Avir At Lancaster
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, Texas.
- Location
- 1241 Westridge Ave, Lancaster, Texas 75146
- CMS Provider Number
- 675809
- Inspections on file
- 58
- Latest survey
- April 11, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Avir At Lancaster during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, and a history of falls was found with a swollen, bruised, and painful right leg and knee during care. A CNA notified an LVN, who assessed the resident and contacted hospice; a hospice RN assessed the resident and obtained a STAT x-ray order, but the x-ray vendor did not arrive as expected. Despite the STAT designation and subsequent instruction to use the facility’s own x-ray provider, the first x-ray was not performed until the next day, revealing a tibia fracture, and a second x-ray later that day showed a right knee fracture. Approximately 33 hours passed from the initial STAT x-ray request to the resident’s transfer to the ER, during which facility staff did not ensure timely completion of the ordered STAT imaging or clearly document follow-up, resulting in delayed diagnosis of the fractures.
A resident with severe cognitive impairment, prior femur fracture, dementia, epilepsy, and other comorbidities was care planned as a fall risk requiring frequent checks, increased supervision in staff-visible areas, and use of a low bed with a fall mat. Despite these interventions, the resident was seen on the floor by a roommate and later found by a CNA with a markedly swollen, painful right leg, screaming on touch, after apparently getting herself up from the floor and back into her wheelchair without staff assistance. The LVN and DON noted swelling, bruising, and twisting of the right knee, and staff acknowledged the resident sometimes got up without help and was occasionally found on the fall mat or in her chair. Although hospice ordered a STAT x-ray after being notified, the imaging was not completed until the next day, revealing fractures of the tibia and right knee, and the resident was not sent to the ER until many hours later. The facility’s investigation and observations showed no obvious environmental tripping hazards but confirmed that the fall was unwitnessed and that staff could not explain how or when the injuries occurred, demonstrating a failure to provide adequate supervision and a safe environment for this high-risk resident.
A resident with cognitive and visual impairments received cash withdrawals from the trust fund without the required witness signature, as mandated by facility policy. The business office manager often dispensed funds without a second staff member present, and several transactions lacked proper documentation. Although the resident was able to account for her money and provide receipts, the facility failed to consistently follow procedures for safeguarding resident funds.
A resident with end stage renal disease and anxiety disorder, who was cognitively intact, did not receive monthly statements of personal funds held by the facility for several months despite requesting them. The Business Office Manager confirmed the absence of statements and could not provide evidence that the required information was given, resulting in the resident lacking knowledge of his account balance.
A resident with dementia and psychiatric diagnoses was physically and allegedly sexually assaulted by another resident with a known history of inappropriate sexual behavior. The assaulted resident was found with bruises and red marks on her neck and reported being choked and touched inappropriately. The perpetrator, also cognitively impaired, denied involvement. The facility had previously identified the perpetrator's behavioral risks but did not maintain enhanced supervision or preventive interventions, and staff had not been fully trained on resident-to-resident abuse prevention at the time of the incident.
The facility failed to deliver mail to residents within the required twenty-four hours, as per their policy. Interviews and observations revealed that residents did not receive mail regularly, with some never receiving it. The AD and BOM confirmed irregular mail distribution, typically once a week, with delays for weekend deliveries. An observation showed undelivered mail from the previous Friday. The ADM was unaware of the current mail policy, leading to potential impacts on residents' well-being.
The facility failed to maintain a safe and clean environment in resident bathrooms, with issues such as grime buildup, missing baseboards, gaps around toilets, and insect presence. Residents reported seeing insects and having holes in their bathroom walls. Staff were aware of these issues, but repairs had not been completed due to time constraints.
The facility failed to meet food safety standards, with issues such as improper thawing of lunch meat, inadequate labeling of food items, and improper storage of raw meat. Open items in refrigerators and freezers were not sealed, and dented cans were not stored properly. The ice machine was unclean, indicating lapses in maintenance. Staff interviews revealed non-compliance with the facility's food service policy.
