Avir At San Antonio

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 comprehensive care plan was reviewed and revised by the interdisciplinary team after each required assessment for a resident. Specifically, the resident's comprehensive care plan was not reviewed or updated following both a quarterly and an annual Minimum Data Set (MDS) assessment, despite the resident having multiple complex diagnoses including Alzheimer's disease with early onset, vascular dementia, schizoaffective disorder - bipolar type, Parkinson's disease, and hallucinations. The last documented review and update of the resident's care plan occurred several months prior to these assessments. Interviews with facility leadership revealed that the care plan should have been updated after each MDS assessment, but this did not occur. The facility had recently transitioned between electronic health record (EHR) systems, and during this period, some records were managed manually. Despite this, no updated care plan could be located for the resident. Staffing changes, including the termination of the prior MDS coordinator and reliance on part-time and regional coordinators, were also noted, but the MDS coordinators had full access to the EHR and were responsible for care plan updates.

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 the facility failed to ensure a safe, clean, comfortable, and homelike environment for a resident, as evidenced by the presence of ants in the resident's room and bed. On the morning of 9/5/25, staff were notified of ants found under the resident's sheets, and maintenance was called to address the issue. Despite these actions, the resident was exposed to ants, which were observed coming from the window or AC unit area. The resident, who had intact cognition and required assistance with personal care due to muscle weakness and polyneuropathies, reported feeling something crawling on her shoulder, and staff subsequently discovered numerous ants on her bed. Following the incident, the resident developed ant bites on her bilateral inner thighs and right flank area, which were documented as red, raised areas with fluid-filled pustules. These findings were confirmed through skin assessments, progress notes, and photographic evidence submitted to the regulatory agency. The resident did not initially report pain or discomfort from the bites, but the presence of the bites was verified by both the resident and the treatment nurse during a later assessment, with small circular scars noted in the affected areas. Interviews with staff, including the DON, LVNs, CNA, and maintenance staff, confirmed the timeline of events and the presence of ants in the resident's room. The facility's maintenance logs also documented the report of ants in the resident's bed. The administrator acknowledged the importance of monitoring for pests and ensuring a pest-free environment, and staff interviews indicated that the ants were traced to the AC unit. The facility's policy emphasized the right of residents to a homelike environment, but this was not upheld in this instance due to the pest infestation and resulting ant bites.

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 all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, specifically not later than 2 hours after the allegation was made, as required when the events resulted in serious bodily injury. In this case, a resident with a history of muscle weakness, polyneuropathies, and other nervous system disorders was found to have ants in her bed, which led to ant bites on her bilateral inner thighs and right flank area. Documentation showed that staff were aware of the ant presence and bites, with progress notes and skin assessments recording the incident and subsequent injuries. The resident, who had intact cognition, reported the presence of ants and resulting bites, and staff observed and documented fluid-filled pustules and redness on the affected areas. Despite these findings and the facility's policy requiring prompt reporting of such events, there was no evidence that the incident was reported to the state survey agency as required. Review of the facility's intake records confirmed that no self-reported incident was submitted regarding the ant bites. Interviews with staff and the administrator confirmed awareness of the pest issue and the resulting injuries, but the required reporting procedures were 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

