and weekend supervisor were responsible for this task. The DON acknowledged the document was outdated and attributed the failure to issues with the facility's printers and a recent change in ownership, which affected staff access to printing resources. A review of the facility's policy indicated that nurse staffing data should be posted daily for each shift within two hours of the beginning of each shift, in a prominent and accessible location. The policy also specified the required information to be included on the posting. Despite these requirements, the facility did not ensure the daily posting of current nurse staffing and census information for the reviewed period, as confirmed by both observation and staff interviews.
Failure to Honor Resident DNR Status During Emergency Response
Penalty
Summary
The facility failed to ensure that personnel honored a resident's advance directive regarding resuscitation. A resident with an Out-of-Hospital Do Not Resuscitate (OOH-DNR) order and a documented DNR status in the medical record was found unresponsive. Despite the clear DNR status, a nurse initiated CPR and performed two chest compressions, causing the resident to moan in pain. The nurse admitted to not being aware of the resident's DNR status at the time and did not check the code status binder on the crash cart before starting CPR. The nurse only became aware of the DNR after a subsequent phone call with the physician and upon later review of the binder. Multiple staff interviews confirmed that the code status binder, which contains up-to-date information on all residents' resuscitation preferences, was available and located on the crash cart. However, the nurse involved did not consult this resource before acting. Other staff members, including CNAs, stated they attempted to communicate the resident's DNR status to the nurse during the event, but the nurse did not hear or respond to this information. The facility's policy required staff to check the code status before initiating CPR, but this protocol was not followed in this instance. The resident involved had a history of multiple rib fractures, dementia, Parkinson's disease, and cognitive impairment, and was admitted for rehabilitation. Documentation showed the resident's DNR status was consistently recorded in the admission record, care plan, and physician orders. The incident was not immediately reported to the state agency, and there was a lack of documentation and training regarding code status protocols among staff at the time of the event.
Unattended Laptop Exposes PHI of Multiple Residents
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of personal and medical records for 11 residents. During an observation, a medication cart was found unattended in a hallway with a laptop computer on top, actively displaying protected health information (PHI) for these residents. The laptop was left unsupervised and unlocked for at least five minutes, during which time several staff members, including a housekeeper, a driver, and a CNA, walked past the exposed information. The surveyor eventually alerted an LVN, who then notified the DON, resulting in the computer being locked and closed. Interviews with the DON and the medication aide assigned to the cart confirmed that the computer contained PHI and should have been secured when not attended. The medication aide stated she believed she had locked the computer and was unsure how it became open, acknowledging the risk to residents' privacy. A review of the facility's HIPAA Sanctions policy indicated that leaving a secured application unattended while logged on is a violation of facility policy.
Failure to Initiate and Document Grievance Process
Penalty
Summary
The facility failed to ensure that residents had the right to voice grievances without discrimination or reprisal, and did not follow its own grievance policy for at least one resident. Multiple complaints and grievances were made on behalf of a resident with significant medical conditions, including cerebrovascular disease, COPD, and cancer of the intestines. The resident's representative reported ongoing issues with care, communication, and staff behavior to the previous Administrator and the DON through various means such as text messages, emails, and verbal communication over a period of months. These complaints included concerns about pain management, staff responsiveness, changes in the resident's condition, and the handling of care plan documentation. Despite these repeated complaints, the facility did not initiate the formal grievance process as required by its policy. The complaints were acknowledged in some cases by the DON and the previous Administrator, but there was no evidence that the grievances were documented, investigated, or resolved according to the facility's procedures. The facility's grievance log did not contain any record of the grievances made on behalf of the resident during the relevant time period. Interviews with facility leadership confirmed that the staff did not recognize or act upon these grievances as required, and the DON admitted to not understanding the grievance process due to lack of training from the previous Administrator. The facility's own policy requires that all grievances be documented, investigated, and resolved promptly, with written decisions provided to the complainant. However, the actions of the previous Administrator and the DON did not meet these requirements, as they failed to record or process the grievances received. This lack of adherence to policy resulted in the resident's grievances not being formally heard or addressed, as confirmed by record reviews and staff interviews.