The facility failed to maintain an effective pest control program, resulting in live roaches and flies in shower rooms and resident rooms. Observations and resident reports indicated the presence of pests, but there was no consistent documentation or reporting in the maintenance log. Staff interviews revealed a lack of awareness and use of a pest sighting log, and pest control visits were not documented beyond July 2024.
A resident with significant mobility impairments suffered a fracture due to an improper transfer by a CNA who was unaware of the resident's need for a mechanical lift. Despite existing protocols and available information on transfer requirements, the CNA attempted a manual transfer, resulting in injury. The incident revealed a failure to adhere to safety procedures and communication lapses within the facility.
The facility failed to protect the personal property of two residents, resulting in the loss of clothing items. One resident with depression and intellectual disabilities lost several clothing items, while another with schizophrenia and dementia was missing shoes, a jacket, and shorts. Staff interviews revealed issues with labeling and returning clothing, and the ADM was unaware of a grievance regarding missing items.
A resident's grievance about missing clothing was not resolved in a timely manner, as required by the facility's policy. The grievance, filed by the resident's family, was not documented or addressed within the specified timeframe, and the grievance log was incomplete. The new administrator was unaware of the issue until the survey and had not contacted the family member who filed the grievance.
A facility failed to complete a mandatory inventory form for a resident with depression and mild intellectual disabilities, leading to incomplete medical records. Staff interviews revealed that the inventory form, which should have been completed upon admission and updated with new items, was missing from the resident's EMR. This oversight could risk the loss of personal items, as the facility's policy required nursing assistants to assist with inventorying residents' personal effects.
The facility failed to store and handle food according to professional standards, as observed in their kitchen and storage areas. Withered and exposed food items were found in the refrigerator, dry storage, and outside freezer. The Dietary Manager acknowledged the responsibility for proper food storage to prevent food-borne illnesses, as per the facility's policy and FDA guidelines.
A facility failed to ensure a resident's advance directive was accurately documented, leading to a discrepancy between the care plan's DNR status and the physician's Full Code orders. Despite procedures to ensure accurate documentation, the resident's end-of-life wishes were not properly reflected in the electronic medical record, risking non-compliance with their preferences.
A facility failed to maintain a homelike environment for a resident with severe cognitive impairment, as a significant hole in the wall of the resident's room went unnoticed by both the Maintenance Supervisor and the Administrator. Despite daily rounds, the need for repair was not identified, violating the facility's policy on providing a safe, clean, and comfortable environment.
A resident with severe cognitive impairment and multiple health conditions experienced weight loss due to the facility's failure to administer the prescribed tube feeding regimen. The resident was supposed to receive two cans of Jevity 1.2 four times a day but was only receiving one can during certain feedings due to reported intolerance, which was not documented or communicated to the physician. This led to a risk of increased weakness and weight loss.
A CNA failed to perform proper hand hygiene while providing incontinent care to a resident, leading to an infection control deficiency. The CNA did not wash hands or change gloves during the care process, despite recent infection control training. The DON confirmed that staff are expected to follow hand hygiene protocols to prevent infection spread.
The facility failed to maintain a safe and comfortable environment due to disrepair of ceiling tiles. Observations revealed a swooping, discolored tile and an unsecured tile in hallways where residents walked. The Maintenance Supervisor was aware of the issues but cited surveyor presence as a barrier to repairs. The Administrator also knew of the needed repairs, expecting prioritization by the Maintenance Supervisor.
