Avir At Schertz
Inspection history, citations, penalties and survey trends for this long-term care facility in Schertz, Texas.
- Location
- 3301 Fm 3009, Schertz, Texas 78154
- CMS Provider Number
- 676301
- Inspections on file
- 44
- Latest survey
- March 21, 2026
- Citations (last 12 mo.)
- 13 (2 serious)
Citation history
Health deficiencies cited at Avir At Schertz during CMS and state inspections, most recent first.
A resident with dementia, DM, lymphedema, and multiple pressure-related wounds had physician orders for wound care to the great toes every shift, heels on specific days, and sacrum every shift and PRN. Review of the March TAR showed multiple dates where these ordered treatments were not documented. The ADON and Regional RN identified two LVNs as responsible for the wound care and acknowledged they could not explain the missing entries, while staff interviews indicated that wound care was reportedly performed on several of the undocumented dates but not charted. A photo of the sacral area and a text message from an LVN were cited as proof that care was provided, yet the facility’s documentation policy requiring all services to be recorded was not followed.
A resident with intact cognition, obesity, hypertensive heart disease, and muscle wasting used bilateral 1/4 bed rails as an enabler for bed mobility and positioning while requiring mechanical transfers with two staff. The care plan and physician orders authorized the rails and required quarterly nursing assessments to ensure safe, least-restrictive use, but no bed rail assessments were completed for two consecutive quarters. During observation, both rails were found in the up position and jammed, unable to be lowered by a CNA, and neither the CNA, an LVN, nor the DON were aware of the malfunction until the survey, despite a facility policy requiring proper installation, use per manufacturer instructions, and ongoing evaluation of bed rail safety.
A resident with TBI, mood disorder, anxiety, cognitive impairment, and left-sided hemiplegia/hemiparesis was verbally and physically abused by an RN during early-morning care. According to an LVN and a CNA, the RN loudly cursed at the resident in a public area, called her a "fucking whore" and "slut" for being shirtless, aggressively wheeled her back to her room, forcefully removed her clothing from a contracted arm despite the resident stating it hurt, and shoved her wheelchair into the room hard enough to slam into the bed. Another resident reported hearing the RN call someone a whore and a slut. Although the LVN stated she checked the resident for injuries and found none, this was not documented, and no investigation report was completed at the time, despite a facility policy requiring identification and investigation of all possible abuse incidents.
A resident with TBI, mood disorder, anxiety, cognitive deficits, and hemiplegia/hemiparesis was allegedly subjected to verbal and physical abuse by an RN, who used profane, degrading language about the resident’s exposed breasts and forcefully pushed the resident in a wheelchair into her room, as witnessed by an LVN and a CNA. The LVN documented only the resident’s combative behavior and clothing issues, did not document a post-incident injury check, and did not immediately report the abuse to the administrator or authorities as required by facility policy and federal regulations. No investigation report was initiated at the time, and the administrator learned of the incident only days later, despite corroborating accounts from multiple staff and another resident who heard the RN yelling derogatory terms. Surveyors determined this delay in reporting and failure to promptly investigate constituted noncompliance at the Immediate Jeopardy level.
Surveyors found a medication cart on one hall left unlocked and unattended by an LVN, contrary to facility policy requiring locked storage of medications. During a narcotic count, an RN and LVN identified a discrepancy between the narcotic count sheet and the actual number of hydrocodone/acetaminophen tablets for a resident; the MAR showed a recent PRN dose, but the narcotic log had not been signed out for that administration, and the LVN stated he had forgotten to document it. The surveyor also observed another resident’s hydrocodone/acetaminophen blister pack with a broken seal over one pill; the RN and LVN initially attempted to discard a pill from a different resident’s blister pack of an unknown medication before correcting themselves and discarding the correct pill from the damaged pack.
A resident with severe cognitive impairment and multiple neurological and psychiatric diagnoses had conflicting documentation regarding code status, with the admission record, care plan, and active orders listing Full Code while a signed DNR form and hospice interdisciplinary notes identified DNR. The DON reported placing DNR information in the file and stated that either she or the MDS nurse would update the care plan, but the code status was not changed. The social worker believed the MDS nurse would update the care plan when a DNR was written, and the MDS nurse stated that no one had communicated the code status change and that care plan meetings had not been held prior to his assuming the role. This lack of communication and failure to revise the care plan and orders resulted in an inaccurate code status being maintained in the resident’s record.
A resident with severe cognitive impairment and multiple neurological and psychiatric diagnoses had an OOH-DNR form signed by the responsible party and filed under miscellaneous documents, while the admission record, face sheet, care plan, EMR summary page, and active physician orders all continued to list the resident as Full Code. A hospice interdisciplinary group report identified the resident as DNR, but this was not translated into updated physician orders or core clinical documentation. Interviews with the SW, DON, and MDS nurse revealed that responsibilities for updating code status were unclear and that communication about the change in code status did not occur, resulting in inconsistent and incomplete documentation of the resident’s wishes.
A resident with a history of mood and schizoaffective disorders became involved in a verbal altercation with another resident who had dementia and impulse disorders after refusing to share personal coffee creamer. The resident reported the incident as a grievance to an LVN, but no grievance report was generated, and the facility's grievance log remained blank for the month. This failure to document and address the grievance was contrary to facility policy and residents' rights.
Two residents with cognitive and behavioral health diagnoses engaged in a verbal altercation involving an attempt to take personal property, resulting in shouting and emotional distress. An LVN intervened and documented the incident but failed to report the allegation of verbal abuse and exploitation to facility leadership and authorities as required by policy.
A resident returned from the hospital with a fractured arm and physician orders for a stabilization sling, but the care plan was not updated to include this intervention. Although staff assisted the resident with the sling as ordered, the care plan lacked documentation of the new care needs, contrary to facility policy requiring comprehensive, person-centered care plans.
Surveyors observed improper storage of oxygen tubing for a resident with chronic lung and heart conditions, with tubing left uncovered and on the floor, as well as two CNAs failing to perform hand hygiene between distributing meal trays to different residents. Staff interviews and facility policy reviews confirmed that these actions did not meet infection control standards.
