Avir At Kingsland
Inspection history, citations, penalties and survey trends for this long-term care facility in Kingsland, Texas.
- Location
- 3727 W Ranch Rd 1431, Kingsland, Texas 78639
- CMS Provider Number
- 676035
- Inspections on file
- 33
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Avir At Kingsland during CMS and state inspections, most recent first.
The facility failed to prevent physical abuse when a resident with dementia and moderately impaired cognition, whose care plan did not address potential aggressive behavior despite increased confusion and paranoia, struck another resident with a cane multiple times to the head and arm. The assaulted resident, who had Alzheimer's disease and muscle wasting, sustained superficial scalp scratches, reported head and arm pain, and guarded the affected arm. Staff heard yelling, witnessed the assault, and intervened, but the incident demonstrated a failure to ensure residents were free from abuse as required by the facility's abuse prevention policy.
A resident with multiple complex conditions and moderate cognitive impairment, care planned as a moderate fall risk, experienced a fall near the nurses’ station during the night shift. An LVN completed an incident report documenting assessment and treatment, but the section for notifications showed none, and progress notes contained no evidence that the resident’s family or representative was informed. The family later reported they only learned of the fall during a subsequent visit, demonstrating a failure to notify the resident’s representative of a change in condition as required by facility policy and resident rights.
A resident with Type 1 DM, multiple neurologic and medical comorbidities, and moderate cognitive impairment had an admission MDS documenting DM and regular insulin injections, along with active orders for Lantus and Humalog. However, the comprehensive care plan only addressed ADL self-care deficits and fall risk related to confusion and did not include the resident's DM, insulin use, or blood glucose monitoring. After the resident sustained a fall and was diagnosed in the ER with a right-sided zygomaticomaxillary complex fracture, the condition was documented in a progress note but never added to the care plan. Interviews with the MDS nurse and Regional Nurse confirmed that the comprehensive care plan was not fully developed or updated as required by facility policy and MDS triggers.
A resident with multiple complex conditions and dysphagia was admitted with a hospital Speech-Language Pathology recommendation for a pureed diet with thin liquids, but nursing communicated a regular-texture, NCS diet with thin liquids to dietary. Dietary staff, who rely on nursing dietary slips and do not routinely review clinical records, provided regular-texture meals for several days until a later slip changed the order to pureed texture. The admitting LVN could not recall the initial diet details, and leadership confirmed the nurse was responsible for transmitting the correct diet from the hospital documentation, with staff acknowledging that receiving regular instead of pureed texture food placed the resident at risk for aspiration, choking, and weight loss.
A resident with multiple complex conditions and moderate cognitive impairment was admitted with physician orders for PT, OT, and ST to evaluate and treat as indicated, and the care plan identified ADL self-care deficits, fall risk, and an intervention for PT to evaluate and treat after any fall. Despite these orders and facility policies requiring therapy screening on all new admissions and PT evaluation after falls, the therapy department did not evaluate the resident at admission and did not complete a PT evaluation after a documented fall and a nursing therapy screen request. The DOR reported she did not perform the admission screening due to perceived lack of payer authorization and did not see the post-fall referral in the electronic system, while the BOM, Administrator, and Regional Nurse stated that all new admissions and post-fall events should be screened by therapy regardless of payer source.
A resident with fragile skin and multiple comorbidities experienced significant bleeding from skin tears that occurred during care. CNAs reported the bleeding to an LVN, who did not assess or intervene, citing being busy with medication administration. The resident continued to bleed until an RN on the next shift discovered the situation and provided necessary wound care. There was no handover or report to the oncoming staff about the resident's condition.
A resident with fragile skin and multiple comorbidities experienced significant bleeding from skin tears that occurred during care. CNAs reported the bleeding to an LVN, who did not assess or intervene before leaving her shift. The resident continued to bleed until an RN on the next shift was notified and provided care. There was no handover or report to the oncoming staff, resulting in a delay in intervention and physician notification.
