Avir At Veterans Memorial
Inspection history, citations, penalties and survey trends for this long-term care facility in Houston, Texas.
- Location
- 1424 Fallbrook Drive, Houston, Texas 77038
- CMS Provider Number
- 676252
- Inspections on file
- 34
- Latest survey
- April 18, 2026
- Citations (last 12 mo.)
- 20 (3 serious)
Citation history
Health deficiencies cited at Avir At Veterans Memorial during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple mobility-related diagnoses was observed with a painful, bruised, and misaligned lower extremity. Nursing staff called the provider for a STAT x-ray instead of immediately transferring the resident by EMS, and the x-ray later showed displaced tibia and fibula fractures. The resident was not sent to the ER until several hours later, after ongoing pain and abnormal findings were documented.
A resident with severe dementia and a left tibia/fibula fracture had pain signs documented throughout the day, including grimacing, clenched fists, pulling away, and saying “ouch” during turning and incontinent care. Staff noted the leg was discolored, warm, painful, and out of alignment, but the resident remained in the facility for hours before x-ray confirmed displaced fractures and she was later transferred to the hospital. The provider stated the delay was too long for a displaced fracture and that the resident would have been in a high level of pain.
Failure to Maintain Resident Dignity and Respect: A resident with depression and moderate cognitive impairment was unable to watch the TV channels she preferred because staff did not promptly address the programming issue after repeated requests. Another resident with vascular dementia and severe cognitive impairment had a training mannequin stored in the unoccupied bed of his room for about two weeks, and he reported that staff laughed when he asked for it to be removed.
Incomplete Care Plans for ADLs and UTI/Isolation Needs: The facility failed to develop comprehensive person-centered care plans for three residents. One resident with cognitive impairment and extensive ADL assistance needs had no care plan focus, goals, or interventions for bathing, dressing, toileting, transfers, hygiene, or bed mobility. Two other residents had UTI-related diagnoses and were on contact isolation, but their care plans did not address the UTI, isolation status, or antibiotics, despite MDS triggers, physician orders, and resident interviews confirming the conditions.
A resident with dehydration, AKI, and hypokalemia had an IV left in the L hand after IV fluids were held, but the site was not flushed as expected and remained in place despite the MD’s verbal direction to remove it. The resident reported tenderness, and surveyors observed redness, dried blood, and discoloration under the dressing. Staff interviews confirmed the IV should have been checked daily, flushed when not running, and removed when no longer needed, but this did not occur.
Expired medications were found in multiple medication carts and in the medication storage room refrigerator, including glucose strips, calamine lotion, sodium chloride tablets, bisacodyl suppositories, saline nasal spray, eye drops, and insulin lispro. Staff said cart checks were expected each shift, but this did not always happen, and one med aide reported checking her cart only monthly. The DON stated opened eye drops, nose sprays, and insulin were only good for 30 days after opening, and the facility policy required outdated medications to be removed from storage.
A resident admitted with multiple diagnoses, including dementia, CKD, afib, and a right lower leg fracture, had no code status documented on the face sheet, baseline care plan, or physician orders during the chart review period. Although the care plan noted a full code preference, staff interviews showed inconsistent methods for locating code status, the code cart lacked a code book, and the DON stated the admission nurse likely forgot to enter the order, which could delay care if the resident became unresponsive.
Failure to maintain a clean resident room environment: A resident with COPD, Crohn's disease, hemorrhoids, constipation, bowel and bladder incontinence, and moderate cognitive impairment had BM smears in his room, including a thick brown smudge on the wall, stained linens, a strong BM odor, and flies observed in the room. Staff interviews indicated he needed follow-up toileting assistance and that he sometimes smeared BM around his side of the room, while the wall smudge remained in place for several days.
Failure to complete a new PASRR review after a resident developed additional psychiatric diagnoses. A resident with severe cognitive impairment, total ADL dependence, and ongoing psych services had a prior PASRR Level 1 that was negative for MI, ID, DD, or dementia as the primary diagnosis. The record later showed recurrent MDD, GAD, mood disorder with mixed features, and adjustment disorder, with orders for antidepressants, anxiolytic medication, Depakote, and behavior/side effect monitoring. The MDS Coordinator said she did not submit a new PE because she believed the resident would not qualify.
A resident with moderately impaired cognition, incontinence, and ADL dependence did not receive scheduled bathing assistance as ordered. She was supposed to be showered three times weekly, but the last documented bath was over a week earlier, and she told staff she had gone nearly two weeks without a shower. A CNA said showers were documented in the POC and that staffing assignments sometimes prevented her from completing them, while the DON said residents were expected to receive their scheduled showers and whenever needed.