Delay in STAT X-ray Completion and Fracture Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to provide timely radiology and diagnostic services to meet a resident’s needs after new swelling, bruising, and pain were identified in the resident’s right leg and knee. The resident was an elderly female with traumatic cerebral hemorrhage, a prior left femur fracture, anxiety disorder, hypothyroidism, dementia, and epilepsy, who was severely cognitively impaired and unable to verbally respond, requiring at least supervision or partial assistance for bed mobility and transfers. Her care plan included fall-related interventions such as keeping the bed in the lowest position, use of a fall mat, frequent checks, increased supervision, and evaluation of the environment after falls, as well as monitoring for altered neurological status. On the morning in question, a CNA observed that the resident’s right leg appeared larger than the left and that the resident screamed when her leg was touched during incontinence care. The CNA reported this to an LVN, who assessed the resident and noted swelling, bruising, and a twisted appearance of the right knee and leg. The LVN notified hospice, and the hospice RN came to the facility, assessed the resident, and obtained a STAT x-ray order. The hospice RN then left the facility after calling in the STAT x-ray order. Later that evening, while charting, the hospice RN called the facility and learned that the x-ray technician had not arrived and that the x-ray had not been completed. The hospice RN then instructed facility staff to request x-rays from the facility’s own x-ray provider and sent the STAT x-ray order to the facility. Despite the STAT designation, the first x-ray was not performed until the following morning, approximately 24 hours after the initial STAT x-ray request. That x-ray showed a fractured tibia, and the physician then ordered an additional x-ray of the right knee, which was performed later that afternoon. The repeat x-ray results, received that evening, showed a fractured right knee, and the physician then ordered the resident sent to the ER. In total, about 33 hours elapsed between the original STAT x-ray request and the resident’s transfer to the hospital. Interviews with the DON and LVN indicated that the facility deferred to hospice for treatment decisions for hospice residents, that the facility was responsible for carrying out hospice orders, and that there was no clear documentation of which staff followed up on the delayed x-ray or when. The facility’s own policy required staff to process test requisitions and arrange for tests, and to immediately communicate critical values to the provider, but the STAT x-ray was not obtained or resulted in a timely manner, leading to a delay in diagnosis of the resident’s right femur and right knee fractures.
Unwitnessed Fall and Delayed Diagnostic Response for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe environment and adequate supervision to prevent accidents for a cognitively impaired resident with a history of falls and significant medical conditions. The resident was an elderly female with traumatic cerebral hemorrhage, prior left femur fracture, dementia, epilepsy, anxiety disorder, and hypothyroidism. Her MDS showed severe cognitive impairment (BIMS 00) and functional dependence, requiring at least supervision or touching assistance for bed mobility and partial/moderate assistance for transfers and sit-to-stand. Her care plan, updated after a prior fall beside the bed, identified her as a fall risk and included interventions such as frequent checks at least every two hours, increased supervision by placing her in staff-visible areas, use of a low bed with a fall mat, and evaluation of the environment after falls. Despite these identified risks and interventions, the resident was reported by her roommate to have been seen on the floor on the morning of 04/06/26, with the roommate unsure how she ended up there. The resident reportedly got herself up from the floor and back into her wheelchair without staff assistance. Staff interviews indicated that the resident was known to get on and off the bed without assistance and was sometimes found on the fall mat or in her chair, despite encouragement to ask for help. On the morning of 04/06/26, a CNA discovered that the resident’s right leg was visibly more swollen than the left and that she screamed when her leg was touched during incontinence care. The CNA notified the LVN, who assessed the resident and noted a swollen, bruised, and twisted right knee and leg. The environment around the resident’s bed was observed by the Administrator, DON, and LVN, who all reported seeing a low bed with a fall mat