Two medication carts containing prescription drugs, over-the-counter medications, and prescription creams were found unlocked and unattended near the nurses' station. Nursing and administrative staff confirmed that facility policy requires medication carts to be locked when not in use, and acknowledged the carts should have been secured. Despite staff training and monitoring practices, the carts were left accessible to unauthorized individuals, in violation of the facility's medication storage policy.
A resident with fragile skin, cognitive impairment, and a history of skin tears developed new skin tears with significant bleeding on a lower leg while two CNAs were providing care. The CNAs immediately reported the ongoing bleeding to an LVN, who stated she was busy passing medications and would assess the resident later, and the CNAs applied a towel to the leg before the end of their shift. The LVN did not return to assess or treat the bleeding and did not communicate the situation in shift report, and later called a CNA at home stating she had forgotten to address the wound. At the start of the next shift, an RN was alerted by a CNA and found the resident with heavy bleeding from multiple skin tears, blood-soaked linens, and saturated bandages, and then provided wound care and monitoring. The facility’s own policy requires competent nursing care, including timely response to changes in condition and proper communication, but the LVN’s failure to promptly assess and intervene for active bleeding led to this deficiency.
A resident with dementia, fragile skin, and bilateral leg edema experienced multiple new skin tears with profuse, ongoing bleeding during morning care. CNAs reported the bleeding to an LVN, who stated she was busy with medication administration and did not promptly assess or treat the resident before the end of the night shift, and no handoff about the bleeding was given to the oncoming staff. At the start of the next shift, a CNA and RN found the resident bleeding heavily with blood‑soaked linens and multiple saturated dressings, and the RN had to change several bandages to contain the bleeding. The facility did not immediately consult the resident’s physician regarding this significant change in condition, resulting in a cited deficiency related to failure to promptly respond to and report a substantial change in status.
Surveyors found a medication cart and a treatment cart unlocked and unattended near the nurses’ station, with prescription drugs, OTC medications, narcotics, and prescription creams accessible. An LVN admitted he left a cart unlocked when going to the medication room, and a treatment nurse confirmed carts are supposed to be locked whenever staff are away but could not explain why the treatment cart was left open. The DON and ADM both stated that only authorized staff should access carts and that carts must be locked when not in use, yet neither could explain why these carts were unlocked, in violation of the facility’s written medication labeling and storage policy.
A nurse failed to sanitize a blood pressure cuff and medication cart surface between uses on four residents with various medical conditions, despite facility policy and staff knowledge requiring disinfection of reusable equipment between residents to prevent cross-contamination.
Surveyors identified a medication error rate of 9.38% after observing an LVN crush an extended-release antidepressant against orders and manufacturer guidelines for a resident with cognitive impairment, omit a prescribed anti-anxiety tablet, and provide an incorrect dose of a fluid pill to another resident. Staff interviews confirmed that medications were not administered as ordered, contributing to the elevated error rate.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse when one resident struck another with a cane, causing injury. Resident #1, a male with non-Alzheimer's dementia, alcoholic liver disease, chronic pain, cataracts, and constipation, had a BIMS score of 9 indicating moderately impaired cognition. His care plan, dated 10/14/25, addressed moderately impaired decision-making related to dementia but did not include any interventions for potential aggressive or combative behaviors. Prior to the incident, Resident #1 had exhibited increased confusion and paranoia, and the charge nurse had notified the physician and initiated lab tests and referrals, but the behavior escalated before further interventions were implemented. On 04/20/26 at 10:45 PM, staff heard yelling and observed Resident #1 striking Resident #2 with a cane two times to the head and two times to the arm while threatening to kill him. Resident #2, a male with Alzheimer's disease, muscle wasting, and impaired memory, sustained two superficial scratches to the posterior scalp, reported pain to his head and arm, and exhibited guarding of the right upper extremity. Resident #2 later confirmed he had been struck in the head with a cane by another resident. The facility's abuse prevention policy states that residents have the right to be free from abuse, including physical abuse, but the lack of care plan interventions addressing Resident #1's potential for aggressive behavior and the subsequent assault on Resident #2 constituted the identified deficiency.