Delayed STAT Chest X-Ray: An LPN notified the on-call NP after a resident with COPD and oxygen use reported chest pain, and a STAT CXR was ordered. The resident was told the x-ray would be done that night, but it was not completed until the next day. Staff gave inconsistent accounts of the expected STAT timeframe, and the physician/NP was not notified when the test was not completed during the overnight shift.
Improper Food Storage and Kitchen Door Left Open: The kitchen refrigerator contained an open bag of shredded lettuce that was brown with liquid at the bottom and an unopened bag of mozzarella cheese, both lacking a clear use-by/discard date. Dietary Staff A also propped open the kitchen door while taking out trash, allowing two flies into the kitchen despite a posted sign to keep the door closed. The FSD, DON, and Administrator stated that food should be labeled and discarded by the use-by date and that the kitchen door should remain closed to keep pests out.
Two residents with significant cognitive impairment and high assistance needs had nonfunctioning call lights in their rooms. One resident reported pressing the call light for repositioning without receiving help, and testing confirmed that the bedside and hallway indicators did not activate in either room. Staff, including an LPN, CNA, EVS Director, DON, and Administrator, acknowledged that residents should have functioning call lights, while records showed no outstanding repair requests and only selected rooms were included in routine call system testing.
A resident with severe cognitive impairment and total dependence for transfers was injured when a CNA attempted a mechanical lift transfer alone, without the required second staff member. The sling failed during the process, causing the resident to fall and sustain head lacerations that required medical treatment. The CNA did not follow facility policy mandating two-person assistance and proper equipment inspection prior to transfer.
A resident with a PICC line for IV antibiotics did not have the dressing changed as required after returning from the hospital. Nursing staff failed to obtain or follow orders for weekly dressing changes, and the outdated dressing remained in place until the resident was readmitted to the hospital with a fever. Staff interviews confirmed that the facility's protocol for PICC line care was not followed.
Several residents with complex medical and psychological needs reported being treated disrespectfully and without dignity by a CNA, including feeling threatened, spoken to in a rude or abrupt manner, and being treated like a child. Staff interviews and resident feedback confirmed that the CNA's approach and communication did not honor residents' rights or emotional well-being, leading to a deficiency in upholding resident dignity.
A resident with multiple comorbidities and an indwelling urinary catheter did not have a comprehensive care plan that addressed catheter care, despite physician orders and baseline documentation indicating its presence and required interventions. The omission was confirmed by interviews with the DON and MDS Nurse, who acknowledged that the catheter care was not included in the comprehensive care plan, potentially leaving staff uninformed about necessary care procedures.
The facility failed to store, label, and date foods properly, and did not maintain correct food temperatures on the service line. Unsealed and unlabeled food items were found in storage, and a thermometer used to check food temperature was not calibrated correctly. The Dietary Manager and Aide were unaware of the calibration issue, and the facility did not provide the requested policy and training records.
A medication cart in the facility was found with loose, unlabeled pills and an expired bottle of Thick It thickened water, contrary to professional principles. LVN M, responsible for the cart, acknowledged the oversight, while the DON emphasized the expectation for regular cleaning and organization of medication carts. The facility's policy requires proper labeling and disposal of outdated drugs, which was not followed, risking incorrect medication administration.
A facility failed to maintain accurate medical records for a resident who was hospitalized, with LVNs documenting medication administration and monitoring while the resident was not present. The resident had severe cognitive impairment and multiple medical conditions. The MAR inaccurately showed medications and monitoring as completed during shifts when the resident was at the hospital, violating the facility's documentation policies.
Delayed EMS Transfer for Suspected Fracture
Penalty
Summary
The facility failed to transfer a resident to the hospital by emergency services after she was observed with pain, bruising, and an extremity that was out of normal alignment. The resident had severe cognitive impairment, was dependent for all ADLs, and had diagnoses including dementia, lack of coordination, unsteadiness on feet, muscle weakness, osteoarthritis, malnutrition, and sarcopenia. Her care plan included prior falls and a left tibia fracture requiring splinting. On the day of the event, a nurse documented that the resident’s left lower extremity was discolored, warm to touch, painful when touched, and out of normal alignment. The nurse called the provider, who ordered a STAT x-ray. The x-ray later showed displaced fractures of the mid tibia and fibula. Later nursing notes documented continued pain, discoloration, warmth, a temperature of 100.4 degrees Fahrenheit, and a heart rate of 109. After the x-ray results were reported to the provider, the resident was ordered to be sent to the ER, and 911 was eventually called. The resident was transferred to the hospital several hours after the abnormal limb findings were first observed. Hospital records documented bruising, edema, and a tibio-fibular fracture, and the resident was treated with splinting and fentanyl before admission. Interviews with nursing staff, the NP, ADON, and DON reflected that visible trauma, suspected fracture, or a limb that was not symmetrical would warrant immediate transfer to the hospital by EMS, and that the delay in transfer resulted in delayed treatment.