Failure to Timely Report Allegations of Abuse, Neglect, or Exploitation
Penalty
Summary
The facility failed to ensure that all suspected violations involving abuse, neglect, exploitation, or mistreatment were reported to the state agency within the required timeframe for two residents. In the first case, a nurse performed CPR on a resident who had a documented Do Not Resuscitate (DNR) order, despite the resident's wishes and clear documentation in the medical record and care plan. Staff interviews revealed that the nurse initiated CPR, and another staff member attempted to inform the nurse of the resident's DNR status during the event. The incident was not reported to the state agency as required, and there was no facility-generated report regarding this allegation of neglect for the resident during the relevant period. In the second case, the facility failed to report multiple allegations of neglect made on behalf of another resident. The resident's representative communicated concerns about inadequate pain management, lack of response from nursing staff, and failure to recognize significant changes in the resident's condition through text messages and emails to the previous Administrator and DON. These communications included specific allegations of neglect, such as staff not responding to call bells, not addressing the resident's deteriorating condition, and improper attempts to collect a urine sample. Despite these repeated allegations, there was no evidence that the facility reported them to the state agency as required. Interviews with facility staff, including the current Administrator and DON, confirmed that the previous leadership did not recognize or act upon these allegations as reportable events. The facility's own policies required immediate reporting of such allegations, but these procedures were not followed. The lack of timely reporting of suspected abuse, neglect, or exploitation could place residents at risk by failing to ensure that allegations are properly investigated by the appropriate authorities.
Failure to Investigate and Report Allegations of Abuse, Neglect, or Exploitation
Penalty
Summary
The facility failed to thoroughly investigate and report allegations of abuse, neglect, or exploitation (ANE) to the State Survey Agency within the required 5 working days for two residents. In the first case, a resident with a documented Do Not Resuscitate (DNR) order was subjected to CPR by a nurse, despite clear documentation and communication of the resident's DNR status. Staff interviews revealed that the nurse initiated compressions before being informed of the DNR status, and there was no subsequent investigation or report of this incident to the state agency. The Assistant Director of Nursing (ADON) acknowledged awareness of the code status incident but did not report it, and the previous Director of Nursing (DON) stated she was unaware of the event and would have reported it if informed. In the second case, a resident's representative made multiple allegations of neglect via text messages and emails to the previous Administrator and DON, including concerns about delayed pain medication, lack of recognition of significant changes in the resident's condition, and inadequate response to requests for care. Despite these communications, there was no evidence that the facility investigated these allegations or reported the results to the state agency. The DON and Administrator at the time received and acknowledged the complaints but did not initiate the required investigation or reporting process. Record reviews confirmed that no facility-generated reports regarding these allegations were submitted to the state agency during the relevant periods. Interviews with current and former staff indicated a lack of clarity and follow-through regarding responsibility for investigating and reporting ANE allegations. The facility's own policies required immediate investigation and reporting of such incidents, but these procedures were not followed in the cases reviewed.
Unattended and Unlocked Medication and Treatment Carts
Penalty
Summary
Facility staff failed to ensure that all drugs and biologicals were stored in locked compartments and that only authorized personnel had access to them. During an observation, both a medication cart and a treatment cart were found unattended, unsupervised, and unlocked in a hallway. Over a period of five minutes, several staff members, including a housekeeper, a driver, and a CNA, walked past the unsecured carts. The medication aide assigned to the cart stated she always locked the cart when leaving it but was unsure how it became unlocked. The LVN responsible for the treatment cart admitted to unintentionally leaving it unlocked while providing care in a resident's room. The Director of Nursing (DON) and the Administrator were both made aware of the situation. The facility's policy requires all medications to be stored in locked compartments with access limited to authorized personnel. The failure to secure the medication and treatment carts was directly observed and acknowledged by the staff involved, with the risk for harm identified as unsecured medications.
Failure to Ensure Safe Storage and Labeling of Resident Food Items
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as evidenced by observations in the resident food and snack pantry refrigerator. During an inspection, surveyors found 15 containers of food with various safety concerns, including expired items, unlabeled or improperly labeled foods, and visibly spoiled or malodorous contents. Specific examples included yogurt and fruit with past-due manufacturer dates, facility-made foods without discard dates, unmarked containers with spoiled contents, and leftovers from outside sources lacking proper labeling or dating. Staff interviews revealed a lack of awareness and adherence to food safety protocols. A CNA stated she was unaware of labeling practices and could not confirm the safety of the foods present, noting that some items appeared unsafe and would be reported to nursing staff. The Food Service Manager (FSM) was initially unaware of the existence of the resident snack pantry and its refrigerator, and only upon notification did he recognize his responsibility for food safety in that area. The FSM outlined expectations for labeling and discarding food, but these were not being followed at the time of the survey. A review of the facility's policy on date marking for food safety indicated that perishable foods should be held at 41°F or less, clearly marked with preparation and discard dates, and discarded within specified timeframes. The policy also assigned responsibility for daily and weekly checks to specific staff members. However, these procedures were not being implemented in the resident snack pantry, resulting in the presence of expired, spoiled, and improperly stored foods accessible to residents.
