Alta Vista Rehabilitation And Healthcare
Inspection history, citations, penalties and survey trends for this long-term care facility in Brownsville, Texas.
- Location
- 510 Paredes Line Rd, Brownsville, Texas 78521
- CMS Provider Number
- 455625
- Inspections on file
- 22
- Latest survey
- March 13, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Alta Vista Rehabilitation And Healthcare during CMS and state inspections, most recent first.
A resident with a history of stroke-related hemiplegia, T2DM, and lack of coordination, and documented as moderately cognitively impaired, was started on Trazodone 25 mg at bedtime for insomnia based on a physician order. The medication was administered before the resident’s legal representative signed the psychoactive medication informed consent form, and when the form was later signed, the section indicating whether consent was granted was not completed. During interview, the DON confirmed that the consent for Trazodone was not properly completed prior to administration, despite facility policy requiring review of psychotropic orders and efforts to obtain and document prior informed consents on admission.
A resident with a history of stroke-related hemiplegia, type 2 DM, and lack of coordination, and who was moderately cognitively impaired and required moderate ADL assistance, received Trazodone 25 mg at bedtime for insomnia based on a physician order. The medication was administered before an informed consent for psychoactive medication was signed by the resident’s legal representative, and when the consent was later completed it indicated that the representative did not consent to the Trazodone. During interview, the DON stated that medications were not supposed to be given without a consent form, and facility policy required review of psychotropic orders and efforts to obtain and document prior informed consents on admission.
Surveyors found a wound care treatment cart left unlocked and unattended in a hallway, containing medications and wound care supplies. An RN responsible for the cart acknowledged she was expected to lock it when walking away and that an unsecured cart could allow a resident to access medications not prescribed for them. The DON confirmed that she, the ADON, and other staff were responsible for ensuring medication carts remained locked when not in use, consistent with the facility’s medication storage policy requiring medication supplies to be secured and accessible only to authorized personnel.
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen administration. A resident with respiratory failure was observed receiving oxygen at a lower rate than prescribed, and the care plan did not include oxygen therapy. Another resident with vascular dementia received oxygen at a higher rate than ordered, with an outdated care plan. A third resident with severe cognitive impairment received oxygen at a lower rate than prescribed due to an adjustment error. These discrepancies highlight lapses in following established procedures for oxygen administration.
The facility failed to update care plans for two residents receiving oxygen therapy, despite their medical needs. One resident with severe aortic stenosis and another with cognitive impairment were both observed using oxygen, but their care plans lacked necessary updates. Interviews revealed that MDS nurses were responsible for care plan updates, and the oversight was acknowledged by the DON.
A resident's care plan was not updated to reflect a new oxygen order, leading to discrepancies in the oxygen settings administered. The resident, with multiple health conditions, had a physician's order for oxygen at 2L/min, but the care plan still indicated 4L/min. Observations showed the oxygenator set at 3L/min, and staff interviews revealed a lack of timely monitoring and updating of the care plan.
A nurse in an LTC facility failed to check gastric residuals before administering medication via G-tube to a resident with severe cognitive impairment and a feeding tube. Despite being trained and evaluated on this procedure, the nurse did not follow the facility's protocol, which requires checking residuals before medication administration. This oversight was identified during an observation and confirmed through interviews with the nurse and the DON.
A resident's mini refrigerator contained unlabeled and undated food items, contrary to the facility's policy requiring all outside food to be labeled and dated by the charge nurse. The resident, with severe cognitive impairment and multiple health conditions, had food brought by his daughter that was not properly managed, posing a risk of foodborne illnesses. Staff interviews revealed a breakdown in the process, as the Business Office Coordinator noticed the issue but failed to address it.
A facility failed to report an alleged neglect incident involving a resident within the required 24-hour timeframe. The incident involved two CNAs, one of whom alleged abuse by the other. The resident, who had mild cognitive impairment, denied any abuse. The DON did not report the allegation, and the administrator reported it only after returning from vacation.
Failure to Obtain Informed Consent Before Administering Psychoactive Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was fully informed in advance and that consent was obtained prior to administering a psychoactive medication. Resident #1 was admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and lack of coordination. An admission MDS assessment documented that the resident was moderately cognitively impaired, required moderate assistance with most ADLs, and received antipsychotic and antidepressant medications for seven days during the assessment period. The consolidated physician orders showed an order dated 03/08/26 for Trazodone 25 mg by mouth at bedtime for insomnia, unspecified. Record review showed that the informed consent for psychoactive medication form for Trazodone was signed by Resident #1’s legal representative on 03/10/26, and the section indicating whether the representative consented to the medication was not completed. The medication had already been administered to the resident on 03/09/26, before the consent form was signed and completed. During an interview, the DON acknowledged that the informed consents for Trazodone were not completed and did not show if the medication was consented to by the responsible party, and stated that informed consents should have been completed prior to administering the medication. The facility’s policy on Chemical Restraints and Psychotropic Medication Management stated that on admission, the admitting nurse will review transfer orders for psychotropic medications and make all efforts to obtain history and prior informed consents, documenting any information obtained in the clinical record.