Pain Not Managed for Resident With Displaced Leg Fracture
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with severe cognitive impairment who had a left tibia and fibula fracture. The resident’s record showed a BIMS score of 3 out of 15, dependence for all ADLs, and chronic diagnoses including dementia, weakness, osteoarthritis, malnutrition, and sarcopenia. Her care plan included pain medication therapy and specific interventions for the left tibia fracture, including monitoring and documenting pain and repositioning as necessary. On 3/29/26, staff identified bruising, swelling, discoloration, warmth, and an extremity that appeared out of normal alignment/misaligned. A CNA reported that when the resident was repositioned around 11:00 a.m., she said “ouch” each time she was turned or provided incontinent care, and the CNA continued to report pain with movement throughout the day. An SBAR at 12:30 p.m. documented grimacing, clenched fists, knees pulled up, pulling or pushing away, striking out, and that the resident was repositioned every 2 hours. A nurse note documented the left lower extremity as discolored, warm to touch, painful, and out of normal alignment, with a timeline showing calls to the provider, notification of the DON and house supervisor, and a delay before x-ray was completed. The x-ray completed that afternoon showed displaced fractures of the mid tibia and fibula. Later that evening, the resident remained painful to touch, hot, and discolored, with a temperature of 100.4 and heart rate of 109. She received scheduled tramadol earlier in the day and PRN Tylenol at 7:37 p.m., and was transferred to the hospital at 8:55 p.m. The provider later stated that the resident would have been experiencing a high level of pain and that 9 hours was too long to wait with a displaced fracture, and facility leadership stated that visible trauma and an injury that could not be managed in house warranted 911 transfer.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that Resident #4 was treated with respect and dignity when her television was not programmed to view all of the channels she wanted to watch. Resident #4 was a woman with diagnoses including generalized anxiety disorder, mood disorder with depressive features, and moderate major depressive disorder. Her care plan identified that she enjoyed watching TV and that she was at risk for poor mood stability, increased depression, and poor quality of life. During observation and interview, she stated that storms caused her TV channels to stop working and that she had asked staff multiple times to fix the problem. She reported that she could not get channels 2, 13, 11, and the game channel, and that staff told her it might take a while because there were visitors in the building. She also stated that staff could do everything for everybody else but not tend to her TV. Further observation showed that Resident #4’s TV was skipping channels and displaying a black and white pixelated screen when those channels were selected directly. A CNA stated that Resident #4 had mentioned the problem but that she did not tell maintenance or the nurse because she was busy. The EVS Director later stated that the channels had probably been knocked off that day and needed to be rescanned, and he was observed resetting the TV. The record also showed that Resident #4 had a BIMS score of 12, indicating moderate cognitive impairment. The facility also failed to ensure that Resident #43 was treated with dignity when a training mannequin was stored in the unoccupied bed of his room. Resident #43 was a male with vascular dementia and severe cognitive impairment, with a BIMS score of 07. His care plan directed staff to use simple communication, consistent routines, and cues to support his needs. On observation, the mannequin was found in the unoccupied bed of the room occupied by Resident #43. Staff members stated that training supplies should not be stored in a resident-occupied room and that the mannequin was usually kept in the DON’s office or an empty room. Resident #43 stated that the mannequin had been in his room for two weeks, that he had asked multiple times for it to be removed, and that staff laughed at him when he asked. He said it felt like a cruel joke and that the facility was his home and he should be treated with dignity and respect.