The facility failed to provide all required documentation and notifications related to a resident's transfer and discharge. Specifically, there was no written notification of transfer provided to the resident or the resident's responsible party/power of attorney (RP/POA) prior to discharge. The responsible party reported not receiving any notification and expressed a desire to have time to search for alternative facilities and to tour the new facility before the transfer occurred. The facility staff confirmed that written notices were not provided in the resident's or responsible party's primary language, and there was no documentation in the medical record regarding the reason for the transfer. Additionally, the facility did not issue a 30-day written discharge notice to the resident, the responsible party, or the ombudsman prior to the discharge, as required. Interviews with staff revealed a misunderstanding of when 30-day discharge notices are necessary, with several staff members indicating that such notices were only given for non-payment situations. The ombudsman confirmed that no 30-day discharge notices had been received from the facility for recent transfers, and staff acknowledged that they did not routinely notify the ombudsman of all discharges. The resident involved had moderate intellectual disabilities, a developmental disorder of speech and language, and required assistance with personal care. The medical record and discharge summary lacked documentation of the reason for transfer, and staff could not provide evidence of whether the discharge was resident-initiated or facility-initiated. The facility's policy required documentation of discharge details and confirmation that the resident and/or responsible party understood the discharge plan, but this was not completed 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 ensure that resident assessments accurately reflected the residents' status for four residents reviewed. Specifically, BIMS (Brief Interview for Mental Status) and PHQ (Patient Health Questionnaire) assessments were completed for these residents while they were hospitalized and not present in the facility, resulting in the resident interviews not being conducted. The assessments were documented as completed during the residents' hospital stays, as confirmed by census data and assessment dates. The residents involved had complex medical histories, including conditions such as anemia, atrial fibrillation, dementia, schizoaffective disorder, osteomyelitis, cerebral infarction, and other chronic illnesses. Interviews with facility staff revealed that the social worker completed the assessments during the residents' hospitalizations because the MDS Nurse indicated they were due, and the social worker was unsure how to complete discharge assessments when the resident was not available for interview. The administrator stated that assessments should be coded as not assessed if the resident is in the hospital, but believed the error was due to inaccurate data entry. The facility did not have a specific policy for resident assessments.

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 a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for several residents requiring Enhanced Barrier Precautions (EBP). Surveyors observed that required signage indicating EBP was missing from the rooms of multiple residents with conditions such as dementia, colostomy, pressure ulcers, and indwelling catheters. In several cases, personal protective equipment (PPE) carts were not present either inside or outside the residents' rooms, despite physician orders and care plans specifying the need for EBP during high-contact care activities. Staff interviews confirmed awareness of the need for EBP but acknowledged the absence of signage and PPE carts, and the Director of Nursing (DON) was unaware that EBP required a PPE cart at each room. Additionally, the facility's infection control policy required signage to alert staff of precautions and the availability of PPE and alcohol-based handrub for staff. However, observations revealed that these requirements were not consistently met. For example, one resident with an indwelling catheter had a PPE cart near the bed but lacked appropriate signage, while another resident had signage but no PPE cart available. Staff interviews further revealed inconsistent understanding and implementation of EBP requirements, with some staff obtaining PPE from central supply rather than having it readily accessible at the point of care. In another instance, staff failed to don appropriate PPE while performing an invasive procedure, specifically the insertion of a peripheral IV for a resident with EBP orders and a care plan intervention explicitly listing IV sites as requiring PPE. The Assistant Director of Nursing (ADON) and other staff involved in the procedure did not use PPE, and the ADON stated that PPE was not typically used for IV initiation, despite the care plan's direction. The facility's infection control policy and care plans were not followed, resulting in lapses in infection prevention practices for residents at risk.

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 complete and accurate medical records in accordance with accepted professional standards and facility policy. Specifically, night nurses did not initial the crash cart supply verification sheet for the 100/200 hall crash cart on six separate days, despite being responsible for daily checks and documentation. Observations confirmed that the crash cart was stocked with required supplies, but the absence of initials on the verification sheet indicated a lack of documented confirmation that checks were performed as required. Interviews with the ADON and DON confirmed that the night nurses admitted to checking the supplies but forgot to initial the sheet, which was contrary to facility policy and expectations. Additionally, a medication aide did not document the exact times of medication administration for a resident prescribed Carvedilol for hypertension. The resident, who had diagnoses including type 2 diabetes, hypertension, hyperlipidemia, cellulitis, and kidney failure, was cognitively intact and independent in most activities of daily living. The medication administration record (MAR) for this resident showed that on three occasions, the times recorded did not reflect the actual administration times, and the aide admitted to charting after completing all medication passes rather than immediately after administration, as required by facility policy. Interviews with the ADON and DON confirmed that the medication aide should have documented the exact time of administration on the MAR immediately after giving the medication, in accordance with facility policy. The failure to document accurate times on the MAR could affect communication among healthcare professionals regarding the resident's medication schedule. Facility policies reviewed specified that crash carts must be checked and documented daily, and that medications must be administered and documented within 60 minutes of the scheduled time, with the MAR initialed by the person administering the medication.