beside it and a wheelchair near the head of the bed, and they stated they did not observe tripping hazards. However, the resident’s care plan called for increased supervision and frequent checks, and staff acknowledged that the resident was a fall risk who sometimes got up without assistance. The facility’s own investigation documented that the resident had been seen on the floor and had then gotten herself back into her wheelchair, yet no staff member could explain when or how the injury occurred. Subsequent x-rays revealed an acute distal femoral fracture and a fractured right knee, consistent with a serious injury following an unwitnessed fall, demonstrating that the resident did not receive adequate supervision to prevent accidents as required by her assessed needs and care plan. In addition to the supervision concerns, there was a significant delay between the initial recognition of the injury and completion of diagnostic imaging and transfer to the hospital. Hospice was notified around midday on 04/06/26 and ordered a STAT x-ray, but the x-ray was not completed until the following morning, approximately 24 hours after the initial request. The first x-ray showed a fractured tibia, and a repeat x-ray later that day showed a fractured right knee. The resident was not sent to the emergency room until that evening, approximately 33 hours after the original x-ray request. During this period, the resident received multiple doses of morphine for pain and shortness of breath. The report identifies that the facility failed to ensure the resident received adequate supervision when she experienced a fall that resulted in fractures to her right thigh and right knee, placing residents at risk for injuries and a decline in health. The facility’s fall management policy identified risk factors such as cognitive impairment and neurological disorders and required staff to monitor and document residents’ responses to fall-prevention interventions and to re-evaluate interventions if falls continued. In this case, the resident had a documented history of falls, severe cognitive impairment, and neurological conditions, and her care plan specified increased supervision and environmental evaluation. Nonetheless, the fall that led to her fractures was unwitnessed, the exact circumstances were unknown to staff, and the resident was able to get herself up from the floor without staff involvement. These facts, combined with the delayed diagnostic response after the injury was identified, form the basis of the cited deficiency for failure to maintain a safe environment and provide adequate supervision to prevent accidents.
Failure to Follow Policy for Resident Trust Fund Disbursements
Penalty
Summary
The facility failed to properly safeguard and manage the personal funds of a resident by not following its own policy requiring two staff signatures when cash was disbursed from the resident trust fund. Multiple withdrawals were made for one resident, each signed only by the resident and lacking the required witness signature. The facility's policy specifically mandates that when a resident cannot sign to approve a withdrawal, a witness signature is required, and the witness must not be the person responsible for accounting for the funds, their supervisor, or the individual accepting the withdrawn funds. However, review of the trust fund petty cash logs revealed several instances where cash was withdrawn and only the business office manager's (BOM) signature was present, with no witness signature documented. The resident involved had a history of schizoaffective disorder, bipolar disorder, cataracts, choroidal atrophy, transient visual loss, and major depressive disorder. The resident was assessed as having impaired vision and a BIMS score indicating moderate cognitive impairment. Interviews with the resident confirmed that she regularly requested and received varying amounts of cash, which she kept in her possession and used for personal purchases. The resident was able to account for her money and provided receipts for some purchases, but discrepancies in the amounts withdrawn and the amounts reportedly received were noted during the investigation. Interviews with facility and corporate staff confirmed that the BOM did not consistently follow the required procedure for cash disbursement, as some transactions had witnesses while others did not. The issue was identified during a corporate audit, which led to further review of the records. Although the facility and corporate staff did not find evidence of missing funds, the lack of adherence to the required process for safeguarding resident funds constituted a deficiency in the facility's management of resident trust funds.