Staff failed to consistently knock and announce themselves before entering the rooms of two cognitively intact female residents, with one CNA entering without any announcement and another entering while simultaneously saying "knock knock." Interviews with staff confirmed that facility policy requires knocking and announcing before entry to maintain resident privacy and dignity, but these procedures were not followed.
A resident with COPD and coronary artery disease, requiring continuous oxygen therapy, was found with their oxygen tubing disconnected from the oxygen machine despite the machine being on and set to deliver oxygen. The resident believed the oxygen was running, and the charge nurse confirmed the tubing was not properly connected. The care plan included oxygen interventions but lacked a specific focus area for COPD, and the facility did not provide a respiratory care policy when requested.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions, as observed in the care planning documentation.
A resident with severe cognitive impairment and high fall risk did not have access to a working call light system, as confirmed by the DON during testing. The care plan lacked interventions for a call system, and there was no maintenance log or work order for repair. The Administrator, responsible for maintenance, acknowledged the absence of routine checks and the need for manual resets on the aging call system, contrary to facility policy requiring functional call systems at all times.
The facility did not ensure accurate nutritional status monitoring for residents, as evidenced by missing height documentation, overdue scale calibration, and inaccurate meal intake records. Additionally, significant weight loss in two residents was not reported to the registered dietitian or physician, and a required nutritional evaluation was not completed. These failures affected all residents reviewed for nutrition and resulted in inadequate monitoring and assessment of their nutritional needs.
A resident with multiple health conditions was identified as being at risk for malnutrition, and their care plan required a Mini Nutritional Evaluation and possible dietician consultation. The assessment was started but not completed, and the RD was not informed of the need for the evaluation, resulting in the care plan interventions not being fully implemented.
Two residents with cognitive impairments did not have care plans accessible in the current electronic medical record system due to incomplete transfer of records during a system change. Staff relied on requesting information from the MDS Coordinator, but there was no specific training on this process, resulting in incomplete documentation as required by facility policy.
The facility failed to provide adequate supervision and security, resulting in several residents testing positive for amphetamines. Residents were observed smoking unsupervised, and the back door was not secured, allowing access to the outside area. This lack of supervision enabled substance use among residents, as confirmed by drug tests.
The facility failed to obtain informed consent for psychotropic medications for three residents, leading to deficiencies in their care. A resident with schizophrenia was given paliperidone without a signed consent form. Another resident with dementia and depression received medications like trazodone and paroxetine without proper consent, as the family member listed was unaware of the medications. A third resident with schizoaffective disorder was prescribed Seroquel and ABH gel without a physically signed consent form, despite facility policy requiring written consent.
A resident with multiple health conditions and limited mobility was left without access to a call light after returning from dialysis, causing her to be in pain and unable to call for help. The van driver who assisted her did not place the call light within reach, and the facility's policy requires call lights to be accessible to residents. The DON and Administrator acknowledged the oversight, noting the importance of call light accessibility.
A facility failed to report drug use and abuse allegations involving four residents who tested positive for amphetamines. Despite staff observations of suspicious behavior and unsupervised smoking, the facility did not report the findings to the state, believing it was unnecessary due to voluntary drug use. This oversight could contribute to further abuse and neglect among residents.
The facility failed to provide adequate respiratory care for two residents requiring oxygen therapy. A resident with a history of acute respiratory failure and COPD did not have an oxygen sign posted on his door despite having an oxygen tank and concentrator in his room. Another resident with acute respiratory failure and heart failure lacked appropriate signage, had no active physician order for oxygen, and had oxygen tubing on the floor, undated, and not properly maintained. The facility's policy required oxygen signs and proper dating of equipment, but these protocols were not followed.
A facility failed to coordinate hospice care and maintain required documentation for a resident receiving hospice services. The resident, with multiple health conditions, lacked necessary hospice forms in their records, including the Individual Election/Cancellation/Update and Physician's Certificate of Terminal Illness. The facility's administrator acknowledged the absence of these forms and the lack of assigned responsibility for ensuring proper documentation.
The facility failed to develop comprehensive care plans for seven residents, omitting specific instructions for bed-to-chair transfers despite varying assistance needs. Interviews revealed reliance on resident profiles for transfer information, but the omission in care plans posed a risk of incorrect transfers and potential injuries.
A resident's privacy was compromised during peri-care when CNAs failed to fully close privacy curtains, leaving the resident exposed while a roommate was present. The resident, with multiple medical conditions and moderate cognitive impairment, required assistance with ADLs. The facility's policy on dignity, which mandates privacy during personal care, was not followed.
A resident with severe cognitive impairment and multiple medical conditions did not receive proper incontinent care. An LVN cleaned the resident's buttock with only one pass of a wipe, leaving residual stool, and placed a new brief without ensuring thorough cleaning. The resident expressed concern, and a CNA completed the cleaning. The facility's policy required more thorough cleaning, which was not followed, posing a risk of infection.
A nursing cart in the 200-hall was found unlocked and unattended, exposing medications to potential misuse. LVN-F left the cart unlocked while assisting a resident, acknowledging the safety risk. The DON confirmed the cart should have been locked, as per facility policy.
A facility failed to follow Enhanced Barrier Precautions (EBP) when two CNAs did not wear gowns while providing peri-care to a resident with a Foley catheter and an open wound. Despite an EBP sign and PPE supplies, the CNAs only wore gloves. Interviews revealed a lack of awareness of EBP requirements, although the facility's policy mandates gown and glove use during high-contact activities to prevent infection spread.
