Avir At Town Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Palestine, Texas.
- Location
- 1816 Tile Factory Rd, Palestine, Texas 75801
- CMS Provider Number
- 455565
- Inspections on file
- 43
- Latest survey
- February 18, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Avir At Town Creek during CMS and state inspections, most recent first.
Two male residents with significant cognitive impairments were involved in a resident-to-resident altercation when one resident was observed by an LVN striking another in the face with a closed fist. The LVN immediately separated the residents, notified the DON, NP, and responsible party, and completed a skin assessment that showed no injuries, while both residents were later observed clean, well groomed, and without bruising or skin tears. One resident had autism, severe intellectual disability, and behavioral symptoms such as yelling, while the other had dementia, a psychotic disorder, and severely impaired cognition but no prior documented aggression. Despite facility policies and staff training requiring immediate reporting of suspected abuse to authorities, the DON and ADM decided the incident was not reportable based on their belief that the aggressor’s limited cognition meant he could not willfully act, resulting in a failure to report the alleged abuse as required.
Surveyors found that food items in the kitchen refrigerator and freezer were not consistently labeled or dated, including premade waffles, chicken, fruit cups, ground beef, and ham. Staff interviews confirmed that food should be labeled and dated upon delivery or when opened, but this was not done according to facility policy and federal food codes.
The facility did not establish or maintain a required infection prevention and control program, as observed by surveyors during their review of facility practices.
A resident with a gastrostomy tube and intact cognition was left exposed to the hallway during tube care when the ADON did not pull the privacy curtain or close the door. Staff and the resident confirmed that this lack of privacy caused embarrassment, and facility policy required privacy to be maintained during care.
A resident with significant medical and cognitive needs was left in a room with a broken window frame that was detached from the wall, exposing screws and nails. Staff and department heads failed to notice or report the issue despite daily environmental rounds and established reporting procedures, resulting in the maintenance problem going unaddressed until discovered during a survey.
Feeding tubes were utilized for a resident without clear medical justification or documented consent, and appropriate care for a resident with a feeding tube was not provided according to regulatory standards.
A designated smoking area was found with a fire can containing a plastic liner, cigarette butts, and paper and plastic trash, contrary to facility policy. Staff interviews revealed confusion about responsibility for maintaining the smoking area, and the Maintenance Director was unaware of proper procedures. The facility's policy required metal containers for ash disposal, but this was not followed, resulting in an unsafe smoking environment.
A facility failed to ensure safe and sanitary storage of a resident's food items, as a personal refrigerator contained expired cheese. The resident, with cerebral palsy and mild intellectual disabilities, required assistance with eating. There was confusion among staff about who was responsible for checking food expiration, leading to non-compliance with the facility's policy and potential risk for foodborne illnesses.
A resident with diabetes and chronic ulcers developed facility-acquired wounds due to inadequate care. The facility failed to conduct regular skin assessments and did not provide a bed of appropriate size, leading to the resident's feet pressing against the footboard. Despite staff reporting the issue, the problem persisted, resulting in harm to the resident.
A resident in a facility was not provided with a bed of proper size, leading to discomfort and the development of diabetic ulcers. Despite being 80 inches tall, the resident's feet hung over the edge of the mattress, and the footboard was removed after ulcers developed. Staff acknowledged the bed was too small, but the facility initially failed to provide a suitable alternative, resulting in harm to the resident.
The facility failed to maintain RN coverage for at least eight consecutive hours a day, seven days a week, on four days in June 2024. This occurred due to the departure of the DON and the unavailability of corporate travel nurses, with agency nurses calling in and no replacements provided. The facility's policy required RN services daily, which was not met during these days.
The facility's kitchen failed to maintain sanitary conditions, with the dish machine's sanitizer levels consistently above the manufacturer's guidelines. A scoop was improperly stored in a flour bin, and baking sheets had baked-on buildup. The Dietary Manager and Administrator were unaware of the correct sanitization levels, leading to these deficiencies.
The facility failed to submit complete RN staffing data to CMS for several dates in 2024 due to an oversight in capturing hours for the DON, traveling nurses, and agency nurses. The absence of RN coverage on specific dates was due to the departure of the DON and lack of available corporate RNs.
A resident was administered multiple psychotropic medications without obtaining informed consent, as required by facility policy. The resident, with complex medical conditions, received medications such as mirtazapine, risperidone, and others without documented consent. Facility staff acknowledged the oversight and began an audit to address the issue.
