Avir At New Braunfels

Penalty

Fine: $16,355

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves a failure to ensure a resident’s right to be free from abuse, neglect, and misappropriation of property. A male resident with Alzheimer’s disease, bipolar disorder, anxiety, schizophrenia with mania and depression, cognitive impairment, lack of coordination, and severe cognitive impairment (BIMS score of 3) was involved. His care plan identified needs for assistance with ADLs, especially transfers, due to muscle weakness, impaired cognition, lack of coordination, and Alzheimer’s disease, and included behavioral interventions such as redirection, structured activities, and moving the resident to a quiet area when agitated. The resident was ambulatory, a wanderer, and incontinent of bowel and bladder. On the night of the incident at approximately 10:25 p.m., the resident picked up a chair to sit near the nurse’s station in a secure men’s unit. According to an LVN’s nurse note and written statement, as well as a CNA witness statement, CNA A attempted to take the chair away from the resident, telling him he could not sit near the nurse’s station. A struggle or “tug of war” over the chair ensued. The LVN reported seeing CNA A peel the resident’s fingers from the chair, and the CNA witness reported seeing CNA A remove the chair from the resident. Both the LVN and the CNA witness stated that during this interaction, CNA A grabbed the resident by the wrists and pushed him to the floor, and when the resident got up and approached CNA A again, CNA A pushed the resident into or against the wall. The LVN documented that the resident was assessed afterward and had redness to both wrists and his back, and the resident was sent to the ER for evaluation, where no injuries were found and x‑rays were negative. Law enforcement was contacted and responded, and no arrest was made. In a subsequent email and interview, CNA A stated he was defending himself, that he took the chair to protect residents and staff, held the resident’s hands because the resident tried to hit him, and denied pushing the resident to the floor or wall or willfully abusing him. The facility’s abuse policy defined abuse as the negligent willful infliction of injury resulting in physical or emotional harm or pain to an elderly or disabled person by the person’s caregiver. Based on the eyewitness accounts, documentation, and the physical findings of redness to the resident’s wrists and back following the struggle, surveyors determined that the resident was subjected to physical abuse by CNA A, constituting noncompliance with the requirement to protect residents from abuse. During a later observation, the resident was seen wandering the halls in the secure unit without visible injuries such as skin tears or bruises and stated he felt safe but could not recall details of the incident and declined further interview. Review of logs showed no prior incidents involving this resident and CNA A, and no prior grievances or incidents involving CNA A with other residents in the preceding 90 days. The facility’s own HHS 3613‑A form documented a finding of confirmed abuse related to this event. The survey identified this as past noncompliance at the Immediate Jeopardy level, based on the incident in which CNA A physically handled and pushed the resident during the chair struggle, resulting in the resident’s fall to the floor and contact with the wall and requiring ER evaluation for redness to the wrists and back. The noncompliance was determined to have begun on the date of the incident and ended on a later specified date, with the surveyors noting that the facility had already corrected the noncompliance before the survey began. The report explicitly states that this failure could result in residents suffering injury, a diminished quality of life, and/or death. The nursing home is disputing this citation, but the survey findings, including staff statements, documentation, and the facility’s own internal abuse investigation form, support the conclusion that the resident was not protected from physical abuse during the incident with CNA A.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide a safe, comfortable, and homelike environment by not ensuring that resident bathrooms and showers were maintained in usable condition for an extended period. Four bathrooms in the women’s secured unit had their doors screwed shut after a contractor began but did not complete shower renovations around July or August 2025. The Maintenance Supervisor reported that the contractor discovered more damage than expected, requested additional funds, and when that request was denied, the renovation work stopped. To address the unfinished and potentially unsafe showers, the facility screwed the bathroom doors shut, leaving multiple residents without access to the toilets and showers in their own rooms for about six months. Resident #1, who had Alzheimer’s disease, a psychotic disorder with delusions due to a known physiological condition, anxiety disorder, and major depressive disorder, had moderate cognitive impairment with a BIMS score of 12/15 and was frequently incontinent of bowel and bladder. She required supervision and setup or clean-up assistance with toileting. Her bathroom door was observed to be screwed shut, and she stated she could not use her own toilet because it was locked and that she did not like having to use a different bathroom. Her family member reported that Resident #1 could not remember where the designated bathrooms were and had to be led there by CNAs, and that Resident #1 disliked using another resident’s bathroom. The family member described feeling awkward entering other residents’ rooms, noted that other residents stared at them, and stated this had been an ongoing issue since at least October 2025. Resident #2, who had unspecified intellectual disabilities, unspecified dementia of unspecified severity without behavioral, psychotic, mood, or anxiety disturbance, and bipolar disorder, had a BIMS score of 9/15 indicating moderate cognitive impairment and was occasionally incontinent of bowel and bladder. She required supervision to extensive assistance with toileting, and her care plan called for routine and PRN toileting assistance. She stated she hated not having her own bathroom and having to go to another resident’s room to use the toilet, and reported that the residents whose bathrooms she used did not like it either. Resident #3, with age-related cognitive decline, lack of coordination, and unsteadiness on her feet, had a BIMS score of 8/15 indicating severe cognitive impairment, was continent of bowel and bladder, and required supervision or setup assistance with toileting. She stated it was an inconvenience to use another resident’s bathroom and to walk down a cold hallway to the shower carrying her toiletries, and that it had been a long time since her bathroom had been locked and she wished they would fix her shower. CNA A, who had worked at the facility for about one year, confirmed that four bathrooms in the women’s secured unit had been inaccessible since July or August 2025 because their doors were screwed shut after the incomplete shower remodeling. She stated that affected residents, including Resident #1, Resident #2, and Resident #3, were instructed to use toilets in specific