Incomplete and Inaccurate Documentation of Wound Care in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident receiving wound care. The resident was an elderly male with dementia, surgical aftercare for the digestive system, HTN, muscle wasting, lymphedema, and DM, who was admitted with no cognitive impairment per BIMS and was totally dependent for transfer and mobility. His care plan included wound care for pressure ulcers, notifying the MD of changes, following treatment orders, use of a pressure-relief mattress, and nutritional supplements and proteins. Physician orders for March included wound care to the great toes bilaterally every shift, to the left and right heels on Tuesday/Thursday/Saturday, and to the sacrum every shift and PRN. Record review of the March Treatment Administration Record (TAR) showed multiple dates where ordered wound care was not documented. For the great toes, wound care was not documented on several specified dates; for the heels, wound care was not documented on two specified dates; and for the sacrum, wound care was not documented on multiple specified dates. The ADON stated that the resident had lymphedema with swelling and oozing to both legs and confirmed the wound care orders, including additional orders for both legs on specific days and PRN. The ADON identified LVN B and LVN C as the nurses responsible for the wound care and acknowledged she could not explain why the physician-ordered wound care was not documented on the TAR on the identified dates. Interviews with facility staff revealed that wound care was reportedly performed on some of the dates where no documentation existed. The Regional RN stated that the lack of documentation on one date corresponded with the resident being in the hospital for observation after a fall, and reported that LVN B told him wound care was done but not documented on another date. LVN A reported witnessing LVN C provide wound care on one of the undocumented dates but was unsure if it was charted. LVN B admitted applying a wound patch on one date but forgetting to document it. The ADON reported monitoring wound care on another undocumented date and having a photo of the sacrum as proof care was done, and a text message from LVN C stated she performed wound care on three of the undocumented dates. The DON stated that, to her knowledge, wound care was provided on several of the dates in question but not documented, despite the facility’s policy requiring that all services provided and changes in condition be documented in the medical record.
Failure to Perform Required Bed Rail Safety Assessments and Maintenance
Penalty
Summary
The deficiency involves the facility’s failure to follow its own bed safety and bed rail policy and the resident’s care plan requirements for assessment and monitoring of bed rails. The facility was required to assess residents for safety risks related to bed rails, review risks and benefits with the resident or representative, obtain informed consent, and ensure proper installation and maintenance of bed rails. For one resident, the facility did not complete the required quarterly bed rail safety assessments as outlined in the comprehensive care plan, which specified that nurses would review bed rails quarterly to minimize risks and ensure the device was least restrictive. The resident involved was an adult female with diagnoses including hypertensive heart disease, obesity, and muscle wasting and atrophy. Her Quarterly MDS showed intact cognition with a BIMS score of 15/15, no functional limitation in range of motion of upper and lower extremities, and dependence on staff for chair-to-bed and toilet transfers, requiring mechanical transfers with two persons. The care plan and physician orders documented the use of bilateral one-quarter bed rails to promote independence with bed mobility and positioning, and a bed rail assessment completed in May 2025 indicated that side rails/assist bars were appropriate and served as an enabler to promote independence. However, there were no subsequent bed rail assessments completed for the second and third quarters of 2025. During observation, surveyors noted that the resident’s bed had bilateral one-quarter bed rails in the up position, and a CNA was unable to lower either rail because they were jammed. The CNA and an LVN both stated they were unaware that the bed rails could not be lowered and reported that the resident had not complained about the rails. The DON acknowledged that the bed rails should have been able to be lowered without difficulty for safety, confirmed that quarterly bed rail assessments were not completed as required, and stated that because these assessments were not done, the facility did not know the bed rails were not functioning correctly. The facility’s written policy required that bed rails be properly installed and used according to manufacturer’s instructions and that residents be evaluated for bed rail use if alternatives did not meet their needs, but these processes were not carried out as required for this resident.
Verbal and Physical Abuse of a Resident by RN and Failure to Investigate Incident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse by a registered nurse. The resident was an adult female with a history of diffuse traumatic brain injury, mood disorder due to a physiological condition, anxiety disorder, unsteadiness on feet, cognitive communication deficit, insomnia, conversion disorder with seizures, speech and language disorder following cerebral infarction, cerebral infarction, and left-sided hemiplegia/hemiparesis. Her discharge MDS showed moderately impaired cognition with a BIMS score of 10. Her care plan noted a history of reporting that care had not been provided when it had, claiming staff tossed her down hallways without evidence of injury, and throwing herself out of bed while stating someone else had thrown her. On the morning of 10/4/25 at approximately 5:20 a.m., an LVN heard a CNA calling from the resident’s room, reporting that the resident was kicking and punching her and asking the LVN to witness the behaviors. The LVN documented in a nursing note that the resident was hitting and kicking the CNA, that staff assisted and changed the resident into clean clothes, and that the resident came out of her room naked with her breasts exposed after taking off her clean shirt. The LVN’s later written statement described that when the RN arrived, the resident came out of her room shirtless with her breasts exposed, and the RN shouted, in the presence of the CNA, “What is this a fucking whore house, out here for everybody to see your tits,” then wheeled the resident back to her room. Inside the room, according to the LVN’s statement, the RN pulled the resident’s shirt off aggressively and continued verbal abuse, calling the resident a “fucking whore” and stating this was a place of business, not a whore house. The RN reportedly acknowledged to the LVN and CNA that she “went a little overboard” and that she knew it was verbal abuse. The LVN’s statement further described that after the three staff went outside briefly, they saw through a window that the resident again had her shirt off with her breasts exposed. The RN extinguished her cigarette, stated she was “done,” and went back inside, followed by the LVN. The RN then pushed the resident in her wheelchair very fast and aggressively, leaned to the resident’s ear, and called her a “fucking whore” and “slut,” adding that this was why her husband left her there because he did not want a whore. The RN then, at full force, pushed the resident into her room and released the wheelchair, causing it to roll into the room and slam into the bed, which the LVN heard as a loud thud along with the resident’s scream. The LVN reported that the RN ripped the shirt off the resident’s contracted arm, causing the resident to say, “stop that hurts you bitch,” and then aggressively and forcefully removed the sweater and put on another shirt while continuing to call the resident a slut and whore, before leaving and slamming the door. The LVN stated she checked the resident for injuries and found none but did not document this assessment. A subsequent skin assessment on 10/7/25 documented no new or unusual markings or bruises. Another CNA corroborated that the resident was combative and agitated that morning and that she saw the RN get aggressive by pushing the resident into her room, calling her a slut, and shutting the door. Another resident reported being awakened by the RN yelling and hearing the RN call someone a whore and a slut, and later being told by the RN that she had been talking to the resident because she was naked. The facility did not complete an investigation report for the 10/4/25 incident at the time it occurred, despite having a written abuse, neglect, and exploitation prevention policy requiring identification and investigation of all possible incidents of abuse and protection of residents from abuse by anyone.