The facility failed to maintain proper infection control practices during care for two residents. A CNA did not change gloves or perform hand hygiene during incontinent care for a resident with hemiplegia, while an LVN used improperly cleaned scissors during ostomy care for another resident. Both staff members were aware of the correct procedures but did not follow them, posing a risk of infection.
The facility failed to implement comprehensive care plans for four residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. This included not providing necessary meal assistance, missing fortified foods, and failing to perform required weekly weight checks.
The facility failed to maintain acceptable nutritional status for 15 residents, including inadequate communication with dietary staff, insufficient monitoring of weight changes, and failure to provide therapeutic meals and necessary assistance during meals. These deficiencies placed residents at risk of severe weight loss, delayed interventions, and worsening health conditions.
A resident with a history of dysphagia choked on every bite of food during breakfast, but the facility failed to notify the physician and responsible party. The resident's diet was downgraded without proper notification, and the resident was observed eating alone and without assistance. Staff interviews revealed that the facility's policy for notifying significant changes was not followed.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed expired and improperly labeled food items in the dry storage area and refrigerator. The Dietary Manager confirmed the oversight, citing staff shortages as a contributing factor. The Administrator emphasized the importance of discarding expired food to prevent foodborne illnesses, in line with the facility's food storage policy.
The facility failed to ensure that licensed nurses had the necessary competencies to care for a resident with dysphagia. After a choking incident, the resident's diet was changed without proper assessment or physician notification. The resident, who required assistance during meals, was observed eating alone and quickly, leading to coughing and potential aspiration risks. Staff interviews revealed that facility policies were not followed, and the necessary evaluations were delayed.
The facility failed to ensure RN coverage for at least eight consecutive hours a day, seven days a week, as required. Specifically, RN coverage was missing on one day in December 2023. The ADON, new to her role, was still learning her responsibilities, which contributed to the oversight. The DON and ADON typically provide coverage themselves if no other RN is available, but this did not occur on the specified day.
The facility failed to ensure proper labeling of an insulin vial for a resident with multiple diagnoses, including dementia and type 2 diabetes. The insulin was found opened and undated, posing a risk of reduced effectiveness in controlling blood sugar levels. The nurse responsible was unaware of the opening date, and the ADON confirmed the labeling should have been done upon first use.
Failure to Timely Report Resident-to-Resident Physical Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to immediately report an alleged resident-to-resident physical abuse incident to the appropriate authorities as required. On the date in question at approximately 3:38 p.m., an LVN (LVN A) heard someone call out for the nurse, exited a resident’s room, and observed one resident (Resident #2) make contact with another resident (Resident #1) on the cheek with what appeared to be a closed fist. LVN A separated the residents, notified the DON, NP, and responsible party, and completed a skin assessment on Resident #1, which revealed no injuries or alterations in skin integrity. The incident was documented as physical aggression on an incident report. Resident #1 was a male with autistic disorder, muscle wasting and atrophy, diabetes mellitus, and severe intellectual disability. A recent MDS indicated he was rarely or never understood, and he required varying levels of assistance with toileting hygiene, dressing, personal hygiene, eating, oral hygiene, and footwear. His care plan, dated 2/4/26, documented behavioral symptoms related to severe intellectual disability, including self-biting and yelling out when agitated, with interventions such as maintaining a calm environment, using calming techniques and words, and removing him from the area if his behavior interfered with others. Following the incident, Resident #1 was assessed as nonverbal and not appearing emotionally distressed, and later observation showed him clean, well groomed, and without suspicious marks, skin tears, or bruising. Resident #2 was a male with unspecified dementia and a psychotic disorder with delusions due to a known physiological condition. His admission MDS showed severely impaired cognition with a BIMS score of 4 and indicated he required supervision or assistance with eating, oral hygiene, dressing, personal hygiene, toileting hygiene, showering/bathing, and footwear, with no documented physical or behavioral symptoms directed toward others. His care plan, dated 2/4/26, identified risk for impaired social interactions related to mood and psychotic disorders, with interventions including administering medications as ordered and monitoring for side effects and effectiveness. The DON and ADM acknowledged being notified of the altercation and stated they determined it was not reportable to the state because, in their view, Resident #2’s limited cognition meant he could not willfully act. This decision was made despite facility policies stating that suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source must be reported immediately to the administrator and other officials according to state law and HHSC reporting guidelines, and despite staff training on abuse and reporting requirements.