Failure to Notify Resident Representative After Fall Event
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition following a fall. A male resident with multiple complex diagnoses, including Type 1 DM with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension, was admitted with moderate cognitive impairment as evidenced by a BIMS score of 09. His care plan, initiated 12/31/2025, identified an ADL self-care performance deficit related to confusion and a moderate risk for falls related to confusion. An incident report dated 01/17/2026 at 9:00 p.m., completed by LVN A, documented that the resident was found on the floor near the nurses’ station after he slipped. The report noted that vital signs, neuro checks, and blood sugar were obtained, glucose was given, and his post-treatment blood glucose was 118, and that he was ambulatory without assistance. The incident report section for agencies/people notified reflected “No Notifications found,” and review of the resident’s progress notes for 01/17/2026 showed no evidence that the resident’s family was notified of the fall. The resident’s face sheet listed a responsible party, and facility policy stated that residents have the right to be notified of their medical condition and any changes in condition, and to be informed of and participate in care planning and treatment, including through a legal representative appointed in accordance with state law. During an interview on 01/27/2026 at 10:40 a.m., the resident’s family reported they were not notified of the fall and only learned of it the following day when visiting. This sequence of events formed the basis for the cited deficiency related to failure to inform the resident’s representative of a change in condition.
Failure to Care Plan Diabetes and Post-Fall Facial Fracture
Penalty
Summary
Surveyors identified a failure to develop and implement a person-centered comprehensive care plan that addressed all of a resident's medical, physical, mental, and psychosocial needs. The resident was an adult male admitted with multiple diagnoses, including Type 1 DM with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension. The admission MDS documented a BIMS score of 09 (moderate cognitive impairment) and an active diagnosis of DM, with Section N indicating the resident received insulin injections five days a week. Despite this, the care plan initiated on 12/31/2025 only addressed an ADL self-care performance deficit related to confusion and a moderate risk for falls related to confusion, and did not include the resident's Type 1 DM or insulin use. Record review showed active physician orders for Lantus (insulin glargine) 15 units subcutaneously once daily starting 12/28/2025 and Humalog (insulin lispro) per sliding scale before meals starting 12/29/2025 for DM management. These active insulin orders and the documented DM diagnosis were not reflected in the resident's care plan, meaning there were no care-planned interventions for blood glucose monitoring or insulin administration. The facility's own policy required that the comprehensive, person-centered care plan include measurable objectives and timeframes and describe services to meet the resident's physical, psychosocial, and functional needs, derived from the comprehensive assessment and completed no more than 21 days after admission. In addition, the facility failed to update the care plan after the resident experienced a fall on 01/10/2026, was sent to the ER, and was diagnosed via CT maxillofacial imaging with a right-sided zygomaticomaxillary complex fracture. A progress note documented the resident's return from the ER with a diagnosis of facial fractures and no new orders, with a plan to continue monitoring, but this new condition was never added to the care plan. Interviews with the MDS nurse and Regional Nurse confirmed that the resident's comprehensive care plan was incomplete, that the DM diagnosis and facial fracture should have been care planned, and that the comprehensive care plan should have been developed and updated in accordance with facility policy and MDS triggers, but this did not occur.