other resident rooms (rooms 36 and 38), the main shower room, and the room across from the shower room, which were at a distance and not liked by residents, especially at night when it was cold. She reported that residents in the designated rooms questioned why others were using their bathrooms and that affected residents and some family members complained frequently about when the bathrooms would be fixed. CNA A described the situation as inconvenient for the affected residents and a privacy issue for the residents sharing their bathrooms. The ADON and Maintenance Supervisor acknowledged that the four bathrooms were locked down and that residents were directed to other bathrooms, and the ADON stated he understood all residents should have their own bathroom and that it was an inconvenience, but said he could not do anything because approval for renovations rested with upper management. The Administrator and DON reported that corporate had requested bids for the shower renovations, that bids were obtained and sent to corporate, and that the matter was stalled with the main owner, while acknowledging that the situation had been ongoing for months, that affected residents should have their own bathrooms, and that it created inconvenience and privacy issues. The facility’s Homelike Environment policy stated that staff should provide person-centered care emphasizing residents’ comfort, independence, and personal needs and preferences, and that management should maximize characteristics reflecting a personalized, homelike setting.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to treat a resident with respect and dignity and to provide care in an environment that promoted maintenance or enhancement of quality of life, specifically by not providing an accessible toilet in the resident’s room. The resident was admitted with Alzheimer’s disease, psychotic disorder with delusions due to a known physiological condition, anxiety disorder due to a known physiological condition, and major depressive disorder. A quarterly MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, frequent bowel and bladder incontinence, and a need for setup or clean assistance with toileting. Her care plan documented moderate cognitive impairment and a need for supervision with toileting. During observation, the bathroom door in her room was found screwed shut and nonfunctional. The resident reported she could not use the toilet in her own bathroom because it was locked, resulting in accidents when she could not reach another bathroom in time. She stated she felt “yucky” and embarrassed when she had accidents and did not like having to use a different bathroom. Staff interviews revealed that four bathrooms in the secured women’s unit had doors screwed shut after a contractor began but did not complete shower remodeling, and that these bathrooms had been inaccessible since around July or August of the prior year. CNAs reported that the resident was redirected to use toilets in other resident rooms, the shower room, or a bathroom across from the shower room, which were located down the hall, and that affected residents disliked going to these distant areas, especially at night when it was cold. A CNA described an incident where she was leading the resident to the room next door to use the toilet, but the resident did not make it in time and urinated on the floor, became very upset, and started crying. The CNA stated that the resident and other affected residents complained frequently about the bathroom situation, and that some residents questioned why others were entering their rooms. The resident’s family member reported that the resident could not remember which bathrooms were designated for her use and had to be led by CNAs. The family member also described an episode where the resident urinated on the floor in another room, cried frantically with tears falling down her face, and said, “I feel ashamed.” Facility leadership, including the ADON, ADM, DON, and maintenance staff, acknowledged that four bathroom doors in the women’s secured unit were screwed shut for months, that residents from those rooms were directed to use other residents’ bathrooms or common bathrooms, and that this was an inconvenience, a privacy issue, and, if it led to accidents, a dignity issue for the residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that agreements with outside professional resources for dental services were in place and specified in writing that the facility assumed responsibility for obtaining services that meet professional standards. Record review of the facility’s contract binder on 01/30/2026 showed there was no contract with the dental service provider. The Administrator reported that a new company purchased the facility in November 2025 and should have contracted with a local dental facility to provide dental services to residents who needed dental care, but she did not know why a contract had not been established. She stated that a local dentist had visited the facility and provided dental care to residents on 01/27/2026, and that residents’ doctors might choose the dental provider. The Administrator and regional company leaders were identified as responsible for obtaining contracts with outside resources, and the Administrator acknowledged that without a contract, residents might not have dental care. The DON stated that residents received dental services if needed because their doctors might choose community dentists, but also acknowledged that without a contract with a dental facility there was a potential risk of residents not receiving dental care. Review of the facility’s policy titled “Dental Services,” revised 12/2016, indicated that routine and 24-hour emergency dental services were to be provided through a contract agreement with a licensed dentist who comes to the facility monthly, or by referral to the resident’s personal dentist, community dentists, or other health care organizations that provide dental services. Despite this policy, the facility did not have the required written agreement with a dental service provider at the time of the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, as evidenced by a lack of regular in-service training for all kitchen staff reviewed. Interviews revealed that instead of formal training, staff received group text reminders regarding procedures such as food temperature logging, food labeling, and sanitation, with no documentation of the frequency or content of these reminders. The Registered Dietitian Nutritionist (RDN) expressed concerns about food temperatures and indicated that ongoing staff education was expected but not documented. The Administrator was unable to provide any in-service training records for the food service staff within the requested three-month period, and it was noted that a change in the contracted food service company had occurred two months prior. Additionally, one staff member did not have documentation of a current and valid Food Handler's Certificate, as required by state regulations. The facility's policies on food preparation, service, and sanitation did not specify training expectations or qualifications for food service staff. Review of state requirements confirmed that food service employees must complete accredited food handler training within 30 days of employment. These