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 wound care in accordance with physician orders and the residents' care plans for two residents. For one male resident with severe cognitive impairment and multiple comorbidities, including dementia, peripheral vascular disease, and lymphedema, wound care was not administered on two consecutive scheduled days. The Treatment Nurse documented a refusal on the first day but did not re-approach the resident or communicate the refusal to the next shift. The following day, the nurse did not attempt wound care or notify other staff, resulting in the resident's dressings remaining unchanged for several days. The resident expressed confusion about refusals and stated he wanted his wounds changed, while the regular charge nurse reported that refusals were not consistently communicated to her. For a female resident with severe cognitive impairment, peripheral vascular disease, chronic osteomyelitis, and diabetes, wound care was also missed on a scheduled day. The Treatment Nurse marked the treatment as not administered due to the resident being unavailable after dialysis but later acknowledged the resident had returned in time for the dressing change. The nurse made only one attempt to provide care, did not communicate the missed treatment to the next shift, and did not notify the physician. The nurse stated she typically left a note at the nurse's station but did not ensure verbal communication with other staff. Interviews with facility staff revealed a lack of consistent communication and documentation regarding wound care refusals and missed treatments. The Assistant Director of Nursing confirmed that the expectation was for multiple attempts and clear communication with other staff when wound care could not be completed. The Treatment Nurse did not consistently follow these expectations, leading to lapses in care for residents requiring wound management.

Penalty

Inspection fine: $10,036

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 food prepared in the correct form to meet the needs of a resident, leading to a choking incident. The resident, a female with a history of Alzheimer's Disease, aphasia, dysphagia, and other conditions, was supposed to receive a pureed diet with nectar thickened liquids. However, on the day of the incident, she was mistakenly given a mechanical soft diet, which was not in accordance with her physician's orders. This error occurred when an agency CNA, unfamiliar with the residents and the facility, fed the resident the wrong meal tray. The incident unfolded when the agency CNA, who had not received proper orientation for the hall she was assigned to, mistakenly fed the resident a meal intended for her roommate. The error was discovered when another CNA noticed the resident showing signs of distress, such as vomiting and a flushed face. The charge nurse was alerted, and immediate action was taken to address the choking, including performing the Heimlich maneuver and calling for medical assistance. The resident's oxygen levels were monitored, and a chest x-ray was ordered, which later showed no signs of aspiration. Interviews with staff revealed that the agency CNA was not familiar with the facility's residents and had not been oriented to the specific hall where the incident occurred. The facility's policy required licensed nursing staff to check meal trays for accuracy, but this procedure was not effectively followed, leading to the mix-up. The incident highlighted a breakdown in communication and procedural adherence, particularly concerning the distribution of meals and the orientation of agency staff.

Removal Plan

• Resident #1 will receive the appropriate physician ordered diet for all meals.
• Resident #1 has had a chest x-ray. The results reveal no negative outcome to her lungs.
• Resident #1's physician who is also the medical director has been notified both of the incident and the IJ status at the facility.
• A facility audit took place to ensure that all residents requiring modified texture diets for meals will receive their meals in the appropriate texture.
• DON and the dietary consultant audited all residents who require their diet to be served in an altered texture for meals to ensure that their meal tickets reflect the residents individual needs regarding texture with food in accordance with physician's diet orders.
• The dietary department designee will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate.
• The nurse in the dining room will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate.
• The nurse on the hall will check all meals coming from dietary to compare the ticket with what is actually being served on the tray/plate.
• The DON will monitor meals to ensure staff compliance with ensuring that all meals/trays have the appropriate texture that matches the meal ticket and the physician ordered diet.
• Residents meal texture statuses will be audited upon admission, change of condition, appropriate MDS cycles and or anytime necessary.
• All trays will be compared to the actual plated meal for the resident by a licensed staff member prior to being served to the resident. The printed meal ticket will be compared to the tray/plate for accuracy.
• The Assistant Director of Nursing provided education to all staff regarding residents requiring specially textured meals to ensure those residents will receive the appropriately textured meal at all times.
• Licensed staff will be assigned by the DON to ensure that all trays/plates are correct prior to being served to the residents. Diet orders will match correctly to what is being served to the residents.
• The Regional Clinical Consultant provided education to Administrator and Director of Nursing regarding residents requiring specially textured diets for meals.
• The regional clinical consultant will be responsible for ensuring that staff receive the inservice/training regarding residents requiring specially textured food for meals.
• The residents dietary food texture status will be communicated to facility staff directly by the DON and ADON. This process will be accomplished through photo copy and or written communication.
• The DON or their designee will be responsible for ensuring that the residents who require specially textured diets receive their food with the appropriate texture according to the physician's ordered diet.
• During the daily stand up process all recommendations and orders will be audited by the clinical team in consultation with the dietary supervisor to ensure compliance and follow up for all residents with orders and recommendations.
• The clinical consultant will review orders and recommendations as a tool for oversight to ensure compliance.
• Staff have been re-educated to identify the resident's diet by room number and bed designation of A or B.
• 100% Staff education compliance for those who may serve food to a resident will be completed.