Failure to Follow Hospital Dysphagia Diet Recommendation for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to provide a prescribed therapeutic diet for one resident with significant medical conditions and dysphagia. The resident, an older male admitted from the hospital with diagnoses including Type 1 diabetes with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension, had a hospital Speech-Language Pathology recommendation for a diet of thin liquids and pureed consistency. The admission MDS showed a BIMS score of 09, indicating moderate cognitive impairment, and the care plan later reflected ADL self-care deficits and moderate fall risk related to confusion. The facility’s policy required therapeutic diets to be prescribed by the attending physician or delegated dietitian and that diet orders match food and nutrition services terminology, including altered consistency diets. On admission, the communication of the resident’s diet from nursing to dietary was incorrect. A dietary communication slip dated 12/27/2025, completed by LVN B, indicated a regular/liberalized, no concentrated sweets (NCS), regular texture diet with thin liquids, rather than the pureed texture recommended by the hospital. The Dietary Manager stated that for new admissions, dietary relies on the dietary communication slip from nursing and does not review the clinical record directly. Based on this initial slip, the resident received regular texture food from 12/27/2025 through 12/31/2025. During this period, the physician order dated 12/31/2025 later reflected a regular diet with pureed texture and regular liquid consistency, and the care plan initiated 01/05/2026 documented an NCS diet with pureed texture and thin liquids. Interviews confirmed that the admitting nurse and dietary staff depended on the information transmitted via the dietary communication slip rather than verifying the hospital discharge recommendations. LVN C, identified as the admitting nurse, stated she would have looked at the discharge papers to determine the diet but could not recall the resident’s admitting diet or whether she received a nurse-to-nurse report. The Dietary Manager confirmed that the resident’s meals were prepared as regular texture until a subsequent dietary communication slip dated 12/31/2025 changed the diet to pureed texture with thin liquids. The Regional Nurse stated that the admitting nurse was responsible for sending the correct diet order to dietary based on the hospital clinical information and should have called the hospital for clarification if unsure. Staff interviews noted that providing regular texture food instead of pureed for a resident requiring pureed texture created a risk for aspiration, choking, and weight loss.
Failure to Provide Ordered Therapy Evaluation at Admission and Post-Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that specialized rehabilitative services were provided by qualified personnel as ordered by a physician and as outlined in the resident’s care plan. A male resident with multiple complex diagnoses, including Type 1 diabetes with kidney complications, sepsis, nontraumatic subarachnoid hemorrhage, hemiplegia and hemiparesis following cerebral infarction, acute bronchiolitis due to RSV, and orthostatic hypotension was admitted with a physician order for PT, OT, and ST to evaluate and treat as indicated. The admission MDS showed moderate cognitive impairment with a BIMS score of 9 and documented that the resident required setup or clean-up assistance for some functional activities. Despite the standing physician order for therapy evaluation and treatment, the therapy department did not screen or evaluate the resident upon admission. The resident’s care plan, initiated on the date of admission, identified an ADL self-care performance deficit related to confusion and a moderate risk for falls, and it documented a fall on a later date with an intervention specifying that PT was to evaluate and treat as needed after a fall. The resident experienced a fall next to the kitchen door, and nursing completed a Nursing to Therapy Screen Request in the electronic record, indicating a post-fall reason and requesting PT due to recent physical function changes. However, the Director of Rehabilitation (DOR) did not act on this request and did not perform a screening or evaluation following the fall, despite the care plan intervention and the facility’s process that a fall triggers a therapy evaluation request. Interviews revealed that the DOR chose not to screen or evaluate the resident upon admission because she believed there was no payer authorization from the hospital and stated that the therapy department usually did not treat residents without funding unless directed by the Administrator. The Business Office Manager (BOM) stated that all new admissions were to be screened or evaluated by therapy unless admitted only for nursing services and that treatment decisions were based on payer source, but also indicated that this resident was to be handled through an administrative authorization process. The Administrator and Regional Nurse both stated that all new admissions should be screened by therapy regardless of payment source and that PT should evaluate after every fall per facility standard, with payer source not preventing evaluation. The DOR later