findings were based on interviews, record reviews, and policy examinations, and involved all ten kitchen staff reviewed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature, as observed during meal service and confirmed through interviews and record reviews. Food items such as oatmeal, grits, pureed bread, pureed sausage, and pureed egg were served below the minimum required temperature, with some items significantly under the standard. The dietary staff checked food temperatures on the service line after the last meal was served, revealing several items below the required 135 degrees Fahrenheit. The dietary manager admitted to only occasionally checking tray temperatures and not documenting these checks, while the cooks only recorded temperatures before service, not after food was plated or delivered to residents. A resident with moderate intellectual disabilities, GERD, and dementia, who was cognitively intact and required supervision with eating, reported that the food was cold, unappetizing, and made her feel unwell. Resident council and family grievances were documented regarding cold food and poor meal presentation, with concerns raised about food being served too cold or not edible. Despite these complaints, the dietary manager and administration believed that food temperatures were within required standards based on logs, but these logs only reflected temperatures at the point of service, not at the point of consumption. The facility's policy required that potentially hazardous foods be maintained at or above 135 degrees Fahrenheit to prevent the growth of pathogens, and that food temperatures be monitored throughout meal service. However, the lack of consistent and documented temperature checks after food was plated and delivered, combined with multiple complaints and direct observations of food served below safe temperatures, led to the deficiency. Staff interviews confirmed that there was no systematic process to ensure food remained at safe and appetizing temperatures up to the point of resident consumption.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified multiple failures in the facility's food service operations, specifically regarding the storage, preparation, and serving of food. During an observation, three sealed plastic containers containing cheesecake, mashed potatoes, and carrots were found in the walk-in refrigerator without any labels or dates. Staff confirmed these items were from the previous day's service and acknowledged the lack of labeling and dating. The dietary manager was not aware of these unlabeled items until after the surveyors' discovery, and subsequent inspection by the dietary manager revealed additional unlabeled food items. Record reviews showed that food temperatures were not documented for several meals over multiple days. The temperature logs lacked staff names, initials, signatures, or times, making it unclear who was responsible for checking and recording food temperatures. Staff interviews revealed that food temperatures were sometimes not taken due to being busy, and there was a habit among staff to write temperatures on separate pieces of paper without transferring them to the official log. The dietary manager admitted to not providing formal training on labeling food or logging temperatures, instead relying on reminders. Additionally, improper sanitization practices were observed. A staff member was seen using Sani-Cloth germicidal wipes, which are not food-safe, to clean the food thermometer probe between food items. Both the dietary manager and the registered dietitian confirmed that Sani-Cloths should not be used for this purpose, as they are not food grade and could contaminate food. The registered dietitian had previously reported issues with unlabeled food and incomplete temperature logs to facility leadership, but these issues persisted at the time of the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's right to reasonable accommodation of needs and preferences was met, specifically regarding access to the call light system. On the date of observation, the resident was found asleep in bed with the call light lying across the footboard and onto the floor, making it inaccessible. The resident did not have a roommate, and the second call light in the room was also observed on the floor. The resident was unresponsive and unable to demonstrate whether he could reach or use the call light. According to the care plan, the call light was to be kept within reach at all times due to the resident's risk for falls and impaired mobility. The resident had severe cognitive impairment, was dependent for self-care and mobility, and had a history of falls and attempts to self-transfer. Staff interviews revealed that the CNA was aware the call light was out of reach and stated that the resident often threw items, including the call light, off the bed. The CNA also indicated that the resident was not impacted by the call light being out of reach because he was not capable of using or understanding it, so staff were expected to monitor him. Facility leadership confirmed that if the care plan required the call light to be within reach, it should have been so, regardless of the resident's cognitive status. Facility policy required that each resident be provided with a means to call for assistance, and if unable to use the standard system, an alternative should be documented in the care plan. No alternative means of communication was documented for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to post required cautionary and safety signage indicating the presence of oxygen in a resident's room, as mandated by facility policy. Observation on 12/29/2025 revealed a portable oxygen tank in the resident's room with no oxygen tubing attached and no signage posted on or around the door. Interviews with nursing staff and administration confirmed that facility policy requires an 'Oxygen in Use' sign to be posted whenever oxygen is present in a room, regardless of whether it is actively in use or scheduled. Record review of the resident's care plan and physician orders did not reflect an active order for oxygen therapy, but the oxygen tank was still present in the room without appropriate signage. The resident involved was a male with severe cognitive impairment, multiple physical disabilities, and a history of falls, who was dependent on staff for self-care and mobility. Staff interviews indicated that all staff members are responsible for ensuring the signage is posted, but this was not done in this instance. Facility policies reviewed included requirements for clear identification of oxygen storage areas and the posting of 'No Smoking' and 'Oxygen in Use' signs, which were not followed at the time of the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to store over-the-counter medications and supplements in accordance with accepted professional principles in the medication storage room of the secure Co-ed unit. Specifically, four expired supplemental shakes with expiration dates of 09/10/2025 were found on the counter during an observation. When questioned, a CMA indicated that expired liquids are usually removed and stored elsewhere, but acknowledged the expired date on the supplements and stated they would notify a nurse. Further interviews revealed that the supplements remained in the medication room because there was uncertainty between the dialysis clinic and the primary physician regarding who would write the order for the resident's supplements, resulting in an unfilled order. The RN confirmed that medication aides are responsible for removing expired medications, and the RNC stated that all expired medications, including over-the-counter items and supplements, should be pulled from medication rooms and disposed of properly. The presence of expired supplements in the medication room was directly observed and confirmed by staff.