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen inspection, multiple food items in both the refrigerator and freezer were found to be undated and unlabeled, including premade waffles, precooked and uncooked chicken, breaded squash, fruit cups, ground beef, and ham. Staff interviews confirmed that food should be dated and labeled upon delivery, when opened, or when removed from original containers, but this was not consistently done. The facility's own policy and federal food codes require all food items to be properly labeled and dated to ensure safety and prevent contamination. Staff members, including the dietary manager, cooks, dietitian, and administrator, acknowledged during interviews that the lack of dating and labeling could result in the use of expired or contaminated food, and that proper procedures were not followed. Record review of facility policy and federal regulations further supported the requirement for labeling and dating all food items. No specific residents were identified as being directly affected at the time of the deficiency.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified through surveyor observation and review of facility practices, which revealed that the required infection control measures were not established or maintained as mandated. The report specifically notes the absence of a comprehensive program designed to prevent and control infections within the facility. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Maintain Resident Privacy During Care
Penalty
Summary
A deficiency occurred when the Assistant Director of Nursing (ADON) failed to provide full privacy to a male resident during gastrostomy tube care. The resident, who had a history of tracheostomy, gastrostomy, cerebral ischemia, muscle wasting, and dysphagia, was observed receiving care with the privacy curtain not pulled and the door to the hallway left open. This allowed the resident to be visible from the hallway while visitors, staff, and other residents passed by. The resident was dependent on staff for gastrostomy tube care and had intact cognition, as indicated by a BIMS score of 14. Interviews with the ADON, a CNA, the Director of Nursing (DON), and the Administrator confirmed that all staff had been trained on the importance of maintaining resident privacy and dignity, and that the privacy curtain should have been used during care. The resident indicated feeling exposed and embarrassed when privacy was not maintained. Facility policy also required that each resident be cared for in a manner that promotes well-being and self-esteem, which was not followed in this instance.
Failure to Repair Broken Window Frame Compromises Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for a resident by not repairing a broken window frame in the resident's room. The window frame was detached from the wall, with exposed screws and nails protruding about half an inch, and this issue was not reported or addressed until it was observed during the survey. Staff members, including CNAs and the social worker, were either unaware of the problem or had not checked the window due to closed blinds or lack of observation. Maintenance records showed no prior request for repair, and the Maintenance Supervisor was not aware of the issue until the day of the survey. The resident affected had multiple medical conditions, including schizoaffective disorder, atherosclerotic heart disease, and polyosteoarthritis, and required substantial assistance with personal hygiene and bed mobility. The facility had procedures in place for staff to report maintenance issues, such as scanning QR codes or reporting during morning meetings, but these were not utilized in this instance. Daily environmental rounds were conducted by department heads, but the deficiency was not identified or communicated, resulting in the resident living in a room with an unrepaired, unsafe window frame.
Inappropriate Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for residents without documented medical necessity or without evidence of resident consent. Additionally, care provided to residents with feeding tubes was not appropriate, as required by regulations. The report identifies failures in ensuring that feeding tubes were only used when medically indicated and with resident agreement, as well as deficiencies in the ongoing care and management of residents with feeding tubes.
Failure to Maintain Smoking Area Safety and Enforce Smoking Policy
Penalty
Summary
The facility failed to enforce its smoking policy and maintain smoking safety in one of two designated smoking areas, specifically the secured unit smoking area. During an observation, a red fire can in the smoking area was found to contain a plastic liner, cigarette butts, and paper and plastic trash. Staff interviews revealed uncertainty about who was responsible for maintaining the fire cans, with a CNA stating that everyone was responsible but unsure who placed the liner or trash in the can. The Maintenance Director, who was new to the position, was also unaware of the proper procedures for the fire cans and acknowledged the potential fire hazard. The facility's Resident Smoking Policy required accessible metal containers with self-closing covers for ash disposal, but the observed fire can did not meet these requirements due to the presence of inappropriate materials. The Administrator confirmed that the Maintenance Director was responsible for maintaining the smoking areas, but all staff assisting residents with smoking should ensure proper use of the fire cans. The lack of clear responsibility and adherence to the smoking policy led to improper disposal of trash in the fire can, creating an unsafe smoking environment.