Incomplete Care Plans for ADLs and UTI/Isolation Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for three residents to address their identified needs. Resident #3, a female admitted with left vertebral artery occlusion and stenosis, had a Quarterly MDS showing moderate cognitive impairment and dependence or assistance needs for bathing, bed mobility, dressing, personal hygiene, toilet use, and transfers, but her undated care plan did not include a focus, goal, or interventions for ADLs. During interview, she stated she could stand with little assistance and usually had one aide present when she needed help with transfers, repositioning, toileting, and hygiene. Resident #9, a cognitively intact female admitted with a wedge compression fracture of the second lumbar vertebra, had a Quarterly MDS that triggered for UTI as an active diagnosis. Her care plan dated 04/01/2026 did not address UTI or contact isolation. During interview, she stated she was on contact isolation for a UTI, had started antibiotics on 4/14/26, and expected to complete them on 4/17/26. She also reported having issues with UTI prior to admission. Resident #12, a female admitted with metabolic encephalopathy, hypertension, cirrhosis, heart failure, chronic kidney disease, acute cystitis with hematuria, and asthma, had an admission MDS showing moderately impaired cognition and that she was always incontinent of bowel and bladder. Her care plan dated 1/13/26 did not mention her UTI, contact isolation, or antibiotics. Physician orders dated 4/1/26 included contact isolation for VRE/UTI and recollection of UA C&S 48 hours after antibiotics were completed. Progress notes documented completion of Macrobid for VRE UTI and a pending follow-up urine culture, while interviews and observations showed she remained on contact isolation.
Failure to Manage an IV Site Consistent With Orders and Standards
Penalty
Summary
Safe, appropriate administration of IV fluids was not provided for one resident with COPD, anxiety, morbid obesity, PTSD, mood disorder, depression, impaired mobility, incontinence, and altered respiratory status related to sleep apnea. The resident had an IV in the left hand for hydration and electrolyte management after being treated for acute kidney injury, dehydration, and hypokalemia. Physician orders and NMAR documentation showed IV normal saline flushes were ordered, then later held and discontinued while oral fluid intake was encouraged, but the IV remained in place after the order was no longer active. During observation, the resident reported the IV had been changed but had not been flushed since that time and stated the site was tender. The IV was observed in the left hand under a transparent dressing with visible dried blood beneath the dressing, redness at the insertion site, and yellow discoloration of the surrounding skin. The resident also stated the IV had not been changed or flushed since the prior week. Later observation showed gauze and paper tape where the IV had been removed. Staff interviews showed the IV was expected to be checked daily, flushed when not running, and removed when no longer needed, but this did not occur. An LVN stated IVs should be assessed for date, redness, swelling, and infiltration, and that flushing should occur daily. The MD stated she had verbally told RN G to remove the IV, but this was not documented in the progress note, and she did not know the IV had not been flushed since 4/10/26. RN G stated she forgot to remove the IV despite being told to do so and believed she had flushed it, but she did not document it and could not recall updating the NMAR.
Expired Medications Stored in Medication Carts and Refrigerator
Penalty
Summary
The facility failed to ensure expired medications were not stored with current medications in the 100 hall nurse medication cart, the 200 hall nurse medication cart, the 200 hall med aide medication cart, and the medication storage room. During observation, surveyors found expired Glucose Control Strips, Calamine Lotion, Sodium Chloride Tablets, and Bisacodyl Suppositories in the 100 hall nurse cart; an expired Saline Nasal Spray in the 200 hall nurse cart; and 10 bottles of expired eye drops on the 200 hall med aide cart. In interview, the LVNs and med aide stated they were expected to check carts for expired medications, but this did not always happen, and the med aide reported checking her cart only once a month. Surveyors also found an expired bottle of Insulin Lispro 100u/ml in the medication storage room refrigerator. The insulin had been opened on 2/8/26 and expired on 3/8/26. The DON stated staff were expected to check carts at the beginning of each shift and the medication storage room daily, and that opened eye drops, nose sprays, and insulin were only good for 30 days after opening because bacteria could get inside and they could be less effective. The facility policy stated nursing staff were responsible for maintaining medication storage areas and that outdated medications should be handled through the dispensing pharmacy, and opened multi-dose vials were to be dated and discarded within 28 days unless otherwise specified.
Missing Code Status Documentation
Penalty
Summary
The facility failed to ensure that Resident #80 had a code status on file from admission through the date the record was reviewed. Resident #80 was an [AGE]-year-old female admitted with diagnoses including injury of the right lower leg, orthostatic hypotension, pain in the right ankle and joints of the right foot, dementia, anemia, chronic kidney disease, atrial fibrillation, rheumatoid arthritis, acute kidney failure, and fracture of the right lower leg. Her face sheet and baseline care plan both had the code status left blank, and the admission MDS showed a BIMS score of 14 out of 15, indicating normal cognition. Record review showed a care plan entry stating that Resident #80 desired full code status, but the physician orders reviewed did not contain any advance directive or code status order anywhere in the chart. During observation, the code cart did not have a code book. Staff interviews showed that CNA M said code status was only listed in the EMR, Med Aide F said she would check orders or the physical chart and would perform CPR if no code status could be found, and LVN D said he would check orders or the face sheet and would perform CPR until further notice if no code status was located. The DON stated that code status was only in the orders and that if no code status was available, staff would perform CPR until it could be determined. The DON also said the admission nurse probably forgot to enter the code status and that it could cause a delay in care. The MDS Coordinator said she looked in the EMR, medical records, and physical chart for code status information and stated she was not the one who entered Resident #80's code status on the care plan. The facility policy required the admitting nurse to obtain code status orders and the Social Service Director or designee to verify advance directives and code status within 72 hours of admission.