Removal Plan
- Report the incident to HHSC.
- Start an in-service for all staff on abuse and neglect.
- Complete a head-to-toe assessment by nursing for Resident #1.
- Notify the responsible party of Resident #1 of the incident.
- Conduct resident safety interviews.
- Terminate RN A.
- Have Resident #1 evaluated by a mental health professional.
Failure to Immediately Report and Investigate Alleged Verbal and Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an allegation of verbal and physical abuse of a resident by a registered nurse to the abuse coordinator and appropriate authorities, as required by regulation and facility policy. A female resident with a history of traumatic brain injury, mood disorder, anxiety disorder, cognitive communication deficit, cerebral infarction with resulting hemiplegia/hemiparesis, and moderately impaired cognition (BIMS score of 10) was the subject of the alleged abuse. Her care plan noted a history of making false accusations and claiming care had not been provided, but the incident in question was directly witnessed and described in detail by staff. The facility’s policy on Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating required that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source be reported immediately to the administrator and other officials, with “immediately” defined as within two hours for allegations involving abuse or resulting in serious bodily injury. On the early morning in question, an LVN documented that she was at the nurses’ station when a CNA called from the resident’s room, stating the resident was kicking and punching her and asking the LVN to witness the behaviors. The LVN’s written statement described that when the RN arrived, the resident attempted to remove her shirt, came out of her room shirtless with her breasts exposed, and the RN loudly used profane and degrading language, referring to the environment as a “whore house” and commenting on the resident’s exposed breasts. The LVN stated that the RN wheeled the resident back to her room, aggressively pulled off the resident’s shirt, and continued verbally abusing her with repeated profanities and derogatory terms. Later, after the RN and staff briefly went outside, they saw the resident again without her shirt; the LVN reported that the RN reacted by forcefully pushing the resident in her wheelchair very fast into her room, leaning into the resident’s ear and calling her further profane and degrading names, then pushing the wheelchair into the room at full force so that it slammed into the bed, followed by aggressively removing the resident’s clothing and continuing the verbal abuse. The LVN stated she checked the resident for injuries after the incident and found none, but she did not document this assessment in the record. The nursing progress note entered by the LVN that morning only described the resident as hitting and kicking the CNA, being changed into clean clothes, coming out of the room naked with breasts showing, being instructed to keep clothes on, and being clothed at that time; it did not document the RN’s alleged verbal or physical abuse. No facility investigation report was completed for this incident at the time, and the incident was not immediately reported to the administrator or authorities. The LVN later stated she knew from training that she was supposed to report the incident immediately but delayed, initially attempting to follow chain of command by contacting the DON and believing the incident occurred on a different date. The administrator confirmed he was not informed until several days later, at which time the alleged perpetrator acknowledged telling the resident she was “acting like a whore” and pushing the resident into her room without controlling the wheelchair. Another CNA corroborated that the RN was aggressive, pushed the resident into her room, called her a slut, and shut the door, and a neighboring resident reported hearing the RN yelling and calling someone a whore and a slut. The delay in reporting and lack of immediate investigation and documentation led surveyors to identify noncompliance at the Immediate Jeopardy level from the date of the incident until several days later.
Removal Plan
- Incident reported to HHSC.
- 3613-A report sent to HHSC with the investigation findings.
- Inservice over abuse and neglect started for all staff.
- Head to toe assessment completed by nursing for Resident #1.
- Responsible party of Resident #1 notified of incident.
- Resident safe interviews conducted.
- RN A terminated.
- Resident #1 evaluated by a mental health professional.
Unlocked Med Cart and Improper Narcotic Handling and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications were stored and controlled in accordance with its own policies and accepted professional standards. During an observation, the B hall medication cart was found positioned on the side of the nursing station facing the hallway and left unlocked, while the assigned LVN was seated at the nurses’ station and not in view of the cart. The LVN acknowledged that the cart was unlocked and stated it should not be left in that condition. The facility’s written policy required that compartments containing medications and biologicals, including carts, be locked when not in use and not left unattended if open or otherwise available to others. The surveyor’s review of records for one resident showed an active order for hydrocodone/acetaminophen 7.5-325 mg, to be given every six hours as needed for pain, with the last administration documented on the MAR as occurring that afternoon. When the LVN and an RN later counted the narcotic medications in the B hall cart, the narcotic count sheet for this resident’s hydrocodone/acetaminophen indicated 17 tablets remaining, but the blister package contained only 16 tablets. The narcotic log showed the LVN had last signed out the medication the previous day, even though the LVN stated he had administered a dose that day and had forgotten to document it on the narcotic sheet. The LVN stated that the narcotic log needed to be completed at the time of dispensing to show who had given the medication. During the same narcotic count, the surveyor observed another resident’s blister pack of hydrocodone/acetaminophen 5-325 mg with a broken seal over one of the pills, although the pill remained in the package. The RN asked the LVN if tape could be placed over the package, and the LVN responded that the pill should be discarded. Both then decided to discard the pill. The RN initially dispensed a pill from a different resident’s blister pack of an unknown medication to discard, and the surveyor pointed out that the patient and medication did not match the observed blister pack. The RN and LVN then located and discarded the correct pill from the broken blister pack. The LVN later stated that any blister packs with a hole and the medication still inside should be discarded because they could have been tampered with or might not be the correct medication. The facility’s policies required controlled substances to be securely stored, properly documented, and any broken blister packs to be wasted with two staff as witnesses.