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to post daily nurse staffing and census information as required for 13 out of 15 days reviewed. Observations on 12/29/2025 revealed that the most recent posting was dated 12/16/2025, and interviews with staff indicated confusion and lack of clarity regarding responsibility for updating and posting this information. The Assistant Director of Nursing (ADON) stated that the new Staffing Coordinator (SC) may not have been trained on the process, and the previous SC had left suddenly, resulting in a lapse in the daily posting routine. The Wound Care (WC) Nurse and the new SC both confirmed uncertainty about the procedure for posting the required information, with the SC stating she was learning her responsibilities day by day and had only recently been informed about the posting procedure. Further interviews with the Registered Nurse Consultant (RNC) and the Administrator (ADMIN) confirmed that the SC was responsible for the postings, but there was a breakdown in communication and procedure following the prior SC's departure. The RNC and ADMIN both indicated that, although the staffing book was available for review, the daily posting requirement was not consistently met during the period in question. No specific residents or patient conditions were mentioned as being directly affected in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to store over-the-counter medications, specifically eight bottles of Acetaminophen 325 mg, within the recommended temperature range of 68 to 77 degrees Fahrenheit in the central supply storage room. Observations and interviews revealed that the storage room was hot, stuffy, and lacked proper ventilation, with a thermometer indicating a temperature of 84 degrees Fahrenheit. Staff, including a CNA responsible for organizing the storage room, the maintenance supervisor (MS), and the Director of Nursing (DON), all noted the excessive heat and acknowledged that the temperature exceeded the recommended storage conditions for medications. The thermometer in the room was not functioning properly, and the area was described as being in the 'danger' zone for temperature. Multiple staff members, including the CNA, MS, and DON, reported concerns about the high temperature to facility administration and corporate staff. The MS and DON both stated they were aware of the temperature requirements for medication storage, and the DON confirmed that the acetaminophen bottles were labeled to be stored at 68-77 degrees Fahrenheit. Despite these concerns, the Administrator (ADM) had not yet discussed the issue with current corporate staff and was unable to provide a policy on the storage of over-the-counter medications during the investigation period. No corrective actions or follow-up plans were mentioned in the report.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary maintenance services to ensure a safe, clean, and comfortable environment for a resident whose room and restroom were under prolonged construction. The resident's shower was sealed off with plastic, with drywall and tile removed, leaving the area in a state of disrepair for over two months. The floor in the resident's room had a large, uneven, sunken area with a lip, and there were brown stains on the linoleum under the vanity. The room and restroom also had a noticeable mildew odor. These conditions were directly observed by surveyors and confirmed by interviews with both the maintenance staff and the resident. The resident involved had a history of dementia, lack of coordination, right hip pain, and difficulty walking, but was alert, oriented, and independent in most activities of daily living. She had no history of falls and used a rolling walker. Despite the environmental hazards, she reported no issues walking over the uneven floor and had not experienced any falls. The resident expressed dissatisfaction with the ongoing construction and lack of access to her own shower, though she was able to use a main shower room nearby. Interviews with facility staff revealed that the shower remodeling project was halted when the original contractor withdrew, citing additional plumbing issues and seeking to renegotiate the contract. The project remained at a standstill for about two months, coinciding with a change in facility ownership. The maintenance staff acknowledged the uneven floor as a trip hazard and noted that the building required significant repairs. Facility policies reviewed by surveyors required maintenance to keep the building in good repair and free from hazards, which was not met in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to incorporate recommendations from the PASARR Level II determination and evaluation report into a resident's assessment, care planning, and transitions of care. Specifically, the facility did not submit a completed Nursing Facility Specialized Services (NFSS) application to ensure a resident with severe intellectual disabilities, muscle weakness, and dementia received a specialized motorized wheelchair (CMWC) as recommended by her rehabilitation assessment. The resident was dependent on staff for most activities of daily living and used a manual wheelchair, despite being assessed as needing a tilt-in-space wheelchair with custom support to improve posture and participation in daily activities. The deficiency was due to the facility's inability to obtain a current hospice plan of care signed by the physician, which was required for the NFSS application. The Director of Rehabilitation (DOR) stated he submitted the application, but it was denied for lack of the signed plan of care. Despite repeated requests to hospice staff, including the nurse manager, the required documentation was not provided for several months. The DOR discussed the issue in morning meetings but did not escalate the matter to the Administrator (ADM), his immediate supervisor, for further assistance. The PASARR representative confirmed that the facility was notified and reminded to submit the NFSS request but failed to follow up after the initial denial. Observations showed the resident continued to use a manual wheelchair and was unable to communicate or maintain proper posture. The ADM was unaware of the ongoing issue until much later and acknowledged that the delay in obtaining the necessary documentation resulted in the resident not receiving the recommended specialized equipment.