Avir At Mineola
Inspection history, citations, penalties and survey trends for this long-term care facility in Mineola, Texas.
- Location
- 320 Greenville Highway, Mineola, Texas 75773
- CMS Provider Number
- 675668
- Inspections on file
- 37
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Avir At Mineola during CMS and state inspections, most recent first.
The facility employed a cook who had a prior felony conviction for aggravated assault with a deadly weapon, despite state law barring such individuals from employment and the facility’s own abuse/neglect policy prohibiting hiring persons found guilty of abuse, neglect, exploitation, misappropriation, or mistreatment. The cook’s personnel file showed multiple criminal history checks, and the cook reported serving four years in jail for the offense. The HR Director reviewed the criminal history and identified both a deferred adjudication and a subsequent conviction with a four-year confinement term, concluding this created a lifetime employment bar. The DON stated the HR Director was responsible for criminal history checks and the Administrator for oversight of that process, while the Administrator maintained his belief that the cook remained eligible for employment based on his interpretation of the criminal history and deferred adjudication.
A resident with Alzheimer’s disease, moderate cognitive impairment, and a known history of falls experienced an unwitnessed fall in a secured unit hallway, resulting in a forehead bruise and subsequent hematoma and facial bruising. An LVN documented that the physician had been notified and initiated neuro checks, and the resident’s family and nursing leadership were informed; however, the LVN later admitted she had not actually contacted the physician. The physician stated he first learned of the fall the next day when notified of the resident’s increased facial pain and bruising and said he would have sent the resident to the ER immediately had he been informed at the time of the fall. This sequence of events occurred despite a facility policy requiring prompt physician notification after accidents or incidents involving a resident.
A CNA and an LVN were found in a secured unit living room with a blanket covering the overhead light, which was done because the light could not be turned off and shined into a resident's room. The CNA kept the resident's door open due to a history of wandering. The Maintenance Director confirmed the light switch had been intentionally disconnected, and both he and the Administrator acknowledged that covering lights with cloth is a fire hazard. The facility lacked a policy on this issue.
Three medication carts were found unlocked and unattended in hallways, with staff and residents passing by or sitting near the carts. LVNs admitted to leaving the carts unlocked while working, despite facility policy requiring secure storage accessible only to authorized personnel. The Administrator and ADON confirmed that carts should only be unlocked when staff are actively retrieving medications or standing directly in front of them.
A resident was administered psychotropic medications without a clear clinical indication or was given medications that restrained their ability to function, resulting in a deficiency related to medication management.
A nurse aide worked for several months with an expired certification, providing direct care to residents. The facility lacked a policy for monitoring certification renewals, and administrative staff were unaware of the lapse until notified by another employee. The aide believed the facility would handle her renewal, and the monitoring system in place failed to identify the expired status.
Staff did not immediately inform a resident, the resident's doctor, and a family member about incidents such as injury, decline, or room changes that affected the resident, as required by policy.
A resident with a history of edema, hypertension, and CHF developed a weeping blister and swelling on her leg. Nursing staff applied dressings and wraps without notifying the physician or obtaining orders, and the DON was unaware of the treatment. The physician was not informed of the change in condition, and facility policy requiring prompt notification was not followed.
Two residents with chronic pain had their prescribed hydrocodone-acetaminophen tablets replaced with extra strength Tylenol after being admitted with pill bottles from outside sources. The misappropriation was discovered by a nurse during medication administration, and an internal investigation could not determine when the switch occurred or who was responsible. Both residents reported effective pain management and no complaints at the time of assessment.
A resident's medical record was not accurately maintained when the DON edited a wound care progress note originally written by an LVN, removing information about the previous dressing date without having performed the care herself. The LVN had documented the date found on the dressing, and the DON later acknowledged that the note should not have been changed. Facility policy requires accurate and complete documentation.
A shower room was found with black grime on the walls, a pink stain on the floor, and missing tiles that had not been repaired for over a month. Staff interviews revealed confusion over cleaning responsibilities and a lack of maintenance work orders, despite awareness of the issues by housekeeping and maintenance staff. Facility policy required daily cleaning and prompt repairs, but these were not consistently carried out.
Multiple residents with cognitive and behavioral impairments were not protected from physical abuse, including incidents where one resident slapped another after being startled, a CNA slapped a resident during a transfer, and a family member struck a resident during a dispute over discharge. These events involved both resident-to-resident and staff- or family-initiated abuse, with injuries and emotional distress documented.
The facility did not maintain an effective pest control program, as multiple residents and staff reported ongoing sightings of roaches and water bugs in resident rooms, the dining area, and other areas. Although staff were instructed to document pest sightings in designated binders, they relied on verbal reports, resulting in no written records. The pest control technician confirmed ongoing pest issues despite regular treatments, and the facility's policy requiring an effective pest control program was not followed.