Failure to Update Care Plan and Orders to Reflect Resident DNR Status
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident’s code status. The resident, an elderly female with severe cognitive impairment (BIMS score of 4) and diagnoses including unspecified dementia, depression, epilepsy, paranoid schizophrenia, and Alzheimer’s disease, was admitted with documentation in the admission record and care plan indicating a Full Code status. Her active physician orders also listed her as Full Code. However, the electronic medical record contained a DNR form signed by her responsible party, and hospice documentation from an interdisciplinary group meeting listed her code status as DNR. Interviews and record review showed that the change in code status to DNR was not communicated or incorporated into the resident’s care plan or active orders. The DON reported downloading DNR information into the resident’s file and keeping hard copies, and stated that either she or the MDS nurse would enter the code status into the care plan, but she did not know why this resident’s code status was not updated. The social worker stated that code status would be addressed in care plan meetings and believed the MDS nurse would update the care plan when a DNR was written. The MDS nurse stated that no one had communicated the code status change to him, suggested hospice may not have written a DNR order or informed the charge nurse, and noted he had been in the position for only two months and that no care plan meetings had been held prior to his tenure. As a result, the resident’s care plan and active orders continued to reflect Full Code despite existing DNR documentation.
Failure to Accurately Update and Align Code Status Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records regarding a resident’s code status in accordance with accepted professional standards. A female resident with diagnoses including unspecified dementia, depression, epilepsy, paranoid schizophrenia, and Alzheimer’s disease was admitted with documentation on her admission record, face sheet, care plan, electronic medical record opening page, and active physician orders all indicating a code status of Full Code. Her most recent MDS showed a BIMS score of 4, indicating severe cognitive impairment. Despite this, an out-of-hospital DNR (OOH-DNR) form signed by her responsible party was filed only under Miscellaneous documents in the electronic medical record, and the resident’s code status was not updated in the care plan, admission record, or active orders. Further record review showed that a hospice interdisciplinary group meeting report listed the resident’s code status as DNR, but this information was not reflected in the facility’s primary clinical documentation or physician orders. In interviews, the Social Worker stated that code status would be addressed in care plan meetings and that she believed the MDS Nurse would update the care plan when a DNR was written. The DON reported that she downloaded DNR information into the resident’s file and kept hard copies, and that either she or the MDS Nurse would enter the code status into the care plan, but she did not know why this resident’s code status was not updated or why physician’s orders were not obtained. The MDS Nurse stated that no one had communicated that the resident’s code status had changed and suggested that hospice either did not write a DNR order or did not provide the information to the charge nurse to update the orders.
Failure to Document and Address Resident Grievance Following Verbal Altercation
Penalty
Summary
The facility failed to ensure that residents could voice grievances without discrimination or reprisal, as required by policy. On the morning of 8/14/2025, a resident with a history of mood disorder and schizoaffective disorder became involved in a verbal altercation with another resident who had dementia and impulse disorders. The incident began when the first resident refused to share his personal coffee creamer with the second resident, leading to a shouting match with exchanged insults. The situation escalated to the point that other residents in the dining room were emotionally disturbed. Following the altercation, the first resident was visibly upset and reported his complaint about the other resident's behavior to LVN A, expressing that he felt his grievance was not being taken seriously. Despite the resident's clear attempt to voice a grievance, LVN A did not generate a grievance report as required by facility policy, although she did document the incident in the nursing progress notes and reported it to the RN supervisor. The facility's grievance log for the month was found to be blank, indicating that no grievances were documented, including this incident. Interviews with staff and review of facility policy confirmed that all grievances, whether oral or written, should be documented and reported to leadership for investigation and resolution. The DON was unaware of the grievance and stated that both LVN A and the RN supervisor were responsible for ensuring grievances were documented and reported to the grievance coordinator. The failure to document and address the resident's grievance represented a violation of the residents' rights and facility policy.
Failure to Timely Report Alleged Abuse and Exploitation Between Residents
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—including injuries of unknown source and misappropriation of resident property—were reported immediately, as required by regulation. On the morning of 8/14/2025, a verbal altercation occurred between two residents in the dining room, during which one resident attempted to take another resident's personal coffee creamer, leading to a shouting match with cursing insults exchanged. The incident was witnessed by LVN A, who intervened and redirected the residents but did not report the allegation of verbal abuse and exploitation to the Administrator or follow the facility's established reporting procedures. A review of the residents' records revealed that both individuals involved had significant mental health and cognitive diagnoses. One resident had a history of mood disorder and schizoaffective disorder, with a care plan noting a potential for verbal aggression and a BIMS score indicating moderate cognitive impairment. The other resident had dementia, anxiety, and impulse disorders, with a care plan also noting a potential for verbal aggression and a BIMS score indicating cognitive intactness. Despite these risk factors and the escalation of the incident, the required immediate reporting to facility leadership and state authorities did not occur. Interviews confirmed that LVN A documented the incident in the nursing progress notes and reported it to the RN supervisor but did not escalate the report to the DON or Administrator as required. The DON later confirmed that she had not received any report of the incident and reiterated that staff had been trained to report all allegations of abuse, neglect, or exploitation. A review of the facility's policy confirmed the requirement for immediate reporting of such incidents to the Administrator and appropriate authorities, which was not followed in this case.
Failure to Update Care Plan for Resident's Arm Sling Post-Hospitalization
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who returned from hospitalization with a left arm fracture. Despite physician orders requiring the resident to wear a stabilization arm sling, the care plan did not include any focus, goals, or interventions related to the use of the sling. Record reviews confirmed that the care plan was not updated to reflect the new care needs following the resident's return from the hospital. Observations showed the resident using a soft cast and sling, and interviews with nursing staff and the DON confirmed that the care plan lacked documentation for the prescribed sling, even though staff were aware of and assisted with the sling as ordered. The resident had a history of hemiplegia and required assistance with activities of daily living. The omission in the care plan was identified through review of medical records, staff interviews, and direct observation. The facility's own policy required that care plans be comprehensive and person-centered, including measurable objectives and interventions based on thorough assessment, but this was not followed in the case of the resident's new need for arm stabilization.