Failure to Ensure Safe Storage of Resident's Food
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of a resident's food items, specifically in the personal refrigerator of a resident with cerebral palsy, mild intellectual disabilities, and GERD. The resident's refrigerator contained a plastic bag of sliced cheese that was not in its original packaging and was dated beyond the facility's policy of disposing of food within five days. The resident, who required supervision or assistance with eating, mentioned that his best friend helped him with food from the refrigerator, but there was a discrepancy in their accounts regarding the preparation of a sandwich using the cheese. The facility's policy required housekeeping and/or nursing staff to clean the refrigerators weekly and discard any non-compliant foods. However, there was confusion among staff about who was responsible for checking the expiration of foods in personal refrigerators. Housekeeping staff believed they were only responsible for cleaning and checking temperatures, while the nursing staff were supposed to check for expired foods. The Director of Nursing and the Administrator were unaware of the expired food in the resident's refrigerator, indicating a lack of communication and adherence to the facility's policy, which could place residents at risk for foodborne illnesses.
Inadequate Care Leads to Wound Development in Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, leading to the development and worsening of two facility-acquired wounds. The resident, a male with a history of type 2 diabetes, end-stage renal disease, and chronic ulcers, was admitted without any pressure injuries. However, the facility did not conduct weekly skin assessments as required, with only two assessments documented over a period of time. This lack of regular monitoring contributed to the resident developing diabetic ulcers on his toes. Additionally, the facility did not provide a bed of appropriate size for the resident, who was 6 feet 8 inches tall. The resident's feet were pressing against the footboard, which was later removed, and a mattress extension was added. Despite these adjustments, the resident's feet were still not adequately supported, leading to discomfort and potential skin breakdown. The staff, including a CNA and an LVN, reported the bed size issue to the administration, but the problem persisted until corrective actions were taken. The facility's failure to adhere to professional standards of practice and the resident's comprehensive care plan resulted in harm to the resident. The lack of timely skin assessments and the inappropriate bed size were significant factors in the development of the resident's wounds. These deficiencies highlight the facility's inability to prevent the development and worsening of pressure injuries, placing residents with limited mobility at risk.
Inadequate Bed Size Leads to Resident Harm
Penalty
Summary
The facility failed to provide a resident with a bed of proper size and height, which was necessary for the resident's safety and comfort. The resident, who was 80 inches tall, had been admitted with diagnoses including end-stage renal disease and chronic diabetic ulcers on both feet. Upon admission, the resident informed the staff that the bed was too small and uncomfortable, as his feet pressed against the footboard. Despite this, the facility did not initially provide a suitable bed, leading to the resident's feet hanging over the edge of the mattress and resting on a mattress extension. Interviews with staff revealed that the resident's bed was indeed too small, and the footboard had been removed after the resident developed diabetic ulcers on his feet. The Licensed Vocational Nurse (LVN) reported the issue to the Administrator (ADM), Director of Nursing (DON), and Assistant Director of Nursing (ADON), but was told that the bed was the largest available. The DON acknowledged that a mattress extension had been ordered upon the resident's admission but was misplaced, necessitating a reorder. The ADM confirmed the bed's length was measured and deemed sufficient, but the resident's mobility caused him to slide down, exacerbating the issue. The facility's policy on bed safety required the interdisciplinary team to assess the resident's sleeping environment, considering factors such as safety, medical conditions, and comfort. However, the failure to provide a bed of appropriate size resulted in harm to the resident, as evidenced by the development of diabetic ulcers on January 9, 2025. The facility's actions and inactions in addressing the resident's needs led to this deficiency, as the resident's comfort and safety were compromised due to inadequate bed accommodations.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. This deficiency was identified for four days in June 2024, specifically on the 15th, 16th, 29th, and 30th. During this period, the facility did not have any RN coverage due to the departure of the Director of Nurses (DON) and the unavailability of corporate travel nurses. The facility relied on agency registered nursing staff to meet the required coverage, but on these occasions, the scheduled nurses called in prior to their shifts, and the staffing agency did not provide replacements. Interviews with the facility's Administrator and the corporate compliance officer confirmed the lack of RN coverage on the specified dates. The Administrator, who had been employed since August 2023, acknowledged the absence of RN staff during the reporting period and noted that the DON was the only RN on staff at that time. The corporate compliance officer corroborated that there was no RN employed by the facility on those dates, and corporate RNs were unavailable. The facility's policy, dated September 28, 2023, stated the requirement for RN services for at least eight consecutive hours daily, seven days a week, which was not met during the identified days.