A resident with multiple mental health diagnoses, who was cognitively intact, received Seroquel for bipolar disorder without a signed written consent form as required. Although the resident was aware of the medication, the facility did not obtain the necessary written consent acknowledging the risks and benefits, as confirmed by staff interviews and policy review.
Two residents with intact cognition reported missing personal clothing items—one after a laundry fire and another after her pants went missing. Both informed staff, but no formal grievance was filed, and the items were not replaced. Staff interviews revealed a lack of communication and understanding of the grievance process, and review of records confirmed no grievances were documented as required by facility policy.
A resident with multiple medical conditions and intact cognition did not receive scheduled showers as outlined in his care plan, despite not refusing care. Documentation and staff interviews revealed missed and irregularly timed showers, with staff citing time constraints and workload as reasons for the lapse. Facility policy required assistance with ADLs, but the resident did not consistently receive necessary hygiene care.
The facility failed to ensure a clean, comfortable, and homelike environment due to a shortage of clean bed and bath linens. Observations revealed inadequately stocked linen closets and carts, with staff confirming the shortage and attributing it to staffing limitations and linen being hidden or destroyed. The Housekeeping/Laundry Supervisor noted insufficient staffing and the Administrator acknowledged the risk to residents.
The facility failed to resolve grievances related to missing clothing for four residents, including those with Alzheimer's and dementia. Despite reports from family members, grievances were either not documented or inadequately resolved, leading to ongoing issues with missing personal items. Family members expressed frustration and resorted to handling laundry themselves or purchasing new clothing.
The facility failed to properly label, date, and dispose of food items, leading to potential risks of food contamination. Observations revealed expired and unlabeled items in the kitchen's refrigerator and freezer. Despite regular walk-throughs by the Dietary Manager, these issues were not addressed, and the Administrator was unaware of the deficiencies.
The facility failed to coordinate hospice care effectively for residents, resulting in missing or outdated hospice documentation. This deficiency involved three residents whose hospice binders lacked essential documents like care plans and medication profiles. Interviews revealed that the hospice companies were responsible for providing these updates, but lapses in communication and coordination led to potential risks in resident care.
The facility failed to maintain proper infection control practices, including staff not wearing PPE during care for a resident on enhanced barrier precautions, improper hygiene during incontinent care for a resident with cerebral palsy, and inadequate storage of clean and dirty linens. Additionally, a resident's catheter bag was found on the floor, and a linen cart was left uncovered, all of which pose infection risks.
A resident in an LTC facility was administered Klonopin without documented informed consent from the resident or their responsible party. The LVN assumed consent was unnecessary due to the resident's prior use of the medication. The ADON and DON confirmed the oversight, highlighting the importance of consent for psychotropic medications. The facility's policy requires informed consent and education on medication risks and benefits, which was not followed.
A resident with Alzheimer's disease and a history of falls did not have their care plan updated after three falls, despite interventions being in place. The facility's staff, including the ADON and DON, acknowledged the oversight, which was contrary to the facility's policy requiring care plan revisions after assessments.
A resident requiring moderate assistance with personal hygiene was observed with unaddressed chin hair, despite expressing discomfort. Facility staff, including a CNA and LVN, failed to provide necessary grooming, impacting the resident's dignity and self-esteem. The facility's ADL policy was not followed, leading to a deficiency in care.
A resident with multiple diagnoses, including Alzheimer's, did not have a required Depakote level test conducted as ordered, due to inconsistent nurse staffing and oversight. The ADON acknowledged responsibility, and the DON and Administrator recognized the risk of potential toxicity from the missed lab test.
A resident's bathroom was found to be consistently dirty and unsanitary, with brown stains, sticky floors, and a strong urine odor. The resident, who required assistance with toileting, reported dissatisfaction with the cleanliness. Housekeeping staff admitted to cleaning the bathroom only once a day, and the Housekeeping Supervisor cited staffing shortages as a challenge. The facility's policy emphasized maintaining a clean environment, which was not met in this case.
A facility failed to maintain an effective pest control program, resulting in roaches in a resident's bathroom. Despite multiple pest sightings documented in logs, the Pest Control Technician was unaware of the issue in resident areas, as he only treated the exterior and kitchen. Interviews revealed that the Maintenance Supervisor and Administrator were also unaware of the complaints, highlighting a breakdown in communication and oversight.