Failure to Maintain Infection Control: Improper Oxygen Tubing Storage and Hand Hygiene Lapses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving three residents. For one resident requiring continuous oxygen therapy due to chronic obstructive pulmonary disease and coronary artery disease, the oxygen tubing was observed uncovered and lying on the floor, both at the oxygen machine and portable tank. The tubing was not stored in a protective bag as required, and staff confirmed that such storage was necessary to prevent contamination. The resident was unaware that the tubing was not connected to the machine, and staff acknowledged the tubing was contaminated and needed replacement. Additionally, two certified nursing assistants (CNAs) were observed distributing meal trays to residents without performing hand hygiene between residents. One CNA provided a meal tray and set up the meal for a resident, then immediately proceeded to the next resident's room and handled another meal tray without sanitizing their hands. The second CNA followed a similar process, setting up a meal tray for a resident and then moving to another room without hand hygiene. Both CNAs acknowledged during interviews that hand sanitization was required between residents to prevent infection, and the facility's policy confirmed this expectation. The facility's own infection control policies, including those on standard precautions and hand hygiene, were not followed in these instances. The policies require hand hygiene before and after resident contact and proper handling and storage of resident-care equipment to prevent contamination. These failures were directly observed and confirmed by staff interviews and record reviews, demonstrating a breakdown in adherence to established infection control protocols.
Failure to Ensure Resident Privacy and Dignity During Room Entry
Penalty
Summary
The facility failed to honor residents' rights to a dignified existence, self-determination, and communication by not ensuring staff consistently knocked and announced themselves before entering residents' rooms. Specifically, a CNA entered a female resident's room without knocking or announcing, interrupting an interview with a State Surveyor, and proceeded to set up the resident's meal tray before leaving. The resident, who had an intact cognitive status as indicated by a BIMS score of 14 out of 15, confirmed that she did not hear the CNA knock or announce their presence. In another instance, a different CNA entered another female resident's room while simultaneously saying "knock knock" as they walked in, rather than before entering. This resident also had an intact cognitive status, with a BIMS score of 15 out of 15. Interviews with staff, including CNAs, LVN, ADON, DON, and the Administrator, revealed that the facility's policy requires staff to knock and announce themselves before entering residents' rooms to maintain privacy and dignity. However, the observed actions did not align with this policy, as staff either failed to knock or did so while entering, rather than prior to entry. The facility's written policy on residents' rights also emphasizes the importance of privacy, dignity, and respect, which was not upheld in these instances.
Failure to Ensure Proper Oxygen Administration for Resident Requiring Respiratory Care
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD) and coronary artery disease, who required continuous oxygen therapy, was observed wearing an oxygen nasal cannula that was not connected to the oxygen machine. The oxygen machine was on and set to deliver two liters per minute, but the tubing was disconnected at the machine end, resulting in the resident not receiving the prescribed oxygen. The resident, who had moderate cognitive impairment, stated he wore the oxygen all the time and believed it was running, though he did not feel short of breath at the time of observation. The charge nurse confirmed that the oxygen tubing was not connected to the machine and acknowledged the risks associated with improper oxygen setup. The resident's care plan included interventions for oxygen therapy, but there was no documented focus area specifically for COPD. Additionally, when the facility's respiratory care policy was requested, it was not provided before the survey exit.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where surveyors noted the absence of comprehensive and individualized planning to meet the resident's assessed needs.
Failure to Provide Functional Call Light System for High-Risk Resident
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, high fall risk, and significant physical limitations did not have access to a functional call light system in her room. The resident, who was dependent on staff for transfers and had a history of falls, was observed to lack a working call light, which was confirmed through direct testing by the Director of Nursing (DON). The call light failed to activate at the room wall panel, hallway indicator, or nurse's station, while the roommate's call light was functional. The resident's care plan did not include interventions for a call system, and her fall risk assessment indicated a high risk. Interviews revealed that there was no work order for repair of the call light, no maintenance log for checking call light functionality, and no maintenance staff employed at the time. The Administrator, who was responsible for maintenance, acknowledged the lack of routine checks and explained that the call system was older and sometimes required manual resetting. The facility's policy required that each resident have a functional call system at all times, and alternative communication means should be documented in the care plan if the resident could not use the standard system. The deficiency was identified through observations, interviews, and record review.
Failure to Maintain Accurate Nutritional Status and Documentation
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, including usual or desirable body weight, for all residents reviewed for nutrition status. Specifically, there was a lack of documented heights for all 58 residents, which prevented accurate calculation of BMI and assessment of nutritional needs. Multiple dietary consultant reports noted missing heights and recommended obtaining them, but these were not entered into the current electronic medical record system due to data transfer issues from the previous system. The registered dietitian confirmed that the absence of height data hindered his ability to track low BMIs and provide appropriate interventions. The facility also failed to maintain proper calibration and inspection of the scale used for weighing residents. The last inspection was overdue, and the scale had not been calibrated as required by the manufacturer's maintenance schedule. Staff interviews revealed that the scale's calibration was not up to date, and there was confusion about the accuracy of weights being recorded. Additionally, meal intake percentages were inaccurately documented in advance in the electronic medical record for several residents, with some meals being charted before they were actually consumed. Observations showed discrepancies between the documented intake and what residents actually ate, and staff interviews confirmed that some CNAs were entering meal percentages prematurely or inaccurately. Furthermore, the facility did not notify the registered dietitian or physician when significant weight loss occurred in two residents. There was also a failure to complete a Mini Nutritional Evaluation for a resident as required by her care plan. These actions and inactions, including inaccurate weight and intake documentation, lack of timely communication with clinical staff, and missing nutritional assessments, contributed to the deficiency in maintaining residents' nutritional status.
Failure to Complete Nutritional Assessment per Care Plan
Penalty
Summary
A deficiency occurred when the facility failed to implement a comprehensive, person-centered care plan for a resident with multiple diagnoses, including muscle weakness, atrophy, lack of coordination, and cognitive communication deficit. The resident's care plan identified a risk for malnutrition and included specific interventions such as completing a Mini Nutritional Evaluation and consulting a dietician based on the results. However, the Mini Nutritional Assessment for the resident was started but not completed, and the Registered Dietician (RD) was unaware that the evaluation was required. The care plan interventions were not fully carried out as intended. Interviews revealed a lack of communication and follow-through regarding the nutritional assessment. The RD stated he was not informed that a Mini Nutrition Evaluation was needed, and the Regional Nurse Consultant indicated that care plans should trigger the RD to complete necessary assessments. Facility policy required the care plan to describe services to maintain the resident's well-being, but this was not achieved due to the incomplete assessment and lack of coordination among staff.