Failure to Provide Resident with Timely Personal Fund Statements
Penalty
Summary
The facility failed to provide a resident with timely and requested statements of personal funds held in trust by the facility. Specifically, a male resident with end stage renal disease and an anxiety disorder, who was cognitively intact as indicated by a BIMS score of 14, had not received account statements from July through September, despite requesting them. The resident reported not receiving a statement since July until the new Business Office Manager (BOM) provided one in late October. The BOM confirmed that the resident had requested a printout of his account statements and acknowledged the importance of providing monthly and quarterly statements to residents with trust funds, but could not provide evidence that the requested statements had been given for the months in question. Interviews with the BOM and the Administrator (ADM) revealed that both were recently hired and, upon learning of the deficiency, ensured that residents received their most recent statements. However, prior to their employment, the facility did not provide the required monthly statements or respond to the resident's requests for account information. The facility's failure to provide these statements as required by policy and upon resident request resulted in the resident lacking knowledge of his account balance for several months.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical and Alleged Sexual Assault
Penalty
Summary
The facility failed to protect a resident from abuse, neglect, and exploitation when another resident physically and allegedly sexually assaulted her. The incident involved a female resident with a history of non-Alzheimer's dementia, anxiety disorder, depression, and schizophrenia, who was found with multiple bruises and red marks on her neck. She reported that a male resident had entered her room, attempted to touch her inappropriately, and later, in a common area, choked and sucked on her neck. The male resident, who also had non-Alzheimer's dementia and a prior history of inappropriate sexual behavior, denied any involvement and was unable to provide details due to cognitive impairment. The male resident's care plan had previously identified a risk for inappropriate sexual behaviors, including an incident months earlier where he kissed another female resident. Despite this, there was no evidence of ongoing enhanced supervision or interventions to prevent further incidents, and staff did not observe or anticipate any further behaviors from him. On the day of the incident, staff discovered the injuries after dinner when the female resident was in the TV room with the male resident and another resident. Upon questioning, the female resident identified the male resident as the perpetrator, and her account was consistent with her injuries. Staff interviews confirmed that the residents were often together in common areas and that the male resident had not previously exhibited such behaviors since the earlier incident. The deficiency was identified because the facility did not ensure all residents were free from abuse, as required. The staff had not been fully trained on resident-to-resident abuse prevention at the time of the incident, and the male resident's prior behavioral risks were not adequately addressed to prevent recurrence. The failure to implement sufficient preventive measures and staff training placed residents at risk for abuse.
Failure to Ensure Timely Mail Delivery to Residents
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods, specifically regarding the delivery of mail. Observations, interviews, and record reviews revealed that 7 out of 55 residents did not receive their mail in a timely manner, as per the facility's policy. During a confidential group interview, all 7 residents reported that mail was not distributed regularly, with 6 stating they never received mail. The facility's policy required mail to be delivered within twenty-four hours of arrival, but this was not adhered to. Interviews with the Assistant Director (AD) and Business Office Manager (BOM) revealed inconsistencies in mail distribution practices. The AD stated that mail was delivered once a week without a specific schedule, while the BOM confirmed that mail was typically delivered on Wednesdays. Mail delivered on weekends was not sorted until Monday, leading to delays. An observation of a storage tote revealed undelivered mail from the previous Friday. The Administrator (ADM) expressed expectations for more frequent mail delivery but was unsure of the current policy. The facility's failure to deliver mail promptly could impact residents' psychosocial well-being and quality of life.
Environmental Deficiencies in Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in resident bathrooms on two of the four halls reviewed. Observations revealed significant issues in the bathrooms of several residents, including discolored floors with grime buildup, missing baseboards, gaps between the floor and toilet, and the presence of live roaches. Additionally, a sticky brown substance was found seeping between tiles in one bathroom, and residents reported seeing insects and having holes in their bathroom walls. These conditions were confirmed through interviews with residents and staff, who acknowledged the cleanliness and repair issues. The facility's administration and staff were aware of the environmental deficiencies, as indicated by interviews with the Administrator, Housekeeping Manager, and Maintenance Supervisor. The Administrator acknowledged the importance of maintaining a clean facility and mentioned ongoing refurbishment efforts. The Housekeeping Manager and Maintenance Supervisor both noted that they were informed of repair needs through staff reports and a maintenance log book. However, the Maintenance Supervisor admitted to being aware of some issues but had not yet addressed them, citing time constraints. The facility's policy on providing a homelike environment was not adhered to, as evidenced by the observations and resident complaints.
