Avir At Schertz

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to 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.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to 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.

Penalty

Inspection fine: $14,020

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

Summary

The deficiency involves the facility’s failure to 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.

Penalty

Inspection fine: $14,020

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

Summary

The deficiency involves the facility’s failure to 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.

Penalty

Inspection fine: $14,020

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

Summary

The deficiency involves the facility’s failure to 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.

Penalty

Inspection fine: $14,020

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

Summary

Surveyors identified 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.

Penalty

Inspection fine: $14,020

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

Summary

The deficiency involves the facility’s failure to 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.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that 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.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment—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.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement a comprehensive, person-centered care plan for a resident 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.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by 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.

Penalty

No penalty information released

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

Summary

The facility failed to 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.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a 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.

Penalty

No penalty information released

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

Summary

A deficiency 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.

Penalty

No penalty information released

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

Summary

A deficiency 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.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that 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.

Penalty

No penalty information released

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

Summary

A deficiency occurred when the facility failed to 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.

Penalty

No penalty information released

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

Summary

The facility failed to maintain complete and 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.

Penalty

Inspection fine: $39,470

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

Summary

The facility failed to ensure 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.

Penalty

Inspection fine: $39,470

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

Summary

The facility failed to 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.

Penalty

Inspection fine: $39,470

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

Summary

The facility failed to ensure that a resident 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.

Penalty

Inspection fine: $39,470

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

Summary

The facility failed to 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.

Penalty

Inspection fine: $39,470

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

Summary

The facility failed to provide adequate 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.

Penalty

Inspection fine: $39,470

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

Summary

The facility failed to 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.

Penalty

No penalty information released

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

Summary

The facility failed to develop and implement 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.

Penalty

No penalty information released

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

Summary

The facility failed to ensure 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.

Penalty

No penalty information released

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

Summary

The facility failed to provide 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.

Penalty

No penalty information released

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

Summary

The facility failed to ensure that all 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.

Penalty

No penalty information released

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

Summary

The facility failed to maintain an effective infection prevention and control program, as evidenced by 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.