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, functional, sanitary, and comfortable environment for a resident with moderate cognitive impairment, as evidenced by multiple unresolved maintenance issues in the resident's room and bathroom. Observations revealed holes in the wall covered with an unspecified material, missing linoleum exposing black/brown glue, chipped and splintered baseboards, and uneven floor tiles at the entrance to the shower stall. The bathroom contained two unused shower curtain rods, no shower curtains, and a shower chair with a peeling seat wedged under a safety bar. The maintenance supervisor confirmed these deficiencies, noting that the room and restroom were in poor condition and could pose an accident hazard due to the uneven floor. The supervisor also stated that the facility was old, had many areas needing repair, and that work orders had been submitted but not yet completed. Interviews with the resident indicated confusion and moderate cognitive impairment, with the resident stating that the room's condition did not bother him and that he continued to use the shower despite staff recommendations. The administrator acknowledged the facility's age and the need for extensive repairs and painting, attributing delays to recent changes in ownership and prioritization of other issues. Facility policies reviewed indicated a requirement to maintain the building in good repair and to treat residents with dignity, but these standards were not met in this instance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors identified multiple environmental deficiencies across all four resident hallways, including the A hallway, Women's Unit, C-hall, and Men's Unit. Observations revealed missing overhead light bulbs and a dirty ceiling air vent in the therapy bathroom at the end of the A hallway. Additional issues included a rusted ceiling vent fan, a ceiling vent panel not fully attached, and visible dirt and water stains on ceiling panels in various locations. Mold was observed on shower floors in both the Women's Unit and C-hall, and a bedside light in a C-hall room was not functioning. In the Men's Unit, a bathroom floor molding was found detached from the wall. Interviews with the Maintenance Director and Administrator confirmed that these repairs had not been completed, and the Maintenance Director stated he had not received work orders for the noted deficiencies. Review of the facility's maintenance policies indicated that routine inspections are required to ensure cleanliness and proper repair, but these procedures were not followed, resulting in the identified environmental concerns.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple medical conditions, including major depressive disorder, urinary tract infection, neuromuscular dysfunction of the bladder, and paraplegia. The resident was always incontinent of bowel, as documented in the Minimum Data Set (MDS), and required substantial to maximal assistance for transfers and toileting. Despite these documented needs, the resident's care plan did not include any interventions or guidance for managing bowel incontinence, although it did address bladder and catheter care. This omission was confirmed through record review, staff interviews, and direct observation of care. Staff interviews revealed that both the CNAs and the MDS nurse were aware of the resident's bowel incontinence and the need for staff to check and clean the resident. The MDS nurse acknowledged missing the inclusion of bowel incontinence care in the resident's care plan upon readmission. The Director of Nursing also confirmed that the care plan should have addressed bowel incontinence, as the care plan serves as a blueprint for care. The facility's own policy requires that all areas of concern identified during assessment be evaluated and addressed in the care plan, but this was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a certified nursing assistant (CNA) failed to provide complete perineal and catheter care to a male resident who was incontinent of bowel and had an indwelling urinary catheter. During observed care, the CNA cleaned only the resident's penis, indwelling catheter, and buttock areas, omitting the suprapubic area, left and right groin areas, and scrotum. The CNA acknowledged forgetting to clean these areas due to nervousness, and both the CNA and the Director of Nursing (DON) confirmed that facility policy required cleaning all specified areas to prevent possible infection. The resident involved had a history of major depressive disorder, urinary tract infection, dysuria, neuromuscular dysfunction of the bladder, and paraplegia, and required substantial assistance for transfers and toileting. The resident's care plan addressed bladder and catheter care but did not include a plan for bowel incontinence. Facility policy specified thorough cleaning of the perineal area, including the penis, scrotum, inner thighs, and under the scrotum, anus, and buttocks, which was not followed during the observed care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an ongoing program of activities to support residents in their choice of activities, both facility-sponsored group and individual activities, and independent activities. Observations revealed that the activities board in the men's secure unit (MSU) did not display a current calendar of activities for March, and no formal group activities were observed during scheduled times. Nursing staff were unaware of any planned activities, and residents were often found sitting quietly or resting in their rooms. Interviews with staff, including a CNA and an LVN, indicated that organized activities were rarely hosted within the unit, and bingo was the only consistent activity, although it was not always held as expected. The LVN noted that residents became aggressive due to boredom and lack of stimulation. The Assistant Director of Nursing (ADON) acknowledged the lack of activities and attributed it to the Activities Director's (AD) schedule, which limited his availability to conduct activities. The AD confirmed that activities were planned daily but admitted to delays in posting the monthly calendar and challenges in engaging staff to assist with activities. The facility's policy required at least two group activities per day on weekends and holidays and four on weekdays, but records showed no documentation of group or individual activities for a 90-day period. The AD's documentation consisted only of quarterly progress notes, with no routine records of attendance or individual activities. This lack of organized activities and documentation placed residents at risk for diminished quality of life, isolation, and lack of stimulation.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, specifically in implementing Enhanced Barrier Precautions (EBP) for a resident. The resident, a woman with a history of non-traumatic subarachnoid hemorrhage, stage 4 pressure ulcers, and an indwelling catheter, was observed receiving peri and catheter care without the necessary precautions. The CNA responsible for the care did not wear a gown, and there was no signage or personal protective equipment (PPE) available outside the resident's room, as required by the facility's policy. The CNA was unaware of the EBP requirements, indicating a gap in training, as confirmed by the Director of Nursing (DON). The facility's policy mandates EBP for residents with wounds or indwelling medical devices to prevent the transmission of multidrug-resistant organisms. However, the lack of signage, PPE, and staff awareness led to a failure in implementing these precautions, potentially putting residents at risk for infection spread.