Food Safety and Storage Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. Several deficiencies were noted, including improper thawing of food, inadequate labeling of food items, and improper storage of raw meat. Specifically, lunch meat was found thawing at room temperature in the kitchen sink, which is against the recommended practice of thawing under cold running water or in a cooler. Additionally, food items in the refrigerators were not labeled with necessary information such as item description, preparation date, open date, or expiration date. Raw meat was stored on the top shelf above dairy products, increasing the risk of cross-contamination. Further observations revealed that open items in the refrigerators and freezers were not sealed properly, exposing them to air. This included a large bag of sliced ham, grated parmesan cheese, pork hotdogs, breadsticks, peanut butter cookie dough, churros, cheese and garlic biscuit dough, and pie dough. The facility also failed to store dented cans in a designated area, with dented cans of pinto beans and cheddar cheese sauce found in the dry storage area. These practices could potentially lead to food-borne illnesses and cross-contamination among residents. The facility's ice machine was found to be unclean, with pink and black buildup along the inner guard, indicating a lack of regular maintenance. Interviews with staff members revealed a lack of adherence to the facility's Nutrition & Foodservice Policy, which outlines proper food storage, labeling, and sanitation practices. The staff acknowledged the importance of these practices in preventing illnesses but admitted to lapses in following them, such as not cleaning the ice machine weekly as required.
Deficient Pest Control Program Leads to Roach and Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of live roaches and flies in various areas, including two shower rooms and two resident rooms. Observations revealed live roaches in the South Shower Room and a resident's bathroom, as well as a significant number of live flies in the North Shower Room. Residents reported seeing roaches and flies in their rooms and bathrooms, and some had informed staff about these sightings. However, there was no consistent documentation or reporting of these pest sightings in the maintenance log, which was supposed to be used for such purposes. Interviews with staff, including the Assistant Director of Nursing (ADON), Licensed Vocational Nurse (LVN), Certified Nursing Assistant (CNA), and the Maintenance Supervisor, revealed a lack of awareness and use of a pest sighting log. The Maintenance Supervisor stated that the pest control company was contracted to visit the facility monthly, but there were no recent entries in the maintenance log regarding pest sightings, and receipts for pest control visits were only available up to July 2024. The facility's policy on pest control, revised in July 2013, indicated an ongoing pest control program, but the lack of documentation and communication among staff suggests deficiencies in its implementation.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure a safe environment for Resident #22, who required substantial assistance for transfers due to multiple medical conditions, including a cerebral infarction and a displaced fracture of the right humerus. The resident's care plan specified the need for a mechanical lift with two-person assistance for transfers. However, CNA O attempted to transfer the resident without the necessary equipment or assistance, resulting in a fracture of the resident's right humerus. CNA O was not assigned to the hallway where Resident #22 resided and was unaware of the resident's transfer requirements. Despite the availability of resident profiles and lists indicating the need for mechanical lifts, CNA O proceeded with a manual transfer, which led to the resident's injury. The incident was reported to the charge nurse, and an x-ray confirmed the fracture. Interviews with staff revealed that CNA O was asked to assist with changing the resident but was not supposed to perform the transfer. The facility had policies in place for safe handling and transfer practices, but these were not followed in this instance, leading to the deficiency. The incident highlighted a lack of communication and adherence to established protocols for resident safety.
Failure to Protect Residents' Personal Property
Penalty
Summary
The facility failed to protect the personal property of two residents, leading to the loss of clothing items. Resident #13, who had a history of depression and mild intellectual disabilities, was missing several items of clothing, including Dickies pants and coveralls, socks, and a gray pant suit. The resident's care plan indicated a need for assistance with dressing, and the admission packet stated the facility's responsibility to safeguard personal property. Despite these measures, the resident's closet was found empty except for one unnamed T-shirt, and attempts to contact the family were unsuccessful. Resident #87, diagnosed with schizophrenia and dementia, also experienced a loss of personal clothing, including shoes, a jacket, and shorts. The resident's care plan emphasized the need for proper fitting and appropriate foot attire. Observations revealed a lack of labeled clothing in the resident's closet, and the family had previously complained about missing items. Interviews with staff indicated that clothing was often misplaced or delivered to the wrong rooms, and there was a lack of consistent labeling of clothing items. The facility's policies required nursing staff to label residents' clothing upon admission, but this was not consistently enforced. Interviews with various staff members, including housekeepers, CNAs, and the DON, highlighted a lack of clear responsibility for labeling and returning clothing to the correct residents. The ADM was unaware of a grievance regarding missing clothing until much later, and there was no grievance log for the relevant period. This lack of coordination and communication contributed to the ongoing issue of missing personal property for residents.