Care Plans Not Accessible in Electronic Medical Records
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records in accordance with accepted professional standards for two residents. Specifically, care plans for these residents were not accessible in their current active electronic medical records. One resident, a female with muscle weakness, atrophy, lack of coordination, and cognitive communication deficit, had a moderate cognitive impairment as indicated by a BIMS score of 10 out of 15. Another resident, a female with hypertension, atrial fibrillation, and osteoarthritis of the hip, had a severe cognitive impairment with a BIMS score of 7 out of 15. Despite their needs, neither resident had a care plan available in the current electronic system. Interviews with facility staff revealed that the transition from the former electronic medical record system to the current one (PCC) resulted in incomplete transfer of care plans. The MDS Coordinator acknowledged that not all care plans had been entered into the new system and that staff were instructed to request care plans or MDS assessments from her if needed. However, there was no specific training for staff to know they could contact the MDS nurse or administration at any time for this information. The facility's policy required comprehensive assessments to be maintained in the resident's active record, but this was not followed for the affected residents.
Inadequate Supervision and Security Leads to Substance Use Among Residents
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for several residents, leading to a situation where multiple residents tested positive for amphetamines. Residents were observed smoking unsupervised, and the facility did not adequately secure the back door, allowing residents to access the outside area without supervision. This lack of supervision and security allowed residents to engage in substance use, as evidenced by positive drug tests for amphetamines among several residents. Resident #36, who had a history of schizoaffective disorder and substance use, was found to be acting erratically and admitted to consuming alcohol and smoking outside designated times. Despite being advised against such behavior due to her medical condition and medication regimen, she was observed unsupervised on the back patio with other residents. This behavior was linked to her interactions with other residents who were also involved in substance use, as confirmed by drug tests. The facility's failure to lock the back door and supervise residents adequately led to a situation where residents could access the community and engage in unsupervised activities, including substance use. Staff reported concerns about the unlocked doors and the presence of visitors who might be supplying drugs, but these concerns were not addressed by management. The facility's policies on smoking and substance use were not effectively enforced, contributing to the deficiency.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medications for three residents, leading to deficiencies in their care. Resident #9, a male with a history of schizophrenia and other mental health conditions, was administered paliperidone without a signed consent form. Although a form was partially completed by healthcare professionals, the section for the resident or their representative's signature was left blank, indicating a lack of proper consent. Resident #25, a female with dementia and depression, was given medications such as trazodone, paroxetine, and buspirone without proper consent. The facility had a consent form with a typed name of a family member, but this individual was unaware of the medications and had not been consulted. Interviews revealed that the resident did not know what medications she was taking, and the family member, who was believed to be the representative, had not been involved in the consent process. Resident #30, a female with schizoaffective disorder and other health issues, was prescribed Seroquel and ABH gel without a physically signed consent form. The facility documented telephone consent from a responsible party, but the forms lacked physical signatures. The facility's policy required written consent for psychotropic medications, which was not adhered to in these cases, leading to the administration of medications without proper informed consent.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident received services with reasonable accommodation of their needs, specifically regarding the placement of the call light. The resident, an elderly female with a history of fractures, multiple trauma, atrial fibrillation, heart failure, and renal insufficiency, was observed in a wheelchair by her bedside, unable to reach her call light. Despite having a fully intact cognition, as indicated by a BIMS score of 15, the resident was dependent on others for transfers and had impairment on one side of her body. On the day of the incident, the resident returned from dialysis and was assisted to her room by a van driver who did not place the call light within her reach. Consequently, the resident was in pain and unable to call for help, relying on her roommate to press the call light for her. The Director of Nursing (DON) acknowledged that the van driver should have ensured the call light was accessible to the resident, although the driver is not responsible for transferring residents. The facility had only one working Hoyer lift, which did not affect the timely response for care, according to the DON. The facility's policy on answering call lights emphasizes the importance of ensuring the call light is within easy reach of residents confined to a bed or chair. The Administrator noted that the resident had a cell phone to contact him if needed, but affirmed that the call light should be within reach for all residents.
Failure to Report Drug Use and Abuse Allegations
Penalty
Summary
The facility failed to report alleged violations involving abuse and neglect, specifically related to drug use, to the state reporting agency within the required timeframe. Four residents tested positive for amphetamines during a facility investigation of possible drug use, but the facility did not report these findings to the state. This failure to report could contribute to further abuse and neglect among residents. Resident #9, a male with a history of alcohol or drug abuse, tested positive for amphetamines. His care plan included interventions for supervised smoking breaks due to a history of setting a fire. Resident #36, a female with schizoaffective disorder and a history of drug abuse, exhibited erratic behavior and admitted to taking a pill given by another resident. She was sent to the hospital and later tested positive for amphetamines. Resident #40, a male with a history of illicit drug use, was suspected of distributing drugs to other residents. He tested positive for MDMA, methamphetamine, and amphetamines. Resident #21, a male with a history of alcohol or drug abuse, also tested positive for amphetamines. Interviews with staff revealed concerns about residents accessing drugs and engaging in unsupervised smoking on the patio. Staff reported suspicious behavior and the presence of a visitor entering through an unlocked door. Despite these observations, the facility did not report the drug use to the state, as they believed it was not necessary due to the residents' voluntary drug use. The facility's policy on abuse prevention requires the investigation and reporting of any allegations of abuse within federal timeframes, which was not adhered to in this case.