Penalty

Inspection fine: $10,036

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 comprehensive person-centered care plans for three residents, which resulted in deficiencies in addressing their specific medical and nursing needs. Resident #50, a female with severe dementia and other conditions, was found to have bed rails on her bed without any corresponding care plan or physician orders. The Director of Nursing (DON) stated that the facility did not consider the mobility bar as a bed rail and acknowledged the lack of a care plan for it. Resident #74, a male with severe cognitive impairment and multiple medical conditions, had a catheter that was not reflected in his care plan. Observations revealed the catheter was improperly positioned, touching the floor, and not in a dignity bag. The care plan inaccurately described the resident as incontinent without mentioning the catheter, indicating a lack of proper documentation and planning for his needs. Similarly, Resident #138, a male with severe cognitive impairment and other health issues, had a catheter that was not documented in his care plan or physician orders. The DON admitted that the catheter was placed during a hospital stay and should have been documented upon the resident's return. The facility's policy requires comprehensive care plans to be developed and kept current, but this was not adhered to, leading to inadequate care planning for these residents.

Penalty

Inspection fine: $10,036

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 the correct installation, use, and maintenance of bed rails for three residents. These residents were not assessed for the risk of entrapment from bed rails before installation, and there was no signed informed consent from their responsible parties. Resident #16, a female with a history of myocardial infarction and other conditions, was observed with side rails on her bed despite her care plan not reflecting their use. Similarly, Resident #50, diagnosed with severe dementia and other conditions, had bed rails that were not documented in her care plan. Resident #138, a male with severe cognitive impairment and other medical issues, also had bed rails that were not care planned or assessed for safety. Interviews with facility staff revealed a lack of awareness and documentation regarding the use of bed rails. The maintenance supervisor indicated that he did not keep track of which residents had bed rails and relied on the DON for guidance. The DON stated that the facility did not have bed rails, only grab bars, and that they did not consider these devices as bed rails. The MDS Regional Consultant mentioned that the rails were not considered restraints and thus were not reflected on the MDS. The Administrator acknowledged the absence of a policy for bed rails, as they did not view the assistive devices as bed rails.

Penalty

Inspection fine: $10,036

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 medication error rate below 5%, with a reported rate of 62.96% based on 17 errors out of 27 opportunities. This involved three residents who did not receive their medications on time or as prescribed. Resident #16, a female with a history of myocardial infarction, atrial fibrillation, and other conditions, did not receive her medications at the scheduled times. Observations noted that her medications, including aspirin and apixaban, were administered late. Resident #63, a female with atrial fibrillation and lymphedema, also experienced medication administration issues. Her bumetanide, a diuretic, was not administered as ordered due to a misinterpretation of the blood pressure parameters by the LVN. This error occurred despite the resident's blood pressure being within acceptable limits for administration. Additionally, her other medications were given significantly later than the prescribed times. Resident #79, a male with depression and hypertension, received an incorrect dosage of sertraline. The facility's policy allows for medication administration within a one-hour window before or after the scheduled time, but this was not adhered to. The LVN involved in these errors was not accustomed to the day shift and did not seek assistance from other staff, contributing to the high error rate.