Failure to Prevent Cross-Contamination in Laundry Department
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in the laundry department, specifically regarding the handling, storage, processing, and transport of linens. Observations revealed that clean blankets were stored in the soiled laundry room alongside boxes containing soiled infectious disease laundry. The soiled laundry room was also used to hang clean, wet blankets to dry, resulting in clean and soiled items being stored together. The soiled laundry was stored in cardboard boxes labeled as biohazard, and these boxes contained laundry from residents under isolation precautions due to infections. Laundry aides reported that the only personal protective equipment (PPE) available in the laundry department was gloves, and they did not use full PPE such as gowns when handling soiled infectious laundry. Both laundry aides stated they had not received specific training on handling soiled infectious disease laundry and relied on common sense and general hand hygiene practices. The Housekeeping Director confirmed that training for infectious disease prevention and control was outside his scope and that he had only received general infection control training from the DON, not specific to laundry procedures. The facility's infection prevention and control policy required that clean linen be separated from soiled linen at all times and that staff use PPE according to established policy. However, these procedures were not followed, as evidenced by the storage of clean blankets with soiled infectious laundry and the lack of appropriate PPE use by laundry staff. The DON and Administrator acknowledged that these practices placed residents and staff at risk for cross-contamination and infection.
Failure to Administer Wound Care as Ordered
Penalty
Summary
The facility failed to provide wound care to a resident as ordered by the physician for cellulitis on two consecutive days. The resident, who was diagnosed with leukemia and cellulitis, did not receive the prescribed wound care on the specified dates. The resident's care plan included daily wound care, which was not administered on one of the days by an LVN who later admitted to forgetting due to being busy. The resident reported the missed care to a CNA and expressed concern about not receiving an explanation for the lapse in treatment. The resident's medical records indicated that wound care was not performed on the specified date, and the resident's skin assessment showed redness on the right leg without measurements. Interviews with the nursing staff, including the wound nurse and the DON, confirmed the oversight and highlighted the importance of following MD orders to ensure proper healing. The resident did not suffer any immediate harm, as the skin was intact, and the condition was being treated with antibiotics.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to conduct initial comprehensive assessments of residents' functional capacities within the required 14-day period after admission. This deficiency was identified for four residents, who were not assessed in a timely manner, potentially affecting their care and services. The MDS Coordinator did not complete the necessary assessments for these residents, which included evaluating their needs, strengths, goals, life history, and preferences. Resident #1 was admitted with multiple health conditions, including a fracture, respiratory failure, and chronic kidney disease. The MDS Admission/Medicare-5 Day assessment for this resident was completed and signed late, beyond the 14-day requirement. Similarly, Resident #2, diagnosed with depression, polyneuropathy, and a spinal fracture, had an incomplete MDS assessment that was not signed by an RN Assessment Coordinator. Resident #3, with fibromyalgia, gastroenteritis, and a UTI, also had an incomplete assessment. Resident #6, who had benign prostatic hyperplasia, peripheral vascular disease, and dementia, had their assessment signed late as well. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for completing and signing the MDS assessments. The Regional MDS Coordinator, who was an LVN, could not sign the assessments, and there was no clear process for ensuring timely completion. The Director of Nursing and the Administrator were not fully aware of who was responsible for tracking and signing the assessments, leading to delays and non-compliance with federal regulations.