Failure to Provide Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents requiring oxygen therapy. Resident #29, a male with a history of acute respiratory failure, pulmonary embolism, and COPD, did not have an oxygen sign posted on his door despite having an oxygen tank and concentrator in his room. His care plan required oxygen therapy to maintain SPO2 at 90% or greater, with a physician's order for PRN oxygen via nasal cannula. However, during an observation, it was noted that no signage was present to indicate the use of oxygen. Similarly, Resident #163, a male with acute respiratory failure and heart failure, also lacked appropriate signage to indicate oxygen use. Additionally, there was no active physician order for oxygen, and the oxygen tubing was found on the floor, undated, and not properly maintained. The facility's policy required oxygen signs and proper dating of equipment, but these protocols were not followed. Interviews with staff revealed inconsistencies in the implementation of these procedures, contributing to the deficiency.
Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. Specifically, for one resident, the facility did not maintain the required hospice forms and documentation in the current hospice binders. This included the absence of Form 3071, Individual Election/Cancellation/Update, and Form 3074, Physician's Certificate of Terminal Illness. The lack of these documents could potentially place residents at risk of receiving inadequate end-of-life care due to insufficient documentation, coordination of care, and communication of resident needs. The resident in question was a female with multiple diagnoses, including opioid dependence, schizoaffective disorders, sarcoidosis, hypothyroidism, chronic pain syndrome, unspecified osteoarthritis, and sciatica. The facility's administrator admitted that the hospice company had not provided the required forms and that there was no assigned responsibility within the facility to ensure all necessary paperwork for hospice was present. This oversight was attributed to the resident being private pay for hospice and Medicaid pending, leading to a misunderstanding of the facility's obligations regarding documentation.
Failure to Develop Comprehensive Care Plans for Resident Transfers
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for seven residents, which included measurable objectives and timeframes to meet their medical, nursing, and mental needs. This deficiency was identified during a review of the care plans and interviews with facility staff. The care plans lacked specific instructions on how to safely transfer residents from bed to chair, despite the residents' varying levels of assistance required for such transfers. Resident #1, a female with a history of severe traumatic brain injury and moderate cognitive impairment, required substantial assistance for transfers. However, her care plan did not include instructions for bed-to-chair transfers. Similarly, Resident #2, a male with congenital myasthenia and moderate cognitive impairment, required supervision for transfers, but his care plan also lacked specific transfer instructions. Other residents, including those with dementia, cerebral infarction, and congestive heart failure, were assessed as needing varying levels of assistance, from partial to maximal, yet their care plans did not address the necessary transfer procedures. Interviews with the MDS Coordinator and the regional nurse consultant revealed that the facility relied on resident profiles in the Point of Care system to inform staff about transfer needs. However, the MDS Coordinator acknowledged the omission of transfer instructions in the care plans, recognizing the potential risk of staff performing incorrect transfers, which could lead to injuries. The facility's policy on comprehensive person-centered care plans emphasized the need to describe services to maintain residents' well-being, highlighting the importance of including transfer instructions in the care plans.
Failure to Ensure Resident Privacy During Peri-Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during peri-care, as observed by surveyors. Two CNAs, while providing peri-care, did not fully close the privacy curtains, leaving the resident exposed to view from the sides of the bed. This incident occurred while the resident's roommate was present in the room, compromising the resident's privacy. The CNAs acknowledged the oversight, with one admitting she did not notice the roommate's presence and confirming that she should have closed the curtains completely. The resident involved had a history of multiple medical conditions, including rheumatoid lung disease, noninfective gastroenteritis, rheumatoid arthritis, type 2 diabetes mellitus, major depressive disorder, and a urinary tract infection. The resident was moderately cognitively impaired and required assistance with activities of daily living. The facility's policy on dignity emphasized the importance of maintaining resident privacy during personal care, which was not adhered to in this instance. Interviews with the RN and DON confirmed the expectation that privacy curtains should be fully closed during such care.
Inadequate Incontinent Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate incontinent care for a resident who was incontinent of bladder and bowel. During an observation, an LVN and a CNA were providing care to a resident who had a bowel movement. The LVN cleaned the resident's buttock with only one pass of a cleaning cloth wipe, leaving residual stool on the resident's skin. The LVN then changed gloves and placed a new brief under the resident without ensuring the area was thoroughly cleaned. The resident expressed concern about not being clean, prompting the CNA to take over and clean the area completely. The resident involved was an elderly male with severe cognitive impairment and multiple medical conditions, including a urinary tract infection and hemiplegia. The facility's policy on perineal care required thorough cleaning when a resident is heavily soiled, which was not followed in this instance. Interviews with the LVN, CNA, and DON confirmed that the cleaning was inadequate and acknowledged the potential risk of infection due to improper care practices.
Unattended and Unlocked Nursing Cart
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, specifically with the 200-hall nursing cart. During an observation, the nursing cart was found unlocked and unattended, allowing access to multiple blister packs and bottles of medication. This oversight was noted during a surveyor's visit, highlighting a lapse in the facility's adherence to its medication storage policy. An interview with LVN-F revealed that the cart was left unlocked while attending to a resident's call light, and LVN-F acknowledged the importance of keeping the cart locked for safety reasons. The Director of Nursing (DON) also confirmed that the cart should not have been left unlocked, as it posed a risk to residents and visitors. The facility's policy, revised in 2007, mandates that compartments containing drugs and biologicals must be locked when not in use, and carts should not be left unattended if open.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs who did not adhere to Enhanced Barrier Precautions (EBP) while providing peri-care to a resident. The resident, who had a Foley catheter and an open wound on her back, was at risk for infection and required EBP, which includes the use of gowns and gloves during high-contact care activities. Despite the presence of an EBP sign outside the resident's room and a PPE supply drawer inside, the CNAs only wore gloves and not gowns during the care procedure. Interviews with the CNAs and the RN revealed a lack of awareness and adherence to the EBP requirements. CNA B stated she was unaware of the EBP sign and the need for gowns, while RN A confirmed observing the CNAs' failure to wear gowns. The DON emphasized the importance of using both gowns and gloves to prevent infection spread, noting that all staff had been trained on EBP. The facility's policy on EBP, revised in March 2024, mandates gown and glove use during high-contact activities to reduce the transmission of multi-drug resistant organisms.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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