Failure to Maintain Clean Resident Room Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #85 by leaving a mud brown smudge with a solid consistency on the wall inside his room for 3 days. Resident #85 was an [AGE] year-old man admitted with diagnoses including diverticulosis of the large intestine, COPD, Crohn's disease of the large intestine, hemorrhage of the anus and rectum, hemorrhoids, and slow transit constipation. His record also showed a BIMS score of 9, indicating moderate cognitive impairment, and his care plan identified that he required assistance with ADLs and was incontinent of bowel and bladder. The care plan was updated to note that Resident #85 had a behavior problem of smearing BM everywhere on his side of the room and would try to clean it up at times but would still smear it everywhere. During observation, he was standing near the wall in his room, wearing a t-shirt and an adult brief that appeared full, and the room had a strong BM odor. On the wall where he had been standing was an approximately 8-inch-long mud brown smudge that appeared thick and raised on one side, with no drip lines. Brown stains that appeared to be BM were also observed on his bed linens, and two flies were seen buzzing around the room. In interviews, Resident #85 stated that staff assisted him as needed and that housekeeping cleaned his room daily, while also stating that the stains on his sheets had been given to him and the machine could not get everything out. CNA G stated he needed follow-up assistance after toileting to ensure cleanliness, and CNA R stated he sometimes had loose stool that leaked onto his sheets and that she had not yet gotten to his room to repeat care. The mud brown smudge remained on the wall during a later observation, and the EVS Director stated housekeeping was supposed to clean walls and all areas in resident rooms and that harm in keeping the smudge on the wall could be sickness. The DON stated the harm in leaving substances like the smudge on the wall would be the potential for infections.
Failure to Complete New PASRR Review After Change in Psychiatric Status
Penalty
Summary
The facility failed to refer a resident with newly evident or possible serious mental disorder for a PASRR Level II resident review after a significant change in status assessment. Resident #44 was admitted with diagnoses including mood affective disorder, recurrent major depressive disorder, adjustment disorder with disturbance of conduct, generalized anxiety disorder, and mood disorder due to a known physiological condition with manic features. The resident’s quarterly MDS showed severely impaired cognition with a BIMS score of 4, dependence for all ADLs, wheelchair use, and bowel and bladder incontinence. The resident’s record also showed ongoing psychiatric involvement and treatment. The care plan documented psychology/psychiatry services, anti-anxiety medication use for anxiety disorder, and antidepressant medication use for depression. A PASRR Level 1 screening completed on admission indicated no evidence of mental illness, intellectual disability, developmental disability, or dementia as the primary diagnosis. Later records documented psychiatric diagnoses and treatment that included recurrent major depressive disorder, generalized anxiety disorder, mood disorder due to known physiological condition with mixed features, and adjustment disorder with mixed disturbance of conduct. Physician orders included Depakote, sertraline, bupropion, trazodone, and lorazepam, along with behavior and side effect monitoring. During interview, the MDS Coordinator stated she remembered the resident was negative for the PE when first admitted, then developed other medical conditions, and she did not submit a new PE because she knew he was not going to qualify since he had not been in any psychiatric facilities.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure Resident #12 received scheduled bathing assistance to maintain grooming and personal hygiene. Resident #12 was an older female admitted with diagnoses including metabolic encephalopathy, hypertension, cirrhosis, heart failure, chronic kidney disease, acute cystitis with hematuria, and asthma. Her MDS showed a BIMS score of 9 out of 15, indicating moderately impaired cognition, and she required substantial/max assistance with showers and baths. She was also always incontinent of bowel and bladder, had shortness of breath when lying flat, took diuretics, and used oxygen. Her care plan identified an ADL self-care performance deficit related to weakness and a risk for skin breakdown due to incontinence, with interventions to keep skin clean and dry. Record review showed Resident #12 was scheduled for showers/baths three times weekly on Tuesday, Thursday, and Saturday, but her last documented shower/bath was on 4/9/26. On 4/14/26, she was observed in contact isolation with brown, dirty-looking nails and stated she had not had a bath/shower since moving to the 400 hall and that it had been almost two weeks since her last one. On 4/16/26, she again stated she had not received a shower/bath yet. A CNA said showers were documented in the POC and that if she could not provide a shower because she was pulled to the floor, the CNAs for that hall were responsible for giving their own showers/baths. The DON stated residents were expected to get their scheduled showers/baths and whenever needed, and that there was enough help for every resident to get theirs.