Inaccurate Resident Assessments in LTC Facility
Penalty
Summary
The facility failed to ensure the initial comprehensive assessments accurately reflected the status of two residents, leading to potential risks in their care. For Resident #4, the admission comprehensive assessment inaccurately coded her as having an indwelling catheter, despite documentation and observations indicating she did not have one. This error was identified through a review of her medical records and an interview with the Regional MDS Coordinator, who confirmed the mistake and noted that it would not have impacted her care since the catheter was not present. Resident #5's assessment inaccurately documented her fall history, failing to note a fracture related to a fall within the six months prior to her admission. This discrepancy was discovered through a review of her physician's progress notes and hospital discharge summary, which clearly indicated a fall resulting in a fracture. The Regional MDS Coordinator acknowledged the oversight and stated that the error did not impact Resident #5's care, as she was stable upon admission and received appropriate fall interventions. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a lack of clarity regarding responsibility for the accuracy of MDS assessments. The facility's policy mandates comprehensive and accurate assessments, with interdisciplinary responsibility for completion. However, the corporate company was primarily responsible for entering information into the MDS assessments, which may have contributed to the inaccuracies observed.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental needs. The care plans did not address the residents' full code status, fall risks, or specific interventions to prevent or mitigate injuries from falls. This deficiency was identified through interviews and record reviews, revealing that the care plans lacked essential information despite the residents having a history of falls and requiring assistance for transfers. Resident #1, who was cognitively intact and had a history of falls, did not have a care plan reflecting her full code status or specifying the number of staff required for transfers. Similarly, Resident #4, who was moderately cognitively impaired and had a history of falls, lacked a care plan addressing her full code status and fall risk. Resident #5, severely cognitively impaired and assessed as high fall risk, did not have her fall risk or history addressed in her care plan. Resident #6, moderately cognitively impaired with multiple falls, also lacked a care plan reflecting his full code status, ADL needs, and fall risk. Interviews with facility staff, including the LCSW, Regional MDS Coordinator, and DON, revealed inconsistencies in the care planning process. The LCSW acknowledged the omission of code status in care plans, while the Regional MDS Coordinator and DON discussed the interdisciplinary team's role in care planning. However, there was uncertainty about who was responsible for reviewing care plans for completion. The facility's policy required comprehensive care plans to be developed and implemented within specific timeframes, but these requirements were not met for the residents reviewed.
Failure to Implement Comprehensive Care Plans Leads to Multiple Falls
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which led to multiple falls and injuries. Resident #1, who was admitted with a broken neck from a fall at home, experienced several falls at the facility, including one that resulted in a subdural hemorrhage requiring hospitalization. Despite being identified as a high fall risk, Resident #1's care plan was incomplete, and no interventions were documented to prevent future falls. The facility's lack of a comprehensive care plan for Resident #1 contributed to the repeated falls and subsequent injury. Resident #4, who was assessed as a high fall risk, also did not have a comprehensive care plan in place. The resident experienced a fall in the bathroom, but no interventions were documented to prevent future falls. The facility's failure to develop a care plan for Resident #4 left the resident vulnerable to accidents and injuries. Similarly, Resident #3, who was identified as having a moderate risk for falls, did not have a comprehensive care plan, leaving the resident without documented interventions to mitigate fall risks. The facility's deficiency in developing and implementing care plans was exacerbated by staffing issues, including the absence of an MDS Coordinator and the DON's inability to fulfill her duties due to working as a floor nurse. The lack of comprehensive care plans meant that staff were not adequately informed about residents' needs and interventions, leading to a failure in providing appropriate care and preventing falls.
Inadequate Supervision and Fall Prevention for High-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident with a significant history of falls. The resident, who was admitted with multiple diagnoses including parkinsonism and progressive supranuclear ophthalmoplegia, experienced five documented falls during their stay. Despite being identified as a high fall risk, the resident did not have a comprehensive care plan in place, and interventions to prevent future falls were not documented after each incident. The resident's falls were often unwitnessed, and staff interviews revealed a lack of awareness and training regarding fall prevention measures. The facility's electronic record system did not have updated care plans or Kardexes, leaving staff without clear guidance on interventions. The resident's impulsivity and nocturnal activity were known, yet supervision was inconsistent, and the facility lacked a visual identification system for fall risks. Interviews with staff, including the DON and CNAs, highlighted systemic issues such as understaffing, lack of training, and inadequate communication of fall risk interventions. The facility was newly opened, and the DON was overwhelmed with duties, impacting her ability to implement and monitor fall prevention strategies. The resident's family was aware of the fall risk and had expressed concerns, but the facility did not have a structured fall prevention program in place.
Latest citations in Texas
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