Employment of Staff Member With Disqualifying Aggravated Assault Conviction
Penalty
Summary
The deficiency involves the facility’s failure to prevent the employment of an individual with a disqualifying criminal conviction for aggravated assault with a deadly weapon. The employee, referred to as Cook A, was hired with a documented hire date of 11/04/24 and worked in the facility until 04/24/26. Her personnel file showed that criminal history checks were conducted on three occasions: at hire and on two later dates. During interviews, Cook A stated she had been convicted of aggravated assault with a deadly weapon in the late 1990s, served four years in jail from 1998 to 2002, and was released in 2002. The HR Director reported that she had pulled and reviewed Cook A’s criminal history and stated that, based on the report, Cook A would not be eligible for hire if she applied at the time of the survey because she had a felony from 1996. The HR Director later reviewed the criminal history in detail, noting an arrest for aggravated assault with a deadly weapon under Texas Penal Code 22.02(a)(2), classified as a second-degree felony. The record showed an initial court disposition of deferred adjudication, followed by another court entry reflecting a conviction for aggravated assault with a deadly weapon, a four-year term of confinement, and a sentence expiration date in 2002. The HR Director concluded that this constituted a lifetime bar to employment. Other facility staff provided information about the hiring and background check process. The Dietary Manager stated that the HR Director and Administrator review background checks and inform department heads whether an applicant is acceptable for hire, and that the prior HR Director had indicated Cook A was acceptable. The DON stated that the HR Director was responsible for ensuring criminal history checks on new hires and annually, and that the Administrator was responsible for ensuring the HR Director reviewed criminal history correctly. The Administrator stated his belief that Cook A was eligible for hire and that his understanding of her criminal history was that she was convicted, served time, and then likely received deferred adjudication. The report cites the Texas Health and Safety Code, Chapter 250.006, which bars employment of persons convicted of aggravated assault under Penal Code 22.02, and the facility’s own abuse/neglect policy, which prohibits employing individuals found guilty of abuse, neglect, exploitation, misappropriation, or mistreatment by a court of law.
Failure to Notify Physician After Resident Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of a significant change in condition following a fall with head injury. The resident was an elderly female with Alzheimer’s disease, dysphagia, lack of coordination, and a cognitive communication deficit, with a BIMS score of 08 indicating moderate cognitive impairment. Her MDS and care plan documented a history of falls and risk factors including unsteady gait, wandering, and psychotropic medication use, with interventions such as keeping the bed in the lowest position, call light within reach, and providing reminders not to ambulate without assistance. On the date of the incident, an unwitnessed fall occurred on the secured unit, and the resident was found on the floor in the hallway. A progress note documented that the resident was lying on her side, moving all extremities as prior to the fall, with a light bruise to the left side of her forehead measuring 2.5 cm by 2 cm. Neuro checks were initiated per protocol, vital signs and neurologic results were described as unremarkable, and the resident reportedly denied pain. The nurse documented on the fall incident report that the physician had been notified of the fall that day, and the resident’s son, DON, and ADON were notified of the incident. Subsequent interviews and record review revealed that the physician had not actually been notified at the time of the fall, despite the documentation stating otherwise. The LVN who completed the documentation admitted she did not call the physician and stated she forgot to do so during the excitement of managing this resident and another resident with issues at the same time. The physician later reported he first learned of the fall the following day when contacted about the resident’s increased facial pain and bruising, at which time he ordered the resident sent to the hospital. The facility’s policy on change in condition required prompt notification of the attending physician when there was an accident or incident involving the resident, but this did not occur at the time of the fall with head injury.
Fire Hazard Created by Covering Overhead Light with Blanket in Secured Unit
Penalty
Summary
Staff failed to ensure the resident environment in the secured unit living room was free from accident hazards when a blanket was observed covering the overhead light. On the date of observation, an LVN and a CNA were present in the living room with the blanket covering the light, and the LVN removed the blanket upon the surveyor's entry. The LVN acknowledged that covering the light was unsafe and stated that the CNA typically covered the light in the dining room as well. The CNA explained that the blanket was used because the overhead light could not be turned off and shined directly into a resident's room, and that the resident's door was kept open due to a history of wandering. The CNA was unsure if covering the light with a blanket was safe. The Maintenance Director confirmed that the light switch in the living room had been intentionally disconnected prior to his employment to prevent staff from turning off the light and sleeping during shifts. He stated that staff should not hang blankets over lights, as it is a fire hazard. The Administrator was unaware of the disconnected switch and agreed that covering lights with cloth is a fire hazard. The facility did not have a policy regarding covering lights with cloth or other items.
Medication Carts Left Unlocked and Unattended
Penalty
Summary
Surveyors observed that three medication carts (Medication Cart #1, #2, and #3) were left unlocked and unattended in various hallways of the facility. On multiple occasions, the carts were found unsupervised with residents and staff passing by, and in some cases, residents were sitting near the unlocked carts. Interviews with LVNs revealed that the carts were left unlocked because staff were actively using them or had recently accessed them, but the carts were not secured immediately after use. Staff acknowledged the importance of keeping medication carts locked to prevent unauthorized access but admitted to leaving them unlocked during their shifts. The facility's policy requires that medications and biologicals be stored securely and only accessible to authorized personnel. Despite this, the medication carts containing medications, including PRN medications, were accessible to unauthorized individuals when left unlocked and unattended. Both the Administrator and ADON confirmed that medication carts should only be unlocked when staff are actively retrieving medications or standing directly in front of the cart, which was not consistently followed during the survey observations.