Penalty

Inspection fine: $10,036

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 in the laundry room, as observed during a survey. Specifically, the facility did not properly dispose of and maintain the lint accumulation in the dryers. During an observation, it was noted that two of the three dryers in use had a thick layer of lint, approximately one inch thick, on the lint traps and some lint at the bottom of the dryers. This accumulation of lint was not addressed in a timely manner, which could lead to an unsafe and unsanitary environment. Interviews with the laundry aide and the Laundry/Housekeeping Supervisor revealed that there was no log for tracking the cleaning of the lint traps, and the facility did not have a written policy for this task. The laundry aide admitted to not cleaning the lint traps after every two loads as required, due to being busy with other tasks. The supervisor confirmed the risk of fire if the lint traps were not cleaned regularly. The Administrator, upon inspection, found the lint traps clean and stated that the laundry aide had only done two loads and had cleaned the traps prior. However, the lack of a tracking log or policy was acknowledged.

Penalty

Inspection fine: $10,036

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 accurately complete assessments for two residents, leading to potential inadequate care. Resident #138, a male with severe cognitive impairment and multiple diagnoses including a stage 4 pressure ulcer and acute kidney injury, had an indwelling catheter that was not documented in his care plan or indicated on his Minimum Data Set (MDS). The MDS inaccurately reflected that he was always incontinent of bowel and bladder without any appliances, despite staff providing care for his catheter. The MDS Regional Consultant acknowledged the oversight, attributing it to recent staffing changes among MDS nurses. Similarly, Resident #52, a female with acute systolic heart failure and end-stage renal disease, was not accurately assessed on her MDS, which failed to indicate her ongoing dialysis and oxygen therapy. Her care plan, however, did reflect these needs, including scheduled dialysis appointments and continuous oxygen therapy. The MDS Regional Consultant confirmed the inaccuracies in the MDS, emphasizing the importance of accurate documentation for staff to understand and meet the resident's care needs. The facility relied on the CMS RAI manual for regulatory compliance, but no specific policy on MDS was provided by the Administrator.

Penalty

Inspection fine: $10,036

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 coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program for two residents, leading to deficiencies in their care. Resident #8, a female with diagnoses including dementia, recurrent depressive disorder, psychotic disorder with hallucinations, and paranoid schizophrenia, was admitted without an accurate PASRR Level 1 Screening. Her records indicated severe cognitive impairment and the use of multiple medications for mental health conditions, yet her PASRR screening did not reflect any evidence of mental illness or dementia. This oversight was acknowledged by a regional consultant who noted the need for additional documentation due to the resident's dementia diagnosis. Similarly, Resident #35, who was admitted with unspecified dementia and a psychotic disorder with delusions, also lacked an updated PASRR Level 1 Screening. Despite receiving antipsychotic medications and having a care plan addressing the risks associated with these medications, his PASRR screening from 2017 did not indicate any mental illness. The MDS Regional Consultant admitted that the screening was not updated following his diagnosis of psychosis, which could result in the resident missing out on necessary services. This failure to update the PASRR screenings could prevent residents from receiving needed assessments and specialized services.

Penalty

Inspection fine: $10,036

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 update the care plans for two residents following significant changes in their conditions. Resident #68's care plan was not revised after a significant change Minimum Data Set (MDS) assessment indicated that the resident was dependent on staff for all Activities of Daily Living (ADL) care. Despite this assessment, the care plan did not reflect the resident's dependency on one or two staff members for ADL care. This oversight was confirmed during an interview with the MDS Regional Consultant, who acknowledged that the care plan did not accurately represent the resident's current needs. Similarly, Resident #71's care plan was not updated after the resident developed a venous ulcer on the left shin, which was not present at the time of the admission MDS assessment. The resident was receiving wound treatment for this condition, but the care plan was not revised to reflect this significant change. An interview with the LVN/MDS Regional Consultant revealed that the care plan should have been updated to provide an accurate picture of the resident's physical and medical condition, ensuring that nursing staff understood the care required. The failure to update the care plans could affect any resident and contribute to them not receiving the necessary care and services.