Delayed STAT Chest X-Ray
Penalty
Summary
The facility failed to ensure radiology services were obtained and reported in a timely manner for one resident with COPD who used oxygen and had moderately impaired cognition. The resident developed increasing aching chest pain upon exhalation and was assessed by an LVN, who documented vital signs within normal limits, oxygen saturation of 97% on 2 liters nasal cannula, and pain rated 6 out of 10. Nitroglycerin and PRN pain medication were given, the on-call nurse practitioner was notified, and a STAT chest x-ray was ordered. The resident was told the chest x-ray would be completed the same night, but it was not performed during that shift. The next morning, the resident asked for an update because the x-ray had not yet been done. The resident stated she had chest pain the prior day, that the night nurse had called the NP and said the x-ray would be completed that night, and that she had not received it. The resident was not in pain at the time of the later interview and declined transfer to the hospital when offered. Staff interviews showed inconsistent understanding of the expected timeframe for STAT testing, with responses ranging from 2-4 hours, 3-5 hours, and 4-6 hours. The LVN who received the order stated the lab company had not arrived by the end of the shift and said the information was passed to the next shift because the technician was still within the stated window. Other staff stated that if the x-ray could not be completed within the expected window, the physician or NP should have been notified, but that did not occur during the night shift. The chest x-ray was ultimately completed the next day and showed no abnormal results.
Improper Food Storage and Kitchen Door Left Open
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen. During observation on 04/14/2026, the refrigerator contained an open bag of shredded lettuce that was brown with brown liquid at the bottom of the bag, with a handwritten date of 03/29/2026 and no use-by or discard date written on the package. The refrigerator also contained an unopened bag of mozzarella cheese with a manufacture package date of 02/25/2026 and a handwritten date of 03/26/2026, but no use-by or discard date written on the package. The Food Service Director stated that food items in the refrigerator should be labeled with a delivery date if a manufacture date does not exist, an open date, and a use-by date, and said the lettuce and mozzarella cheese should have been thrown out. On 04/15/2026, Dietary Staff A used a cardboard box to prop open the kitchen door while taking trash out, and two flies entered the kitchen. The staff member then used a towel to swat the flies and closed the door. The kitchen door had a sign posted to keep it closed. In interviews, Dietary Staff A, the Food Service Director, and the Administrator stated that the kitchen door should be closed immediately when entering and exiting to keep pests out and prevent cross contamination and food borne illness. The record review of the policy titled Food Receiving and Storage stated that foods shall be received and stored in a manner that complies with safe food handling practices, and that refrigerated foods are to be labeled, dated, monitored, and used by their use-by date, frozen, or discarded.
Nonfunctioning Resident Call Lights
Penalty
Summary
The facility failed to ensure that resident rooms were equipped with a functioning call system for 2 of 8 residents reviewed, Resident #69 and Resident #109. Both residents had significant cognitive impairment and required substantial assistance or dependence for transfers and other care needs. Resident #69 had diagnoses including Alzheimer's Disease, a BIMS score of 0 out of 15, and a care plan that directed staff to keep the call light within reach and assist with all transfers. Resident #109 had hypertensive chronic kidney disease, a BIMS score of 7 out of 15, and a care plan that directed staff to keep the call light within reach and respond promptly to requests for assistance. During observation and interview, Resident #109 stated she had pressed the call light to request repositioning in bed, but no staff had come. When the call light was tested in her room, the indicator light did not flash at the bedside and did not illuminate in the hallway. LVN H confirmed the call light was not functioning and stated residents had a right to a functioning call light at all times. The EVS Director was notified and also observed that the call light did not function in the room. Resident #69's call light was also tested and did not activate the bedside or hallway indicator lights. CNA P confirmed the malfunction and stated residents had a right to a functioning call light at all times. The EVS Director, DON, and Administrator all stated that residents should have functioning call lights and that staff should report malfunctions to EVS. Record review showed no outstanding repair requests for either room, and the facility's nurse call system testing reports showed that only selected rooms were checked on the listed dates rather than all resident rooms. The facility policy stated that each resident is provided a means to call staff from the bed, toileting/bathing facilities, and the floor, and that the resident call system remains functional at all times.