acknowledged that there was a communication in the electronic medical record regarding the resident’s fall that she did not see because she had not been checking the dashboard daily. Facility policies on fall risk assessment, falls clinical protocol, and resident screening guidelines required interdisciplinary assessment of fall risk factors and therapy screening on all new admissions and upon referral, but these processes were not followed for this resident at admission or after the fall. The facility’s fall risk assessment policy required nursing staff, the attending physician, therapy staff, and others to identify and document resident risk factors for falls and to establish a resident-centered fall prevention plan based on assessment data, including evaluation of ambulation, mobility, gait, balance, ADL capabilities, and cognition. The falls clinical protocol required assessment and recognition of fall risk, documentation of recent falls, and evaluation of musculoskeletal function and neurological status after a fall, with staff attempting to define possible causes within 24 hours. The resident screening guidelines policy required that screenings be completed by licensed therapy staff on all new admissions or upon referral to help identify functional loss and the need for rehabilitation services. Despite these written policies, the resident did not receive the ordered therapy evaluation at admission, and the post-fall therapy evaluation and treatment intervention in the care plan was not implemented after the documented fall and therapy referral. The Administrator stated that the therapy department should have assessed the resident when there was a request in the electronic system and that payer source was not a factor in determining the need for assessment. The Regional Nurse stated that once there is a fall, it triggers a form to be sent to therapy to evaluate the resident and that therapy should screen every resident, with further treatment decisions made after evaluation. The DOR stated she was new to the position, was still learning the process, and had only become aware of the nursing communication regarding the fall after the surveyor’s inquiry. These interviews and record reviews collectively showed that the facility failed to ensure that therapy services evaluated and treated a function impaired by illness or injury and failed to increase the resident’s functioning as ordered, by not conducting the required therapy evaluations at admission and after the fall, contrary to physician orders, the resident’s care plan, and facility policies.
Failure to Timely Assess and Intervene for Resident Bleeding from Skin Tears
Penalty
Summary
A licensed vocational nurse (LVN) failed to assess and perform necessary interventions to stop a resident from bleeding due to skin tears. The resident, an elderly female with Alzheimer's disease, muscle weakness, chronic pain, hypertension, and a history of impaired skin integrity, developed new skin tears on her lower leg that resulted in significant bleeding. The resident was known to have very fragile skin, exacerbated by long-term prednisone use and bilateral leg edema, making her prone to skin injuries. On the morning of the incident, certified nursing assistants (CNAs) discovered the resident bleeding from newly developed skin tears while providing care. The CNAs reported the bleeding to the LVN, who was administering medications at the time. The LVN stated she was busy and would attend to the resident after completing her medication pass. The CNAs attempted to control the bleeding by wrapping a towel around the wound, but the LVN did not assess or intervene before the end of her shift. The LVN later contacted one of the CNAs at home to inquire about the severity of the wound, admitting she had forgotten to address the bleeding. The resident continued to bleed until the next shift, when a registered nurse (RN) was notified and promptly intervened to control the bleeding. The RN found the resident with multiple skin tears and significant blood loss, requiring several bandage changes to contain the bleeding. There was no handover or report given to the oncoming staff regarding the resident's condition, and the incident was only discovered during a routine check at the start of the day shift.
Failure to Immediately Notify Physician and Intervene for Resident's Significant Change in Condition
Penalty
Summary
A deficiency occurred when facility staff failed to immediately consult with a resident's physician following a significant change in the resident's condition, specifically when the resident experienced bleeding from multiple skin tears. The resident, an elderly female with a history of Alzheimer's disease, muscle weakness, chronic pain, hypertension, and impaired skin integrity, was known to have very fragile skin due to long-term prednisone use and bilateral leg edema. On the morning of the incident, certified nursing assistants (CNAs) discovered the resident bleeding from newly developed skin tears on her leg while providing care. The CNAs reported the bleeding to the assigned LVN, who was administering medications at the time and stated she would assess the resident after completing her medication pass. However, the LVN did not assess or intervene for the resident's bleeding before leaving her shift. The CNAs