Unnecessary Use of Psychotropic Medications
Penalty
Summary
The facility failed to prevent the use of unnecessary psychotropic medications or the use of medications that may restrain a resident's ability to function. This deficiency indicates that residents were either prescribed psychotropic drugs without a clear clinical indication or were given medications that limited their functional abilities, contrary to regulatory requirements.
Failure to Ensure Nurse Aide Maintained Current Certification
Penalty
Summary
The facility failed to ensure that a nurse aide, CNA E, had a current and valid nurse aide certification while employed and actively providing care to residents. Record review showed that CNA E's nurse aide certification had expired, and she continued to work her normal full-time shifts, except for four days of paid time off, during the period her certification was not valid. The Business Office Manager (BOM) and Administrator were unaware of the expired certification until it was brought to their attention by another staff member. The facility did not have a policy in place regarding nurse aide certification renewal, expirations, or registry verification, and relied on an annual employee checklist that was supposed to be completed for all employees. Interviews revealed that CNA E was unaware her certification had expired, believing the facility would handle the renewal as her previous employer had done. She also indicated that her work schedule prevented her from seeking assistance with the renewal process. The Administrator confirmed that the facility and corporate office monitor for expiring certifications, but CNA E did not appear on their lists, and there was no explanation for why her certification was not renewed on time. The lack of a clear policy and monitoring process contributed to CNA E working for several months with an expired certification.
Failure to Promptly Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The report specifically notes that the required notifications were not made promptly when events impacting the resident occurred, as mandated by regulations.
Failure to Notify Physician and Obtain Orders for Wound Care
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, staff did not notify the physician of the resident's weeping edema, redness, and blister on her right leg, nor did they obtain physician orders for wound care or the application of dressings prior to applying them. The resident, who had a history of edema, hypertension, and congestive heart failure, was observed with a nonstick dressing and gauze wrap on her right leg, which was swollen and red. The resident reported that nurses had applied these dressings due to a weeping blister and to prevent her sheets from getting wet. Interviews revealed that the physician was not aware of the resident's condition or the need for a dressing, and the Director of Nursing (DON) was also unaware that a dressing had been applied. The DON confirmed that staff had not notified the physician or obtained orders for the ace wrap or for the treatment of the swelling and weeping. Nursing staff admitted to applying dressings and wraps without physician notification or orders, despite facility policy requiring prompt notification of changes in a resident's condition, including skin conditions and swelling.
Misappropriation of Controlled Medication from Resident Supplies
Penalty
Summary
The facility failed to protect two residents from the misappropriation of their prescribed hydrocodone-acetaminophen 5-325 mg tablets. Both residents had a history of chronic pain and were admitted with pill bottles containing this controlled medication, which had been brought from home or another facility. Upon review, it was discovered that a significant number of these tablets had been replaced with extra strength Tylenol, as identified by a nurse during medication administration. The nurse used a pill identifier to confirm that the pills in the bottles were not hydrocodone-acetaminophen but Tylenol, and this was found to be the case for both residents. The facility's investigation revealed that six nurses had access to the locked medication cart from which the pills were taken. Drug testing was conducted on the nurses who had access during the relevant period, and one nurse tested positive for the medication but provided evidence of a personal prescription. However, further testing to determine if the medication in her system was within prescribed limits was inconclusive due to a lab error. The facility was unable to determine exactly when the pill swap occurred or to substantiate which staff member was responsible for the misappropriation. The police were notified, and a report was filed, but the investigation could not confirm whether the hydrocodone was present in the bottles at the time of admission. Both residents involved were assessed and reported that their pain had been well managed, with no complaints or evidence of unrelieved pain at the time of interviews and observations. The facility's policies on abuse, neglect, exploitation, and controlled substances required verification of controlled medications upon receipt, but did not specifically address the verification of medications brought in pill bottles from outside sources or the use of pharmacy blister packs for such medications. This gap in procedure contributed to the failure to prevent the misappropriation of resident property.
Inaccurate Medical Record Documentation Due to Unauthorized Note Editing
Penalty
Summary
The facility failed to ensure that medical records for a resident were complete and accurately documented in accordance with accepted professional standards. Specifically, the Director of Nursing (DON) edited a progress note originally written by an LVN regarding wound care provided to a resident. The LVN's original note indicated that the previous dressing was dated three days prior to the wound care, suggesting a possible lapse in daily wound care. Five days after the original entry, the DON altered the note to remove the reference to the previous dressing date, despite not having performed the wound care herself. Interviews revealed that the LVN documented the date found on the dressing during the wound care and was unaware of why the DON changed her note. The DON admitted to editing the note because she perceived it as a red flag and suspected the LVN of falsifying documentation, but acknowledged that she should not have changed the note and should have addressed her concerns differently. Facility policy requires documentation to be concise, accurate, and complete, and the administrator confirmed the expectation for accurate records.