Penalty

Fine: $128,560

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect residents from abuse, specifically involving a resident who exhibited aggressive and sexually inappropriate behaviors towards other residents. This resident, who had a history of mental health issues including schizoaffective disorder and bipolar disorder, was involved in multiple incidents of physical and sexual misconduct. Despite having a care plan that acknowledged his potential for disruptive behavior, the facility did not effectively address or prevent these incidents, leading to multiple residents being affected. One resident reported being sexually assaulted by the aggressive resident, who invited him to his room under false pretenses and then engaged in inappropriate physical contact. Another resident was physically assaulted in the dining room, resulting in a bruise on his forearm. Additional reports indicated that the aggressive resident made sexually inappropriate comments and gestures towards other residents, further highlighting the facility's failure to manage his behavior effectively. The facility's inaction in addressing these behaviors placed residents at risk of harm. The aggressive resident's behavior was documented in progress notes and event reports, but interventions such as medication and 1:1 supervision were deemed ineffective. The facility's inability to prevent these incidents led to an Immediate Jeopardy situation, although it was later removed, the facility remained out of compliance due to ongoing monitoring of the situation.

Removal Plan

• Staff re-education
• Resident re-education
• Police notified
• State notified
• Administrator notified
• DON notified
• Immediate intervention implemented: Resident placed on 1:1 supervision