Sanitation and Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. The dish machine's chemical sanitizer was not maintained at the appropriate levels according to the manufacturer's guidelines. The dish machine was consistently operating with a sanitizer concentration between 100-200 ppm, whereas the manufacturer's label required a minimum of 50 ppm. This discrepancy was noted throughout September 2024, and the kitchen staff, including the Dietary Manager (DM), were aware of the issue but did not take corrective action until the surveyor's visit. Additionally, the facility did not ensure proper storage of kitchen utensils. During an observation, a scoop was found inside a bin containing flour, contrary to the facility's policy that required scoops to be stored in a protected area. The DM acknowledged this oversight and stated that all kitchen staff were responsible for ensuring proper storage of utensils. Furthermore, the facility had baking sheets with brown and black baked-on buildup, indicating inadequate cleaning practices. Interviews with the DM and the Administrator revealed a lack of understanding regarding the correct sanitization levels for the dish machine. The DM admitted to being unsure of the potential risks to residents from high sanitizer levels, and the Administrator believed the sanitization levels were within acceptable limits. The facility's policies and the Food and Drug Code require accurate testing and maintenance of sanitizing solutions to prevent foodborne illnesses, but these were not adhered to, leading to the identified deficiencies.
Incomplete RN Staffing Data Submission to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS for the third quarter of fiscal year 2024. Specifically, the facility did not report RN hours for several dates in April, May, and June 2024. Although the monthly staffing schedules indicated that an RN was scheduled for most of these days, the time sheets provided proof of RN coverage for all dates except June 15, 16, 29, and 30. During this period, the facility lacked RN coverage due to the departure of the Director of Nurses and the absence of other RNs on staff. The corporate office was responsible for reporting the hours, but the hours of the DON, traveling corporate nurses, and agency nurses were not reflected in the payroll system, leading to incomplete reporting. Interviews with the facility's Administrator, corporate compliance officer, and corporate director of data analysis revealed that the oversight occurred because the hours were assessed through the payroll system, which did not capture hours for the DON, traveling nurses, or agency nurses. The Administrator admitted that the hours were not reviewed before submission to ensure accuracy. The corporate compliance officer confirmed that there was no RN employed by the facility on the dates without RN coverage, and the corporate RNs were unavailable. The corporate director of data analysis acknowledged that the omission of hours was an oversight and that a new system has since been implemented to ensure accurate reporting.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to inform a resident in advance of the risks and benefits of proposed care and treatment related to psychotropic medications. Specifically, the facility did not obtain signed consent for several psychotropic medications administered to the resident, including mirtazapine, risperidone, trazodone, Depakote, clonazepam, and Zyprexa. This oversight was identified during a review of the resident's records, which showed no consents for these medications. The resident, who was admitted to the facility with diagnoses including manic episodes, senile degeneration of the brain, alcohol abuse with alcohol-induced psychotic disorder, anxiety, and dementia, was receiving multiple psychotropic medications. The facility's records indicated that the resident was rarely or never understood, and during a specific period, she was administered antipsychotic, antianxiety, and antidepressant medications. Despite these treatments, there was no documentation of informed consent for the medications in the resident's electronic health record. Interviews with facility staff revealed that a previous Travel DON was responsible for ensuring consents were obtained, but this was not done for the resident in question. The current ADON and Travel DON acknowledged the lack of consents and stated that they had begun an audit to address this issue. The facility's policy required consent to be obtained before administering psychotropic medications, but this was not adhered to in this case, leading to the deficiency.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and equipment cleaning practices observed during care for two residents. Resident #14, a male with hemiplegia and moderately impaired cognition, was provided incontinent care by two CNAs. During the care, CNA B did not change gloves or perform hand hygiene before applying a clean brief and barrier cream, which could lead to cross-contamination and infection. Resident #25, also a male with hemiplegia and moderately impaired cognition, received ostomy care from an LVN. During the procedure, the LVN dropped scissors on the floor, rinsed them under cold water, and continued to use them without proper disinfection. This action violated infection control protocols and posed a risk of infection to the resident. Interviews with the staff involved revealed that both CNA B and LVN A were aware of the correct procedures but failed to follow them. The facility's infection preventionist and DON acknowledged the deficiencies and noted ongoing efforts to retrain staff due to recent management turnover. The facility's policies on hand hygiene and equipment cleaning were not adhered to during these incidents.