attempted to control the bleeding by wrapping a towel around the wound and expected the LVN to follow up. The LVN later contacted one of the CNAs at home to inquire about the severity of the wound, admitting she had forgotten to address the bleeding due to being busy with other tasks. The resident continued to bleed until the next shift, when an RN was notified by another CNA and immediately intervened to control the bleeding, noting that the resident had lost a significant amount of blood and required multiple bandage changes. There was no handover or report given to the oncoming staff regarding the resident's condition, resulting in a delay in care. Interviews with facility staff, including the Director of Nursing (DON) and the Administrator, confirmed that the LVN did not assess or provide timely intervention for the resident's bleeding, and that the resident was left unattended and bleeding for approximately two hours. The facility's policies required staff to identify, document, and report changes in resident condition, and to provide detailed shift-to-shift handovers, but these procedures were not followed in this instance. The deficiency was identified through observation, interviews, and record review, which documented the sequence of events and the lack of immediate physician notification and timely nursing intervention.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that two of three medication carts (MC #1 and TC #2) were left unlocked and unattended near the nurses' station. MC #1 contained residents' prescription drugs, over-the-counter medications, and narcotics secured in a locked box within the cart, while TC #2 contained residents' prescription creams. At the time of observation, no nurses or staff were present in the vicinity of either cart. Interviews with nursing staff, the DON, and the administrator confirmed that facility policy requires medication carts to be locked at all times when not in use and that only authorized personnel should have access. Staff acknowledged awareness of the policy and admitted the carts should have been locked when unattended. The facility's Medication Labeling and Storage Policy, reviewed by surveyors, states that all medications and biologicals must be stored in locked compartments and only authorized personnel may access them. Despite this, both nursing and administrative staff could not provide an explanation for why the carts were left unlocked. The staff described monitoring practices that rely on observation by nurses, administrative staff, and peer-to-peer checks, but these measures failed to prevent the carts from being left unsecured and accessible to unauthorized individuals.
Failure to Timely Assess and Treat Active Bleeding from Skin Tears
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received treatment and care in accordance with professional standards of practice when active bleeding from skin tears was not promptly assessed or treated by a nurse. The resident was an elderly female with diagnoses including Alzheimer’s disease, muscle weakness, chronic pain, hypertension, shortness of breath, and gait and mobility abnormalities. Her care plan identified her as having potential for impaired skin integrity and being at risk of bleeding, with interventions including evaluation of skin for integrity and impaired coagulation. She had a documented skin tear on the right distal lower leg with physician’s orders for daily and PRN wound care, and wound assessments showed improvement over time. On the early morning in question, two CNAs were changing the resident and attempting to separate her contracted, crossed legs when a skin tear occurred on her right lower leg, causing significant bleeding. One CNA reported that the resident’s skin was very sensitive and prone to tearing, and that the bleeding from the new skin tears did not stop. The CNA immediately reported the bleeding to LVN A, who was in the same hall administering medications. According to the CNA, LVN A stated she was busy with medication administration and would assess the resident after finishing her medication pass. The CNAs wrapped a towel around the resident’s leg to apply pressure and minimize further damage, but the bleeding continued. The CNA then completed her shift and left, believing that LVN A would address the bleeding. Later that morning, the oncoming RN was informed by another CNA that the resident was bleeding in bed. When the RN entered the room, she observed heavy bleeding from three skin tears on the resident’s right lower leg, with bed sheets visibly wet with blood and multiple bandages saturated with blood before the bleeding was contained. The RN reported that neither she nor the CNA had received any handoff report from the previous shift about the resident’s bleeding. The resident’s representative stated that CNAs had initially noticed the bleeding and reported it to LVN A, but that LVN A did not perform any interventions and left the facility without assessing the resident, leaving the bleeding to be addressed by the next-shift nurse. The DON and the administrator both acknowledged that LVN A did not assess the resident or perform timely interventions to stop the bleeding, and the DON stated that loss of excessive blood is a threat to the resident’s life. The facility’s policy on sufficient and competent