Failure to Resolve Resident Grievance Regarding Missing Clothing
Penalty
Summary
The facility failed to resolve a grievance for a resident, as documented in a report based on interviews and record reviews. The grievance, filed by the resident's responsible party, stated that the resident was missing several items of clothing, including pants, overalls, a sweat pant suit, and socks. Despite the facility's policy requiring grievances to be addressed within three working days, there was no documentation of efforts to resolve this grievance, and the grievance log for the month in question was incomplete. The resident in question was not available for interview or observation during the survey, and attempts to contact the family were unsuccessful. The newly appointed administrator, who had been in the position for only two weeks, was unaware of the grievance until the surveyor's inquiry. The administrator acknowledged the oversight and noted that some of the resident's clothing had been found, but the family member who filed the grievance had not yet been contacted. The facility's grievance policy mandates prompt resolution of grievances, which was not adhered to in this case.
Incomplete Medical Records and Inventory Form
Penalty
Summary
The facility failed to ensure that the medical records for a resident were complete and accurately documented according to accepted professional standards. Specifically, the facility did not complete the inventory form for a resident who was admitted with diagnoses of depression and mild intellectual disabilities. The resident's medical records, including the face sheet and care plan, indicated that the resident had moderately impaired cognition and required assistance with dressing. However, during a review, it was found that the inventory form, which should have been completed upon admission and updated with any new items, was missing from the resident's electronic medical record (EMR). Interviews with facility staff, including an LVN, the ADON, and the DON, revealed that the inventory form was a mandatory document to be completed upon admission and updated as needed. The staff acknowledged that the inventory form was not located in the EMR for the resident in question. The facility's policy required nursing assistants to assist with inventorying residents' personal effects, but the process was not followed, leading to the potential risk of residents' personal items being misplaced or lost.
Facility Fails to Maintain Proper Food Storage Standards
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. During an inspection, it was noted that the facility's refrigerator contained withered tomatoes with white spots, red bell peppers with a brownish-black spot, and an open bag of turkey exposed to air. In the dry storage area, an open bag of macaroni pasta and an open box of fish fry product were found exposed to air. Additionally, the prep table had a box of quick minute grits open and exposed to air. Further observations in the facility's outside freezer revealed a roll and an ice cream cup on the floor, along with several open and exposed food items, including boxes of frozen dough sheets, sweet roll dough, beef patties, a bag of veggie blend, and a box of fries. The Dietary Manager confirmed that she and the dietary cooks were responsible for ensuring proper food storage and acknowledged the importance of preventing food spoilage and exposure to air to avoid food-borne illnesses. The facility's policy on food storage, dated 2018, and the FDA Food Code, dated 2017, emphasize the need for food to be stored in a clean, dry location, protected from contamination.
Failure to Document Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was honored, specifically for a resident with multiple medical diagnoses including dementia, pruritus, local infection, pain, and other conditions. The resident's care plan indicated a Do Not Resuscitate (DNR) status, but the physician's orders reflected a Full Code status, indicating a discrepancy in the documentation of the resident's end-of-life wishes. This inconsistency placed the resident at risk of not having their end-of-life preferences respected. Interviews with the Director of Nursing (DON) and the facility Medical Director revealed that the facility had procedures in place to ensure code status was documented accurately, including reviewing code status during Standard of Care meetings and maintaining an Advanced Directive binder at the nurse's station. However, the failure to update and document the resident's code status in the physician's orders demonstrated a lapse in these procedures. The resident's Out of Hospital Do Not Resuscitate (OOH-DNR) Order form was completed by the resident's Power of Attorney and signed by a notary and the resident's physician, yet this was not reflected in the electronic medical record.