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for four residents, leading to deficiencies in meeting their medical, nursing, mental, and psychosocial needs. Resident #15, an elderly male with severe cognitive impairment and dysphagia, was observed eating without the necessary physical assistance and verbal cueing, despite his care plan indicating the need for such support. This lack of assistance led to the resident eating quickly, taking large bites, and occasionally coughing, which could pose a risk of choking or aspiration. Resident #25, an elderly female with severe cognitive impairment, was not provided with the fortified foods required by her therapeutic diet during a lunch meal. This oversight occurred despite her care plan indicating the need for fortified foods due to significant weight loss. Similarly, Resident #24, who required supervision and one-person assistance with meals, was observed eating alone without any staff assistance or supervision. Additionally, Resident #24's care plan included weekly weight checks, which were not consistently performed, missing weights on two specified weeks. Resident #33, an elderly male with dementia and dysphagia, also had a care plan that required weekly weight checks due to significant weight loss. However, the facility failed to perform these weight checks on two specified weeks. These failures in implementing care plan interventions could place residents at risk of not receiving the necessary care to meet their identified needs, particularly in terms of nutrition and safety during meals.
Failure to Maintain Nutritional Status and Dietary Management
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for 15 of 34 residents reviewed for weight loss and nutrition. The deficiencies included a lack of communication with dietary staff on dietary changes, inadequate systems to monitor weight changes, and failure to weigh residents according to physician orders and dietary recommendations. Additionally, the facility did not provide assistance and supervision with meals as indicated by resident care plans, nor did it provide therapeutic meals as ordered by physicians and dietary recommendations. The facility also failed to obtain updated baseline weights after replacing the facility scale until state surveyor intervention. For instance, Resident #33, who had diagnoses including unspecified dementia and dysphagia, experienced significant weight fluctuations and was not weighed weekly as ordered. Observations revealed that Resident #33 received incorrect meal portions, contrary to his dietary requirements. Similarly, Resident #13, who had moderately impaired cognition, did not receive the large portions indicated on his tray card, and Resident #18, with moderate cognitive impairment, did not receive the large portions or fortified foods as ordered. Other residents, such as Resident #24, who had a cognitive communication deficit, were observed eating without the necessary supervision or assistance, leading to potential risks. Resident #25, with severe cognitive impairment, did not receive fortified foods as required, and Resident #34 was served the wrong meal tray, posing a risk of allergic reactions or choking. These failures in dietary management and monitoring placed all residents at risk of severe weight loss, delayed interventions, hospitalization, worsening health conditions, and death.
Failure to Notify Physician and Responsible Party of Choking Incident
Penalty
Summary
The facility failed to notify the resident's physician and responsible party when there was a significant change in the physical status of a resident who experienced a choking incident. The resident, who had a history of dysphagia and was at risk for aspiration, choked on every bite of food during breakfast. Despite this, there was no documentation that the resident's primary care provider or responsible party was notified of the incident. The resident's diet was downgraded to pureed with thickened liquids without proper notification to the physician or responsible party. During observations, the resident was seen eating alone and without assistance, despite requiring substantial help with eating. The resident was observed eating quickly, taking large bites, and occasionally coughing when swallowing. Interviews with staff revealed that the nurse who downgraded the resident's diet was an agency nurse unfamiliar with the resident's history. The MDS coordinator and other staff acknowledged that the physician should have been notified immediately, and the incident should have been documented. The facility's policy required prompt notification of the resident's physician and responsible party in the event of significant changes in the resident's condition. However, this policy was not followed, leading to a delay in appropriate medical intervention. The failure to notify the physician and responsible party of the resident's choking incident could have resulted in improper and untimely treatment for the resident.