nursing staff requires that all nursing staff demonstrate competency in skin and wound care and in identifying, documenting, and reporting resident changes of condition consistent with their scope of practice. The policy also emphasizes that staff must have the skills and techniques necessary to care for resident needs, including basic nursing skills and communication. In this incident, the report describes that LVN A did not promptly triage and prioritize the resident’s active bleeding after it was reported by the CNA, did not provide a handoff regarding the bleeding to the oncoming nurse, and later contacted the CNA at home asking about the severity of the wound, stating she had forgotten to take care of the bleeding. These actions and inactions led to the resident remaining in bed with ongoing, heavy bleeding from multiple skin tears until discovered and treated by the day-shift RN. The resident’s representative reported that the resident had been on long-term prednisone, resulting in very fragile skin and bilateral leg edema, and that her skin was prone to tearing easily. The representative stated that CNAs had thrown a towel on the wound to stop the bleeding and reported it to LVN A, but that LVN A did not intervene before leaving. The representative later met with the administrator, expressing concern about LVN A’s competency and describing that LVN A did nothing to stop the resident from bleeding. The report documents that the resident’s condition was stable at the time of survey, with the wound covered by a dressing and the resident appearing calm and without distress, but the deficiency centers on the earlier failure of LVN A to assess and intervene when the resident was actively bleeding from new skin tears. The investigation also notes that staff had attended in-services on abuse and neglect, reporting concerns, and the importance of shift-to-shift handoff, and that the facility had a policy requiring sufficient and competent nursing staff. Despite this, the events described show that the resident’s change in condition—new skin tears with ongoing bleeding—was not promptly addressed by LVN A, and that there was no communication of this issue to the oncoming nurse. This resulted in the resident being found later with copious blood loss and heavily saturated dressings and linens before appropriate wound care and monitoring were initiated by the day-shift RN.
Failure to Timely Assess and Respond to Significant Bleeding from Skin Tears
Penalty
Summary
The deficiency involves the facility’s failure to immediately assess and appropriately respond to a significant change in a resident’s condition when new skin tears with active bleeding occurred, and the failure to promptly notify the resident’s physician of this significant change. The resident was an elderly female with diagnoses including shortness of breath, Alzheimer’s disease, muscle weakness, chronic pain, hypertension, and gait abnormalities. Her MDS indicated she rarely or never understood interview questions, and her care plan identified her as having potential for impaired skin integrity and being at risk of bleeding, with interventions to evaluate skin for integrity and impaired coagulation. She had very fragile skin, reportedly related to long-term prednisone use, and bilateral leg edema, making her prone to skin tears with even mild pressure. On the early morning in question, two CNAs were changing the resident and separating her contracted, crossed legs when a skin tear occurred on her right lower leg, causing profuse, non‑stopping bleeding from multiple skin tears. One CNA immediately reported the bleeding to the LVN assigned to the same hall, who was administering medications at the time. According to the CNA, the LVN stated she was busy with medication administration and would assess the resident after finishing her medication pass. The CNAs wrapped a towel around the resident’s leg to apply pressure and minimize further damage, but the LVN did not come to assess the resident before the night CNA’s shift ended. The night CNA left at the end of her shift believing the LVN would address the bleeding, and later reported receiving a call around midday from the LVN asking how severe the wound was and stating she had forgotten to take care of the resident’s bleeding. At the start of the day shift, another CNA discovered the resident bleeding profusely in bed and reported this to the day‑shift RN. The RN found the resident with heavy bleeding from three skin tears on the right lower leg, with bed linens visibly wet with blood and multiple saturated bandages that required changing before the bleeding was contained. The RN reported that neither she nor the CNA had received any handoff from the previous shift about the resident’s bleeding, and that the resident had lost a copious amount of blood before the RN intervened. The resident’s responsible party later reported that the LVN had not intervened when notified of the bleeding and had left the facility without even looking at the resident, and the administrator and DON both acknowledged that the LVN did not assess or intervene in a timely manner. The report states that the facility failed to immediately consult with the resident’s physician when there was this significant change in condition involving substantial bleeding from new skin tears.