Failure to Maintain Clean and Safe Shower Room Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment in one of its shower rooms, specifically the B hall shower room. Observations revealed thick black grime on the walls, a pink stain on the floor, and missing tiles on the shower floor. Staff interviews indicated that the shower had not been cleaned recently, and the missing tiles had been present for approximately 40-45 days. Housekeeping staff were unclear about their responsibilities for cleaning the shower, and the Maintenance Director acknowledged awareness of the missing tiles for several months, but no work order had been submitted for repairs. The Administrator was only made aware of the condition on the morning of the survey. Record reviews confirmed that no maintenance work orders had been logged for the shower room in question for several months. Facility policy requires daily cleaning of showers by housekeeping and weekly deep cleaning by the Housekeeping/Laundry Supervisor, but these procedures were not consistently followed. Staff interviews highlighted the importance of cleanliness for infection control and resident safety, but also revealed lapses in communication and follow-through regarding cleaning and maintenance responsibilities.
Failure to Protect Residents from Abuse by Peers, Staff, and Family
Penalty
Summary
The facility failed to protect multiple residents from various forms of abuse, including physical abuse by other residents, staff, and a family member. Several incidents were documented where residents with cognitive impairments, such as Alzheimer's disease, dementia, and schizophrenia, were involved in altercations resulting in physical harm. For example, one resident was slapped by another after being startled awake, and another was struck in the face by a peer who believed his foot was at risk. In another case, a resident was hit on the cheek by a fellow resident during a dining room altercation. These incidents occurred despite care plans and staff awareness of the residents' behavioral risks and cognitive limitations. Staff also failed to prevent abuse by facility personnel. In one incident, a CNA slapped a resident on the back of the hand during a transfer when the resident became combative. The event was witnessed by another CNA, and the action was acknowledged as abuse by the facility's administrator. The resident involved was dependent on staff for most activities of daily living and had a history of combative behavior, which was documented in her care plan. The staff member involved was suspended and subsequently terminated, but the incident itself demonstrated a lapse in protecting the resident from staff-initiated abuse. Additionally, the facility did not prevent abuse by a family member. In one case, a resident with severe cognitive impairment was slapped in the face by a family member during a dispute over discharge against medical advice. The incident resulted in visible injury and required intervention by staff and law enforcement. The resident expressed a desire to remain in the facility and not leave with the family member, but the abuse occurred before the situation was de-escalated. These failures to prevent abuse placed residents at risk of physical harm, mental anguish, or emotional distress, as documented in the report.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches and water bugs in resident rooms, the dining area, and other parts of the building. Multiple residents, all with intact or moderately impaired cognition, reported seeing roaches and water bugs in their rooms and common areas, particularly around the dining room coffee area and in bathrooms. These sightings were reported to various staff members, including housekeepers, CNAs, and nurses, who acknowledged the complaints and stated they would report the issues. Staff interviews confirmed the ongoing presence of pests, with CNAs and housekeepers observing roaches in shower rooms and on the unit, and reporting these verbally to the Maintenance Director. However, the required documentation in the pest control binders was not completed by staff, as confirmed by both the Maintenance Director and a review of the binders, which showed no staff entries regarding pest sightings. The Maintenance Director stated that staff were instructed to document pest sightings, but instead relied on verbal reports, leading to a lack of written records. The pest control technician confirmed that the facility was being treated twice a month and identified American roaches and water bugs coming from plumbing areas, as well as German roaches in the kitchen, which were nearly resolved. Despite these treatments, residents and staff continued to observe pests. The facility's policy required an effective pest control program, but the lack of consistent documentation and ongoing pest sightings indicated the program was not effectively implemented.
Failure to Obtain Written Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was fully informed and provided written consent prior to the administration of an antipsychotic medication, Seroquel. Record review showed that the resident, who had diagnoses including personality disorder, bipolar disorder, major depression, and anxiety, was cognitively intact and able to understand and communicate. The resident's care plan and physician orders documented the use of Seroquel for bipolar disorder, and medication administration records confirmed that the medication was being given as prescribed. However, the required Consent for Antipsychotic or Neuroleptic Medication Treatment (Form 3713) was not signed by the resident, despite her being her own responsible party and aware of the medication. Interviews with the resident, ADON, and Administrator confirmed that the consent should have been obtained and signed at the time the medication was ordered, in accordance with facility policy. The absence of a signed consent form indicated that the resident had not formally acknowledged the risks and benefits of the medication as required.