Facility Fails to Maintain Homelike Environment for Resident
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, specifically regarding the condition of the resident's room. The resident, who was severely cognitively impaired with a BIMS score of 0 out of 15, had a hole in the wall above the baseboard in her room. This hole was approximately 1 foot long and 6 inches wide. The resident appeared confused and did not respond to the surveyor's questions during the observation. The Maintenance Supervisor, responsible for facility repairs, was unaware of the hole in the wall and did not know how long it had been there. Despite making daily rounds, the Maintenance Supervisor had not identified the need for repair in the resident's room. The Administrator, who also makes rounds and relies on the Maintenance Supervisor to inform her of needed repairs, was not aware of the issue either. The facility's policy on providing a homelike environment was not adhered to in this instance, as the hole in the wall did not create a homelike environment for the resident.
Failure to Administer Prescribed Tube Feeding
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident, identified as Resident #17, who was severely cognitively impaired and required tube feeding. The resident's care plan indicated a need for enteral feeding with Jevity 1.2, administered as a bolus of two cans four times a day, totaling eight cans daily. However, the resident was only receiving one can during the 6:00 AM and 12:00 PM feedings due to reported intolerance, which was not documented. This deviation from the prescribed feeding regimen was not communicated to the physician or documented, leading to a risk of increased weakness and weight loss for the resident. The resident's weight had been steadily declining from 193 lbs in April to 174 lbs in September, indicating a failure to maintain nutritional status. Interviews with the LVN and DON revealed a lack of communication and documentation regarding the resident's feeding intolerance and the deviation from the prescribed feeding schedule. The physician was unaware of the changes in the feeding regimen, and the facility's policy on reporting significant weight changes was not followed. This oversight placed the resident at risk of health complications related to nutrition and hydration.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as observed during a survey. A Certified Nursing Assistant (CNA B) was seen assisting a resident with incontinent care without performing proper hand hygiene. Specifically, CNA B did not wash her hands or change gloves while assisting the resident in the toilet. The CNA gloved without hand hygiene, assisted the resident with clothing, and cleaned the resident's bottom area without changing gloves or washing hands. Afterward, CNA B continued to touch various surfaces, including the sink and soap dispenser, with the same gloves, before finally removing the gloves and performing hand hygiene. In an interview, CNA B admitted to not completing hand hygiene due to being in a hurry, despite having received infection control training two weeks prior. The Director of Nursing (DON), who also serves as the Infection Preventionist, stated that staff are in-serviced monthly on infection control and are expected to follow the facility's policy, which requires hand hygiene before donning gloves and after providing resident care. The facility's policy emphasizes hand hygiene as the primary means to prevent the spread of infections.
Ceiling Tile Disrepair Compromises Safety and Comfort
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, as evidenced by the condition of ceiling tiles throughout the facility. During an observation, a ceiling tile in one of the hallways was found to be swooping and discolored with a yellowish-brown spot, while another tile in a different hallway was unsecured. Residents were observed walking beneath these compromised tiles, indicating a potential risk to their safety and quality of life. Interviews with the Maintenance Supervisor and the Administrator revealed awareness of the ceiling tile issues. The Maintenance Supervisor acknowledged responsibility for facility repairs and admitted knowledge of the swooping and discolored tile since a few days prior to the observation. However, he was unaware of the unsecured tile and cited the presence of state surveyors as a reason for not obtaining materials to make repairs. The Administrator confirmed awareness of the needed repairs and stated that both she and the Maintenance Supervisor conduct rounds to identify such issues, with an expectation for the Maintenance Supervisor to prioritize repairs. The facility's policy emphasizes providing a safe, clean, and homelike environment, which was not upheld in this instance.
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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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