Unlocked Medication and Treatment Carts Left Unattended
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication storage practices when two of three medication/treatment carts reviewed (Medication Cart #1 and Treatment Cart #2) were found unlocked and unattended near the nurses’ station. On the morning of 11/10/2025, Medication Cart #1, which contained residents’ prescription drugs, over-the-counter medications, and narcotics secured in a locked box within the cart, was observed unlocked with no nurses present. Shortly thereafter, Treatment Cart #2 was also observed unlocked, with residents’ prescription creams in the top drawer and no staff in sight. The facility’s written Medication Labeling and Storage Policy dated 2/2023 requires that all compartments containing medications and biologicals, including carts, be locked when not in use and that transport carts not be left unattended if open or otherwise available to others. In interviews, an LVN stated he had been trained that medication carts must always be locked when not in use and acknowledged he had gone into the medication room without locking the cart, stating he should have locked it when he walked away. A treatment nurse confirmed she had been trained that carts must be locked any time staff are away and that nurses and other staff walking by are responsible for ensuring carts are locked; she did not know why the treatment cart was unlocked or who had used it last. The DON reported that only nurses and medication aides should have access to the carts and that carts must be locked if not within the nurse’s eyesight, but she did not know why the medication and treatment carts were unlocked. The administrator stated he knew from experience that carts must be locked when not actively in use and that administrative staff and peers monitor carts by observation, but he also could not explain why the carts were found unlocked. The report notes that this failure could place residents at risk of unauthorized access to medications, decreased effectiveness of medication, or missing medications.
Failure to Sanitize Equipment and Work Surfaces Between Residents
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a licensed vocational nurse (LVN) during medication administration to four residents. The LVN used a blood pressure cuff on multiple residents without sanitizing it between uses. Specifically, the blood pressure cuff was used sequentially on residents with various diagnoses, including vascular dementia, Alzheimer's disease, chronic pain, diabetes, respiratory failure, colon cancer, and open wounds, and was placed back on the medication cart without cleaning after each use. The medication cart surface was also not sanitized between residents, despite the LVN's hands coming into contact with both the cart and the blood pressure cuff during medication preparation and administration. Observations confirmed that the LVN performed hand hygiene after each medication pass but did not clean the blood pressure cuff or the medication cart surface between residents. This practice was observed repeatedly during the medication pass for all four residents. Interviews with the LVN, certified nursing assistant (CNA), another LVN, the Director of Nursing (DON), and the Administrator confirmed that facility policy required sanitizing reusable equipment and work surfaces between residents to prevent cross-contamination and the spread of infection. All staff interviewed acknowledged the importance of this practice and the potential for negative outcomes if not followed. A review of the facility's infection control policy indicated that reusable items, such as blood pressure cuffs, must be cleaned and disinfected between residents. The failure to follow this policy was directly observed and confirmed through staff interviews, demonstrating a breakdown in the facility's infection prevention and control procedures for multiple residents with significant medical needs.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a calculated error rate of 9.38% based on 3 errors out of 32 observed opportunities. These errors involved two residents during medication administration by an LVN. The first resident, an elderly female with diagnoses including senile degeneration of the brain, anxiety disorder, congestive heart failure, and respiratory failure, had a physician's order for Desvenlafaxine Succinate Extended Release 100mg daily with explicit instructions not to crush the tablet. During observation, the LVN crushed this extended-release medication and administered it to the resident, contrary to both the physician's order and manufacturer guidelines. Additionally, the LVN failed to ensure that a prescribed Lorazepam 0.5mg tablet was present in the medication cup, only discovering the omission after a count discrepancy was noted by the surveyor. The second resident, also an elderly female with chronic pain, repeated falls, diabetes type II, COPD, and bipolar disorder, had an order for three Torsemide 20mg tablets once daily. During medication pass, the LVN placed only two tablets in the medication cup. The error was identified and corrected after the surveyor verified the count, but not before the initial incomplete dose was presented for administration. Interviews with staff, including the LVN, DON, and ADM, confirmed that facility policy requires medications to be administered exactly as ordered by the physician and in accordance with manufacturer instructions. The LVN admitted to being unsure about the appropriateness of crushing the extended-release medication but proceeded regardless. Facility policy and manufacturer guidelines both specify that extended-release tablets should not be crushed, and all staff interviewed acknowledged the importance of following these protocols to ensure resident safety.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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