Failure to Ensure Two-Person Mechanical Lift Transfer and Equipment Safety
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) attempted to transfer a resident with severe cognitive impairment, limited mobility, and total dependence for transfers, using a mechanical lift without the required assistance of a second staff member. The resident, who had diagnoses including epilepsy, contracture, and dementia with agitation, was being prepared for transfer from bed to wheelchair. The CNA positioned the resident in the sling and began lifting her before the second CNA arrived, contrary to facility policy requiring two staff for mechanical lift transfers. During the transfer, the mechanical lift sling failed, with the hooks on one side coming undone. This caused the resident to fall from the bed to the floor, resulting in lacerations to her head that required stitches and staples. The incident was witnessed after the fact by the second CNA, who arrived to find the resident on the floor. The resident was assessed by nursing staff, and emergency medical services were called for further evaluation and treatment at the hospital. The resident returned to the facility the same day and was monitored post-fall. Interviews and record reviews confirmed that the CNA was aware of the two-person requirement for mechanical lift transfers but proceeded alone. The facility's policies clearly stated that at least two nursing assistants are needed for safe mechanical lift use, and that slings and equipment must be inspected for defects prior to use. The sling used in the incident was found to be defective, and the CNA did not wait for assistance before initiating the transfer, directly leading to the resident's fall and injury.
Failure to Follow PICC Line Dressing Change Protocols for IV Therapy
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of IV fluids for a resident by not following professional standards of practice and physician orders regarding the care and maintenance of a PICC line. After returning from the hospital with a PICC line in place for IV antibiotic therapy, the resident did not have the PICC line dressing changed as required by facility protocol and standard practice. The dressing, dated from the time of hospital discharge, remained unchanged for an extended period, as confirmed by both observation and photographic evidence provided by the resident's family member. Record reviews revealed that there was no order for changing the PICC line dressing upon the resident's readmission, and nursing staff failed to initiate or follow up on obtaining such an order. Multiple nurses interviewed acknowledged that dressing changes were scheduled weekly, typically on Sundays, but none noticed or addressed the lack of a current order or the outdated dressing. The responsibility for obtaining the order was not fulfilled by the admitting nurse, and subsequent staff did not identify or correct the oversight. The resident, who had a history of recurrent infections and sepsis, was eventually sent back to the hospital with a fever, where it was discovered that the PICC line dressing had not been changed since the initial hospital discharge. Interviews with staff and the DON confirmed that the dressing was not changed during the resident's stay, and the facility's protocol for weekly dressing changes and daily site assessments was not followed. The failure to adhere to these protocols was acknowledged by the DON and staff during interviews.
Failure to Ensure Respectful and Dignified Treatment of Residents
Penalty
Summary
The facility failed to ensure that multiple residents were treated with respect and dignity, resulting in a deficient practice that affected at least four residents. Certified Nursing Assistant (CNA) G was identified as the staff member whose interactions with residents led to feelings of being threatened, treated like a child, having their feelings hurt, and not being treated as a human. Specific incidents included CNA G making a comment to a resident about taking him outside and 'whooping his butt' when he refused to get out of bed, which the resident reported made him feel uncomfortable and as though he was being threatened, even if not physically. Other residents described CNA G as abrupt, rude, and rough in her approach, with one resident stating that CNA G treated her like a child and another stating that CNA G's tone was boisterous and explosive, making her feel bad. The residents involved had various medical and psychological conditions, including hemiplegia, diabetes, chronic kidney disease, Parkinson's disease, bipolar disorder, dementia, chronic obstructive pulmonary disease, morbid obesity, and epilepsy. Several residents had documented histories of depression and moderate cognitive impairment, as indicated by their Brief Interview for Mental Status (BIMS) scores. These conditions made them particularly vulnerable to the negative effects of disrespectful or undignified treatment. Residents reported that CNA G's manner of communication and approach to care did not honor their preferences or emotional well-being, with some residents stating they did not feel safe or respected and that their feelings were hurt by her actions. Interviews with other staff members, including CNAs, LVNs, the DON, and the Administrator, confirmed that residents have the right to be treated with dignity, to refuse care, to ask questions, and to be treated as adults. Staff were trained in resident rights and recognized that failing to respect these rights could negatively affect residents emotionally. The facility's own policy required employees to treat all residents with kindness, respect, and dignity, and to honor their rights to a dignified existence. Despite this, the actions and approach of CNA G, as reported by multiple residents and corroborated by life satisfaction rounds, did not meet these standards, resulting in a deficiency related to resident rights and dignity.
Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with an indwelling urinary catheter. Despite the resident having a catheter from late January to early April, the comprehensive care plan did not include a care area addressing the catheter, its management, or related interventions. The baseline care plan and physician orders documented the presence and care requirements for the catheter, but this information was not carried over to the comprehensive care plan, leaving a gap in the documentation and communication of care needs. The resident in question had significant medical complexities, including chronic kidney disease stage 4, type 2 diabetes mellitus, hypertensive heart disease with heart failure, and a cognitive communication deficit. The resident was dependent on staff for toileting and had a history of urinary tract infection and renal insufficiency. Although the care plan addressed risks related to renal failure, skin breakdown, and urinary incontinence, it did not specifically address the indwelling catheter, its care, or monitoring for complications such as infection or obstruction. Interviews with facility staff, including the DON and MDS Nurse, confirmed that the catheter was not included in the comprehensive care plan. The MDS Nurse acknowledged that the catheter was documented in the baseline care plan and MDS but was not transferred to the comprehensive care plan. Both the DON and MDS Nurse recognized that the omission could result in staff not being informed about the catheter care requirements, which could lead to negative outcomes such as infection. The facility's policy required that care plans include measurable objectives and timeframes for all identified needs, but this was not followed in this case.
Deficiencies in Food Storage and Temperature Control
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, the facility did not ensure that foods were properly sealed, labeled, or dated while in storage. During an inspection, it was noted that the dry storage container was left open, with unsealed bags of blueberry muffin mix and cereal. Additionally, the walk-in cooler contained an open bag of cheese and three trays of drinks that were not labeled or dated. These oversights in food storage practices could potentially compromise the freshness and safety of the food served to residents. Furthermore, the facility did not maintain proper food temperatures on the service line. Ground meat was found to be held at a temperature of 140 degrees, but the thermometer used by the Dietary Aide was reading 8 degrees too high, indicating it was not calibrated correctly. Interviews with the Dietary Manager and Dietary Aide revealed that they were unaware of the thermometer's calibration issue and did not know how to calibrate it. The Dietary Manager acknowledged the importance of proper food storage and temperature maintenance to prevent foodborne illness, but failed to provide the requested policy on food storage and hot holding, as well as dietary staff training records, before the survey exit.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional principles, as observed in one of the four medication carts reviewed. Specifically, the 300-hall nurse medication cart, assigned to LVN M, contained 35 multicolored pills of different shapes, 5 1/2 white pills of various shapes, and 6 multicolored pills loose at the bottom of a drawer. Additionally, an opened bottle of Thick It thickened water, which was past its recommended usage date, was found in the cart. The manufacturer's instructions required refrigeration after opening and use within 14 days, which was not adhered to. During interviews, LVN M acknowledged responsibility for maintaining the cleanliness and order of the medication cart, including the removal of expired medications and loose pills. The DON confirmed that nurses and medication aides were expected to clean and organize medication carts each shift, removing expired or loose medications. The facility's policy on medication storage emphasized the importance of maintaining a clean, safe, and orderly environment, with proper labeling and disposal of outdated or improperly labeled drugs. The failure to adhere to these protocols posed a risk of residents receiving incorrect or expired medications, potentially leading to adverse side effects.
Inaccurate Medication Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to maintain medical records in accordance with accepted professional standards and practices for one resident reviewed for medication administration. Licensed Vocational Nurses (LVN) A and B documented that the resident was being monitored for behaviors and medication side effects and that medication was administered on specific dates while the resident was actually at the hospital. This inaccurate documentation could potentially lead to resident injury due to the misrepresentation of the resident's health and care. The resident in question was a male with multiple medical diagnoses, including Bipolar Disorder, Unspecified Dementia, and Congestive Heart Failure, among others. He had a Brief Interview of Mental Status (BIMS) score indicating severely impaired cognition and required varying levels of assistance with daily activities. The resident was transferred to the hospital due to a change in condition, specifically respiratory arrest, yet the facility's records inaccurately reflected that he was still present and receiving care at the facility. The Medication Administration Record (MAR) for December showed that medications and monitoring were documented as completed during shifts when the resident was not present. This included antidepressant monitoring and behavior monitoring, as well as the administration of aspirin and the use of a pressure-reducing mattress. The facility's policies on pharmaceutical services and documentation of medication administration were not adhered to, as medications were documented as administered without the resident being present, and reasons for withholding or not administering medications were not documented.
Latest citations in Texas
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