Penalty

Fine: $128,560

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate pharmaceutical services to meet the needs of a resident, resulting in missed doses of critical medications. The resident, a male with a history of vascular dementia, type 2 diabetes, schizoaffective disorder, bipolar type, anxiety disorder, and depression, did not receive timely reorders of Lyrica, Gabapentin, and Clonazepam. This led to the resident missing multiple doses of these medications, which were essential for managing his conditions. The facility's staff did not reorder the medications in a timely manner, and there was a failure to update the resident's insurance information promptly, which contributed to the delay in medication delivery. Additionally, there was an incident where a medication aide administered Gabapentin from another resident's supply to the affected resident, which is against the facility's policy. The aide admitted to borrowing medications from other residents when necessary, despite being aware that this practice was not allowed. This action was taken without proper documentation or notification to the appropriate nursing staff, further complicating the situation and potentially risking medication errors. The facility's communication and documentation processes were inadequate, as evidenced by the lack of timely notification to the Director of Nursing (DON) and other supervisory staff about the medication shortages and billing issues. The DON was not informed until after the resident had already missed several doses, and there was a lack of coordination among the staff to resolve the issue promptly. The failure to administer medications as prescribed and the improper handling of medication orders and documentation highlight significant deficiencies in the facility's pharmaceutical services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement comprehensive person-centered care plans for four residents, which were necessary to address their specific medical and psychosocial needs. Resident #24, diagnosed with dementia, depression, and a cognitive communication deficit, did not have a care plan addressing depression, despite having a physician's order for fluoxetine to manage this condition. Similarly, Resident #59, with severe intellectual disabilities, major depressive disorder, and anxiety disorder, also lacked a care plan focus on depression, even though they were prescribed Prozac for this condition. Interviews with the LVN and DON confirmed that depression should have been included in the care plans for both residents. Resident #88, who has type 2 diabetes, an amputation below the knee, and hypertension, was not care planned for their ability to leave the facility independently, despite having a BIMS score indicating intact cognitive function. The resident expressed confidence in their ability to leave the facility independently, as evidenced by a recent trip to a grocery store. The MDS LVN acknowledged that this aspect of the resident's care should have been addressed in the care plan. Resident #97, diagnosed with vascular dementia, type 2 diabetes, and a history of drug-induced dyskinesia, was admitted to hospice care, but this was not reflected in their care plan. The MDS LVN and DON recognized that the resident's hospice status should have been included in the care plan. The facility's policy mandates the development of comprehensive care plans that include measurable objectives and timeframes to meet residents' needs, which was not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to employ staff with the appropriate competencies and skill sets necessary for the food and nutrition service, as required by regulations. The Dietary Manager (DM) did not possess the necessary certification, education, or qualifications to serve as the Director of Food and Nutrition Services. Specifically, the DM was not a certified dietary manager, a certified food service manager, nor did they have a similar national certification for food service management and safety. Additionally, the DM did not have an associate's or higher degree in food service management or hospitality, nor did they have two or more years of experience in the position of director of food and nutrition services in a nursing facility setting with completed coursework in food safety management. The DM was hired in early 2023 and had completed a Texas Food Safety Manager Certification Examination, which is not recognized as a national certification. The facility's Registered Dietitian (RD) was contracted and not a full-time employee. During interviews, both the DM and the Administrator acknowledged the lack of appropriate certification for the DM's position. The Administrator noted that the DM was hired before his arrival at the facility. This deficiency could potentially place residents at risk of foodborne illness and inadequate nutrition due to the lack of qualified oversight in the food and nutrition services.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety in several areas, as observed during a survey. The Dietary Manager (DM) was noted to wear a facial hair restraint that did not adequately cover all facial hair, specifically leaving hair on the upper lip and sides of the face exposed. This was observed on two separate occasions, and the DM initially did not provide a reason for the inadequate restraint but later adjusted the covering. Additionally, two dietary aides were observed preparing food without wearing hair restraints, which is against the facility's policy and the U.S. Food Code requirements. In the walk-in cooler and dry storage room, food items were improperly stored, labeled, and dated. An opened package of ham, a gallon of milk, and a container of cooked vegetables were found without proper sealing, labeling, or dating. The DM acknowledged these lapses and attributed the responsibility to the cooks, indicating a lack of oversight. Furthermore, an opened bag of cornbread mix was found in the dry storage room without being sealed or dated, posing a risk of spoilage and pest infestation. The facility also failed to maintain appropriate temperatures in one of the reach-in freezers, resulting in thawed food items. The DM and Maintenance Director were aware of the issue with the freezer door seal but did not take timely corrective action, leading to the thawing of food that was supposed to remain frozen. Additionally, in the dish room, plastic cups were stored without air-drying nets, which could lead to microbial growth. These deficiencies collectively posed a risk of foodborne illness to residents receiving meals from the facility's kitchen.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain Freezer #1 in safe operating condition, which could place residents at risk of foodborne illness due to food not being stored at a safe temperature. Observations revealed that the analogue thermometer inside Freezer #1 fluctuated between 40 and 42 degrees Fahrenheit, and several food items were completely thawed. The temperature log showed inconsistent readings, and the Maintenance Director acknowledged that the middle door gasket was not sealing properly, which had been reported multiple times over the past month. Despite a work order being placed, the issue was not resolved in a timely manner, and the freezer continued to be used. Interviews with staff, including the Dietary Manager (DM), Corporate RN, and Maintenance Director, confirmed awareness of the problem with the freezer door seal. The Maintenance Director stated that the part needed for repair had arrived but had not been installed, and he did not have access to check the freezer's contents. The Administrator acknowledged that the freezer should not have been used once the door seal issue was identified. The facility's policy and the U.S. Food Code require freezers to maintain a temperature of 0 degrees Fahrenheit or below to ensure food safety, which was not adhered to in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. Observations revealed several environmental deficiencies, including a 4-foot gap in the wall surface behind a resident's headboard in room #51 and a 6-inch round wall penetration in the bathroom of the same room. Additionally, the hallway shower room had two out of three non-functional lights above the sink vanity and a cracked surface measuring approximately 2x4 inches on the lower right section of the shower stall. Further observations in the men's secure unit identified dust and dirt particles on the bathroom ceiling vents in two resident rooms, and mold was found around all sections of the floor surface in a shower stall with a 4-foot perimeter. The Maintenance Director acknowledged responsibility for these areas but stated that no work order requests had been received for the necessary repairs. The facility's policy on providing a homelike environment, dated February 2021, emphasizes the importance of maintaining a safe, clean, comfortable, and homelike environment for residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a baseline care plan for a resident that included essential information such as the prescribed diet, food allergies, and code status. This deficiency was identified during a review of the resident's care plan, which was missing these critical elements despite being necessary to meet the resident's basic needs. The resident, who was admitted with diagnoses including Type 2 diabetes mellitus, gastro-esophageal reflux disease, and diverticulitis, had specific dietary requirements and allergies that were not documented in the baseline care plan. Interviews with facility staff revealed that the baseline care plan was created by a team effort involving floor nurses, ADONs, the DON, and MDS nurses. However, the staff member responsible for creating the care plan confirmed the omission of the necessary information, attributing it to an oversight. Additionally, the facility was using a template for baseline care plans that did not include sections for prescribed diet, food allergies, or code status, contributing to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a Licensed Vocational Nurse (LVN) during wound care for a resident. The resident, a cognitively intact female with a history of osteomyelitis, surgical amputation of toes on the right foot, and type 2 diabetes mellitus with diabetic peripheral angiopathy with gangrene, was receiving wound care. During the procedure, the LVN did not sanitize or wash her hands between changing gloves, which is a critical step in preventing cross-contamination and infection. The incident was observed during a wound care session, where the LVN cleansed the surgical wound, changed gloves, and continued the care without performing hand hygiene. In an interview, the LVN acknowledged the lapse, admitting that she should have sanitized or washed her hands between glove changes. The Director of Nursing (DON) confirmed that failing to perform hand hygiene between glove changes could lead to infection or contamination. The facility's hand hygiene policy, revised in January 2023, clearly states that hand hygiene must be performed before donning and after doffing gloves.