Failure to Promptly Address and Document Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances for two residents regarding missing personal clothing items. One male resident with intact cognition and a history of dementia and chronic obstructive pulmonary disease reported that all his underwear had been destroyed in a facility laundry fire. He stated he had informed several CNAs, nurses, and laundry staff about the loss, but no one provided information or resolution regarding his missing underwear. Interviews with laundry staff and the Housekeeping/Laundry Supervisor confirmed awareness of the loss, but no formal grievance was filed, and the items were not replaced. A female resident with intact cognition and diagnoses including personality disorder, bipolar disorder, major depression, and anxiety reported missing a pair of pants valued at $40. She stated she had informed the Administrator, but no action was taken, and her pants were neither found nor replaced. The Housekeeping/Laundry Supervisor acknowledged being aware of the missing pants and that extensive searches had been conducted without success, but again, no grievance was filed. Interviews with facility staff, including the Administrator and Social Worker, revealed a lack of communication and understanding regarding the grievance process. Staff members were either unaware of the need to file a grievance or did not convey the information to the appropriate personnel. Review of the facility's grievance log confirmed that no grievances were recorded for either resident during the relevant period, despite the facility's policy requiring all grievances to be documented and resolved within three working days.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
A deficiency was identified when a resident who required assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, did not receive showers as scheduled according to his care plan. The resident, an adult male with diagnoses including myocardial infarction, hypertension, muscle weakness, and chronic obstructive pulmonary disease, was cognitively intact and did not refuse care. His care plan specified that he preferred showers on Tuesday, Thursday, and Saturday, and required assistance from staff to complete these tasks. Record reviews showed inconsistencies in the documentation of showers provided, with some days showing no shower and others indicating showers at irregular times, including multiple entries on the same day. During interviews, the resident reported not receiving a shower in over a week and expressed feeling bad about not receiving regular showers. Staff interviews confirmed that the resident did not refuse showers and that it was the responsibility of CNAs and nurses to ensure showers were provided as scheduled. One CNA admitted to not providing a shower due to time constraints and being busy with other resident needs. The facility's policies required that residents unable to perform ADLs independently receive necessary services to maintain hygiene and grooming. Despite these policies, the resident did not consistently receive scheduled showers, and staff acknowledged the importance of providing this care to prevent skin issues and maintain resident comfort. The deficiency was further supported by the facility's own documentation and staff statements regarding the failure to provide showers as planned.
Deficiency in Providing Clean Linens
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents, as evidenced by the lack of clean bed and bath linens. Observations on multiple occasions throughout the day revealed that the clean linen closets and carts across various halls were inadequately stocked, with some containing only a few pillowcases, gowns, or sheets, and others completely devoid of towels and wash rags. This deficiency was confirmed by interviews with staff, including a CNA who reported having to wait for clean linens and a Housekeeping/Laundry Supervisor who acknowledged the shortage and attributed it to staffing limitations and linen being hidden or destroyed. The Housekeeping/Laundry Supervisor noted that the laundry staff had clocked out early, leaving no one to complete the laundry for the rest of the day. The supervisor also mentioned that the facility's laundry PPD only allowed for 1.4 employees per day, which was insufficient for the facility's census of 78 residents. The Administrator confirmed the expectation for clean towels and wash rags to be available and recognized the risk posed to residents by the lack of these items. The facility's policy on supplies and equipment emphasized the need for housekeeping and laundry supplies to be readily available, which was not adhered to in this instance.
Failure to Resolve Grievances on Missing Clothing
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve grievances related to missing clothing for four residents. Resident #46, who had diagnoses including anxiety, depression, and Alzheimer's disease, had lost four wardrobes of clothes since admission. Despite the family member reporting the issue to the facility, no grievance was documented, and the family member resorted to purchasing new clothes due to the facility's inaction. Resident #73, diagnosed with dementia and other mental health disorders, also experienced issues with missing clothing. A grievance was filed, but the resolution did not confirm whether the missing clothes were found and returned. The family member expressed frustration over the repeated need to purchase new clothing and eventually decided to handle the laundry themselves to prevent further losses. Resident #182, who had Alzheimer's disease and other health conditions, had a grievance filed regarding missing clothing and personal items. The grievance report did not indicate if the items were recovered, and the family member confirmed that the clothes were still missing at the time of the resident's passing. Similarly, Resident #10, who was cognitively intact, reported missing clothes, but no grievance was documented. The family member confirmed the loss of a significant number of clothing items, and the facility's staff had been using the roommate's clothes for the resident.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen's handling of food items. During a survey, it was found that the facility did not label and date all food items, and dietary staff did not dispose of expired food items. Additionally, frozen food items were not effectively resealed, labeled, or dated. These lapses were observed in various storage areas, including the kitchen refrigerator, walk-in refrigerator, and walk-in freezer. Specific observations included expired items such as a bottle of white vinegar and a pitcher of tomato juice, as well as unlabeled and improperly sealed items like shredded carrots, thawed bacon, and various frozen goods including chicken, breadsticks, French fries, and pepperoni. The dietary staff, including a cook with five years of experience, acknowledged the responsibility for labeling, dating, and disposing of expired foods but were unaware of the deficiencies until pointed out by the surveyor. The Dietary Manager, who has been in the role for eight years, also conducted regular walk-throughs but was unaware of the issues. The Administrator, who oversees the Dietary Manager, admitted to infrequent walk-throughs in the kitchen and was unaware of the expired and improperly stored food items until the survey. The facility's dietary policy and FDA Food Code guidelines emphasize the importance of labeling, dating, and discarding expired food to prevent foodborne illnesses, but these were not followed, leading to the identified deficiencies.