Failure to Properly Store and Discard Expired Food
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen. During an observation in the dry storage area, several food items were found to be expired or improperly labeled, including white frosting, bread pudding, yellow cake mix, pasta, grits, thickened coffee packets, soy sauce, and flour. Additionally, the refrigerator contained expired items such as yogurt, prune juice, strawberry topping, and an employee's energy drink. The Dietary Manager (DM) confirmed that these items were not discarded by their expiration dates and acknowledged that consuming expired foods could put residents at risk of foodborne illnesses. The DM also mentioned that the responsibility for checking the fridge, freezer, and dry storage for expired foods was shared among the dietary staff, but due to being short-staffed, these checks were not performed as frequently as required. The Administrator, who had been working at the facility for about eight months, stated that it was the DM's responsibility to ensure all expired food was removed from the kitchen. The facility's policy on food storage, dated 2018, mandates that all food served must be of good quality and safe for consumption, with specific guidelines for labeling and dating opened and bulk items in both dry storage and refrigerators. The policy also requires that leftovers be used within 72 hours and discarded if older. The failure to adhere to these policies and procedures resulted in the presence of expired and improperly stored food items, posing a risk of foodborne illness to the residents.
Failure to Ensure Competent Nursing Care for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for the residents' needs, as identified through resident assessments and described in the care plan. This deficiency was observed in the case of a resident who experienced a choking incident. The MDS coordinator changed the resident's diet from mechanical soft to dysphagia pureed with thickened liquids without performing an assessment or notifying the physician, which could place the resident at risk of not receiving appropriate care and result in deterioration in condition. The resident, an elderly male with diagnoses including unspecified dementia, dysphagia, cognitive communication deficit, and gastro-esophageal reflux disease, had a history of eating too fast and requiring staff assistance during meals. Despite this, the resident was observed eating alone and without assistance on multiple occasions following the diet change. The resident was seen eating quickly, taking large bites of pureed food, and occasionally coughing when swallowing, indicating that the necessary supervision and assistance were not provided. Interviews with facility staff revealed that the nurse who downgraded the resident's diet was an agency nurse unfamiliar with the resident's needs. The MDS coordinator and other staff members acknowledged that the physician should have been notified and that the nurse's progress note exaggerated the choking incident. The speech therapist, who was supposed to evaluate the resident, had not done so due to scheduling conflicts. The facility's policies on changes in a resident's condition and dysphagia management were not followed, leading to a lack of appropriate care for the resident.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. Specifically, the facility did not have RN coverage for one day in December 2023. This deficiency was identified through a review of the CMS Payroll Based Journal (PBJ) report for the fourth quarter of 2023, which indicated missing RN hours on several dates in October, November, and December 2023. The monthly staffing schedules and time sheets confirmed that RN coverage was missing on 12/17/2023. Interviews with the Administrator, Assistant Director of Nursing (ADON), and Director of Nursing (DON) revealed that the ADON was new to her role in December 2023 and was still learning her responsibilities, which contributed to the oversight in scheduling RN coverage for that day. The DON and ADON stated that they typically provide RN coverage themselves if no other RN is available, but this did not occur on 12/17/2023. The facility's policy, dated 9/28/23, mandates the utilization of a registered nurse for at least eight consecutive hours a day, seven days a week. Despite this policy, the facility failed to adhere to it on multiple occasions, with the most notable lapse occurring on 12/17/2023. The Administrator, who had been employed since August 2023, expected RN coverage to be maintained as per the policy. However, the ADON's inexperience and the lack of a scheduled RN on 12/17/2023 led to a failure in providing the required RN coverage, potentially placing residents at risk due to the absence of supervisory RN-specific nursing activities and coordination of emergency care and disasters.
Failure to Properly Label Insulin Vial
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with currently accepted professional principles, specifically regarding the labeling of an insulin vial for a resident. During a medication cart observation, a vial of Levemir insulin was found opened and not labeled with an open date. The nurse responsible for the cart was unaware of when the insulin had been opened and admitted that it must have been missed during daily checks. The Assistant Director of Nursing (ADON) confirmed that the insulin should have been dated by the nurse who opened it and acknowledged the potential risks of administering expired insulin, including reduced effectiveness in controlling blood sugar levels. The resident involved was an elderly individual with multiple diagnoses, including dementia, schizoaffective disorder, bipolar type, type 2 diabetes, and GERD. The resident had a moderately impaired cognition with a BIMS score of 12 and had been receiving insulin injections daily. The facility's policies on medication storage and administration were reviewed, and it was found that the insulin should have been dated upon first use. Interviews with the Regional Nurse and the Administrator further confirmed that the responsibility for dating the insulin lay with the nurse who opened it, and that the failure to do so could result in the medication not being as effective.
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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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