Penalty

Fine: $43,687

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision for two residents, leading to significant incidents. One resident, diagnosed with dementia and severe cognitive impairment, was found outside the facility near a busy street after eloping from the Men's Secured Unit. The facility lacked a monitoring mechanism for the front door, and staff did not maintain eye contact or follow the resident when he exited. The resident's care plan included frequent staff rounding and redirection for wandering behaviors, but these measures were not effectively implemented, resulting in the resident's unsupervised departure. Another resident, an 84-year-old female with dementia and a high risk for falls, suffered a severe head injury from an unwitnessed fall in the Women's Secured Unit. The resident was agitated and left unsupervised in the dining room, where she fell from a rolling stool, resulting in a large subdural hematoma. Despite being identified as high risk for falls, the resident did not receive the necessary supervision, and staff failed to monitor her movements adequately, leading to the fall and subsequent hospitalization. The facility's internal investigations revealed that staff were not adequately trained or prepared to handle these situations, contributing to the incidents. The lack of proper supervision and monitoring systems, such as alarms or doorbells, allowed residents to be at risk of elopement and falls. The facility's policies on wandering, elopement, and fall prevention were not effectively enforced, leading to these deficiencies.

Penalty

Fine: $43,687

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident's personal belongings from being lost when the resident was discharged to the hospital. The resident, a 79-year-old male with severe cognitive impairment, was admitted with diagnoses including dementia, anxiety, and mood disorder. Upon the resident's death, the facility did not document or return his personal belongings, which included six blankets and all his clothes, to the responsible party (RP) or the mortuary. Interviews revealed that no inventory of the resident's belongings was conducted at admission or discharge, and the facility could not locate any inventory documentation. The Director of Nursing (DON) confirmed that the procedure for inventorying personal items was not followed, as no inventory sheet was completed or found in the electronic medical record (EMR). The facility's policies required documentation of personal effects during transfer or discharge, but this was not adhered to in the case of the resident. The lack of inventory documentation and failure to return the resident's belongings to the RP constituted a misappropriation of property, violating the resident's rights as outlined in the facility's policies.