Penalty

Inspection fine: $10,036

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 the proper use of assistance devices to prevent accidents for a resident with a history of falls. The resident, who was admitted with diagnoses including vascular dementia, chronic kidney disease, and congestive heart failure, was dependent on staff for transfers and used a manual wheelchair for mobility. The resident's care plan highlighted a history of falling and included interventions such as keeping the call light within reach and using a low bed with fall mats. During observations, it was noted that CNAs improperly used a gait belt by placing it over the resident's chest instead of the waist during a bed to wheelchair transfer. This incorrect application of the gait belt was due to the CNAs' inability to secure it around the resident's waist because of her breast. Additionally, an LVN transferred the resident from the wheelchair to the bed without using a gait belt, which compromised the resident's stability and safety during the transfer. Interviews with the CNAs and LVN revealed a lack of adherence to the facility's policy, which mandates the use of a gait belt around the waist for safe transfers. The DON and ADON confirmed that the gait belt should always be placed around the waistline to stabilize residents effectively. The facility's policy, dated 12/2017, outlines the correct procedure for using a gait belt to ensure resident safety during transfers.

Penalty

Inspection fine: $10,036

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 appropriate care for two residents with indwelling urinary catheters, leading to potential risks of urinary tract infections. Resident #74, a male with severe cognitive impairment and multiple diagnoses including urinary tract infection and hemiplegia, was observed with a catheter touching the floor, which was stepped on by a staff member. The resident's care plan did not mention the catheter, and the catheter care orders were not properly followed, as confirmed by interviews with the LVN and DON. Resident #138, also with severe cognitive impairment and multiple health issues, had a catheter without documented physician orders or inclusion in the care plan. The DON admitted that the catheter was placed during a hospital stay and returned with the resident, but the facility failed to enter the necessary orders into the electronic medical records. Despite the lack of documentation, the staff reportedly provided daily catheter care. The facility's policy on incontinent care was not adhered to, as evidenced by the lack of privacy and dignity in catheter management.

Penalty

Inspection fine: $10,036

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 to carry out the functions of the food and nutrition service. The Dietary Manager (DM) did not possess the necessary certification, education, or qualifications to serve as the Director of Food and Nutrition Services. The DM's personnel file indicated a hire date of 10/02/23, but lacked evidence of certification as a dietary manager, food service manager, or similar national certification. Additionally, the DM did not have an associate's or higher degree in food service management or hospitality, nor had he completed a comprehensive course in food safety management. Although the DM had experience as an assistant DM in four other nursing facilities since 2014, this did not meet the required qualifications. The DM had only completed a short 4-hour course before taking the Texas Food Safety Manager Certification Examination, which he passed on 10/08/23. However, this certification alone did not meet the national standards for food service management and safety. Furthermore, the facility's Registered Dietitian (RD) was contracted and not a full-time employee, which may have contributed to the deficiency in the food and nutrition service. The lack of appropriate qualifications and certifications for the DM could potentially place residents at risk of foodborne illness and inadequate nutrition.

Penalty

Inspection fine: $10,036

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 properly coordinate and document hospice care for two residents receiving hospice services, leading to deficiencies in their care. For one resident, the facility did not ensure that the most recent Physician Certification of Terminal Illness and the Hospice election form were completed and included in the hospice documents. The form 3071, which should have contained critical information such as terminal diagnoses and attending physician details, was incomplete. Additionally, the form 3074 for the physician certification of terminal illness was missing, which is necessary for recertification after six months. For another resident, the facility did not have the Physician Certification of Terminal Illness completed, nor was the most recent plan of care or hospice physician orders available at the facility. The resident's care plan indicated the need for hospice due to a terminal illness, but there was a lack of communication and documentation between the facility and the hospice agency. Interviews with facility staff revealed that they were aware of these documentation gaps and the need to contact the hospice company to rectify the situation. The absence of a hospice policy further compounded the issue, as it was not provided when requested.

Penalty

Inspection fine: $10,036

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 two specific incidents involving residents. In the first incident, a resident's fall mat was observed to have multiple visible stains and spots, which were dark brown or black on a light gray mat. The resident, who had severe cognitive impairment and a history of climbing out of bed, was unable to be interviewed. The facility administrator was uncertain about the cleanliness of the mat, suggesting it might have been stained despite cleaning efforts or had something spilled on it. In the second incident, an LVN failed to perform hand hygiene between glove changes while administering a bolus tube feeding to another resident. The LVN admitted to not having her usual supplies and forgetting to use hand sanitizer, acknowledging the importance of hand hygiene in preventing infections. The facility's policies on infection control and enteral feeding emphasize the necessity of hand washing and the use of standard precautions, which were not followed in this case.