Deficiency in Hospice Care Coordination and Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was observed in three residents who were reviewed for hospice services. The facility did not maintain the hospice binders for these residents, which should have contained essential documents such as the most recent plan of care, hospice election form, physician recertification, and hospice medication profile. This lack of documentation and coordination could place residents at risk of receiving inadequate end-of-life care. For Resident #27, the facility did not have the necessary hospice documentation in the resident's binder. Interviews revealed that the hospice company was responsible for maintaining these documents, but the binder only contained a sign-out sheet. The hospice RN acknowledged the oversight and planned to deliver the binder. Similarly, Resident #35's binder was outdated, lacking recent IDT meeting notes and medication lists, which could lead to missed orders or treatments. The hospice company was expected to provide updated documents, but this was not consistently done. Resident #15's hospice binder was also missing critical documents, including the most recent plan of care and medication profile. The hospice DON admitted that the documents were not updated due to a lapse in coordination. The facility's policy required obtaining updated hospice documents, but this was not adhered to, resulting in a lack of communication and coordination of care. Interviews with facility staff and the administrator highlighted the expectation for hospice companies to provide updated documents, which was not consistently met, leading to potential medication errors and inadequate care.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during a survey. The Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA) did not wear the required personal protective equipment (PPE) while providing care to a resident on enhanced barrier precautions. This resident had pressure wounds and required specific wound care, yet the staff neglected to wear gowns, which are essential to prevent the spread of infections. The ADON admitted to forgetting to wear the PPE despite knowing its importance. Another deficiency was noted in the care provided to a resident with cerebral palsy, where a CNA failed to follow proper hygiene protocols during incontinent care. The CNA used the same wipe multiple times and did not perform hand hygiene when changing gloves, which is crucial to prevent cross-contamination. The Director of Nursing (DON) and ADON acknowledged the importance of proper PPE use and hand hygiene to protect residents and staff from infections. Additional issues were identified in the facility's laundry room, where clean clothes were found touching the floor, and dirty linens were improperly stored. This improper storage poses a risk of infection. Furthermore, a resident's catheter bag was observed lying on the floor, which could lead to cross-contamination. The facility's linen cart was also found uncovered, exposing supplies to potential contamination. These practices indicate a lack of adherence to infection control policies, putting residents at risk of infection.
Failure to Obtain Informed Consent for Psychoactive Medication
Penalty
Summary
The facility failed to ensure that a resident or their responsible party was informed and participated in treatment decisions, specifically regarding the administration of psychoactive medications. The deficiency involved a resident who was cognitively impaired and required antianxiety medication. The resident was administered Klonopin (Clonazepam) without documented informed consent from either the resident or their responsible party. This oversight occurred despite the facility's policy requiring informed consent for psychotropic medications. The Licensed Vocational Nurse (LVN) involved did not obtain the necessary consent before administering the medication, as she assumed it was unnecessary due to the resident already being on the medication, albeit at an increased dosage. The Assistant Director of Nursing (ADON) and Director of Nursing (DON) confirmed that the consent process was not followed, emphasizing the importance of obtaining consent for psychotropic medications due to their potential to alter mental states and cause other risks. The facility's policy mandates that residents or their representatives be educated on the risks and benefits of such medications, which was not adhered to in this case. Interviews with facility staff, including the LVN, ADON, DON, and Administrator, revealed a lack of adherence to the facility's policy on psychoactive medications. The staff acknowledged the failure to obtain informed consent and the potential implications of this oversight. The facility's policy clearly outlines the necessity for informed consent and the role of the attending physician and psychiatric provider in medication management, which was not executed in this instance.
Failure to Update Resident Care Plan After Falls
Penalty
Summary
The facility failed to ensure that Resident #46's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment. This deficiency was identified for one of the 21 residents reviewed for care plans. Specifically, the care plan was not updated following Resident #46's falls on three separate occasions: 07/09/2024, 07/12/2024, and 08/25/2024. The care plan interventions, which were initially set on 06/14/2024, did not reflect any new measures implemented after these incidents. Resident #46, an elderly male with a history of anxiety, unspecified psychosis, depression, and Alzheimer's disease, was admitted to the facility with significant cognitive impairments. His quarterly MDS assessment indicated he had short-term and long-term memory problems and required substantial assistance with daily activities. Despite having a history of falls, the care plan did not include updated interventions after his falls, which included a laceration on 07/09/2024 and a witnessed fall on 08/25/2024. Interviews with facility staff, including an LVN, the ADON, the DON, and the Administrator, revealed that interventions such as a low bed, fall mat, and regular monitoring were in place. However, these were not documented in the care plan. The ADON and DON acknowledged their responsibility for updating care plans and recognized that the failure to do so could lead to continued falls, as staff would not have the latest information on interventions. The facility's policy required the comprehensive care plan to be reviewed and revised after each assessment, which was not adhered to in this case.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a female resident who required moderate assistance with personal hygiene. The resident, who had a mildly impaired cognitive status with a BIMS score of 13, was observed on multiple occasions with chin hair approximately 3-4 cm in length. Despite the resident expressing that the chin hair made her feel bad and wanting it removed, the facility staff did not address this grooming need. Interviews with facility staff, including a CNA, LVN, ADON, DON, and the Administrator, revealed a lack of awareness and action regarding the resident's grooming needs. The CNA admitted not noticing the chin hair, while the LVN acknowledged its presence but did not take action. The ADON and DON emphasized the importance of grooming for the resident's dignity and self-esteem, yet the task was not completed. The facility's policy on ADLs, which includes grooming, was not adhered to, resulting in a deficiency in providing appropriate care and services.
Failure to Obtain Ordered Lab Test for Resident
Penalty
Summary
The facility failed to ensure that laboratory services were obtained to meet the needs of a resident who required monitoring of Depakote levels. The resident, an elderly male with diagnoses including anxiety, unspecified psychosis, depression, and Alzheimer's disease, had a lab order for a Depakote level to be drawn on a specific date. However, the lab result for that date was not found in the resident's electronic medical record, indicating that the test was not conducted as ordered. This oversight was acknowledged by the Assistant Director of Nursing (ADON), who admitted responsibility for ensuring the lab was obtained. Interviews with the ADON, Director of Nursing (DON), and the Administrator revealed that the failure to obtain the lab was attributed to inconsistent nurse staffing, as the facility had been using agency staff to fill nursing positions. The DON and Administrator both expressed that they expected labs to be obtained as ordered and recognized the risk of not obtaining the lab, which could lead to potential toxicity. The facility's policy required staff to process test requisitions and arrange for tests, but this was not followed in this instance.
Failure to Maintain Clean and Sanitary Bathroom Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment in one of the bathrooms used by a resident. The resident, who was cognitively intact and required assistance with toileting, reported that his bathroom was consistently dirty and unpleasant to use. Observations confirmed the presence of numerous brown stains on the bathroom door, sticky floors, and a strong urine odor. The toilet and surrounding areas were covered with brown substances resembling dried feces, and the toilet water was discolored. The resident expressed dissatisfaction with the cleanliness of his bathroom and preferred to use other toilets in the facility. Interviews with housekeeping staff revealed that the bathroom was supposed to be cleaned daily, but the housekeeper responsible for the area admitted to cleaning it only once a day. The housekeeper also noted that picking up dirty clothing was not her responsibility. The Housekeeping Supervisor acknowledged the unsanitary condition of the bathroom and attributed it to being short-staffed, which affected her ability to monitor cleaning activities effectively. Despite these challenges, the expectation was for all rooms and bathrooms to be cleaned daily to ensure a sanitary environment for residents. The facility's Administrator confirmed that the housekeeping staff was expected to clean each room and bathroom daily. The Administrator also stated that department heads were responsible for ensuring that cleaning was completed each day. The facility's Homelike Environment policy emphasized the importance of maintaining a clean, sanitary, and orderly environment, which was not upheld in this instance, leading to the deficiency.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in Resident #2's bathroom on C Hall. Observations and interviews revealed that the resident had noticed roaches in his room and bathroom since his admission. Despite notifying the facility staff, the issue persisted, and the resident expressed dissatisfaction with the cleanliness maintained by the new owners. During an observation, two small brown roaches were found in the resident's bathroom, confirming the resident's complaints. The pest control logs from May to July 2024 documented multiple instances of roach sightings throughout the facility, including in the kitchen, hallways, and resident rooms. Despite these records, the Pest Control Technician reported being unaware of roach activity in the hallways or resident rooms, as he only treated the exterior and kitchen areas during his visits. The technician also noted that he had not had access to the pest control logs for several months and was not informed of the roach sightings by the Maintenance Supervisor or Administrator. Interviews with the Maintenance Supervisor and Administrator revealed a lack of awareness regarding the roach complaints and sightings. The Maintenance Supervisor stated that he was unaware of any complaints and believed the pest control logs were regularly reviewed. The Administrator also expressed unawareness of the issue and emphasized the importance of maintaining pest control to ensure a bug-free environment for residents. The facility's pest control policy, revised in May 2008, indicated an ongoing program to keep the building free of insects and rodents, but the implementation appeared ineffective in this case.
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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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