Psychotropic Medication Administered Without Informed Consent
Penalty
Summary
Surveyors identified a deficiency related to the use of a psychotropic medication without proper informed consent. Resident #1, admitted with hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and lack of coordination, had an admission MDS showing moderate cognitive impairment and a need for moderate assistance with most ADLs. The MDS also reflected that the resident received antipsychotic and antidepressant medications for seven days during the assessment period. The consolidated physician orders showed an order dated 03/08/26 for Trazodone 25 mg by mouth at bedtime for unspecified insomnia. Record review showed that the informed consent for psychoactive medication for Trazodone was signed by the resident’s legal representative on 03/10/26, and the form indicated that the legal representative did not consent to the medication. Despite this, Trazodone had already been administered to the resident on 03/09/26, prior to obtaining a signed consent. During an interview, the DON acknowledged that medication was not supposed to be given without a consent form because it could cause an adverse effect to the resident. The facility’s policy on Chemical Restraints and Psychotropic Medication Management stated that on admission the admitting nurse would review transfer orders for psychotropic medications and make all efforts to obtain history and prior informed consents, documenting any information in the clinical record, but this process did not prevent administration of Trazodone before consent was obtained.
Unlocked and Unattended Wound Care Medication Cart
Penalty
Summary
Surveyors observed that a wound treatment cart on the 300 hallway was left unlocked and unattended by an RN at 6:03 p.m. The cart contained medications needed for residents’ wound care and wound care supplies. When the surveyor notified the RN that the cart was unlocked, the RN locked it and acknowledged she was responsible for the treatment cart and was expected to lock it whenever she walked away. She stated that if the cart was left unlocked, a resident could open a drawer and take a medication that was not prescribed for them. In a subsequent interview, the DON stated that numerous staff, including herself and the ADON, were responsible for ensuring medication carts were locked and that her expectation was that staff lock the cart when walking away from it. The DON stated that if the cart was left unlocked, a resident or visitor could grab medication from the cart and it could harm them. Review of the facility’s “Medication Storage” policy showed that medications and biologicals must be stored properly and that medication rooms, cabinets, and medication supplies should remain locked when not in use or attended only by persons with authorized access. The observed unlocked and unattended wound care cart was not in accordance with this policy or with accepted professional principles for medication storage and security.
Deficiencies in Oxygen Administration for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in oxygen administration. Resident #225, a male with multiple health conditions including respiratory failure and severe aortic stenosis, was observed receiving oxygen at a rate lower than the prescribed 4 liters per minute (LPM). The resident was found with oxygen set between 2.5 and 3 LPM, which was confirmed by LVN B, who admitted not checking the oxygen rate at the start of her shift. The resident's care plan did not include oxygen therapy, and the Director of Nursing (DON) acknowledged that the charge nurse was responsible for checking oxygen settings every shift. Resident #18, a female with respiratory failure and vascular dementia, was observed receiving oxygen at 3 LPM instead of the prescribed 2 LPM. The discrepancy was noted by a staff member who had not checked the oxygen setting since the start of his shift. The resident's care plan was outdated, and the DON confirmed that the care plan did not reflect the correct oxygen rate. Despite the incorrect oxygen administration, the resident did not exhibit any immediate distress, and the DON conducted an assessment to ensure the resident's condition was stable. Resident #48, a female with severe cognitive impairment and multiple health issues, was receiving oxygen at 3.5 LPM instead of the prescribed 4 LPM. LVN B, responsible for the resident's care, admitted to adjusting the humidifier, which may have altered the oxygen setting. The DON and other staff members routinely checked oxygen settings, but the discrepancy was not corrected in time. The facility's policy on oxygen administration emphasized the importance of adhering to physician orders, yet the failure to maintain correct oxygen levels for these residents highlighted a lapse in following established procedures.
Failure to Update Oxygen Therapy in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which included measurable objectives and timeframes to meet their physical needs. Resident #225, a male with multiple diagnoses including respiratory failure and severe aortic stenosis, was prescribed oxygen therapy at 4LPM via nasal cannula as needed. However, his care plan, dated 8/2/24, did not reflect this oxygen use. Observations confirmed the resident was using oxygen, but the care plan was not updated to include this critical aspect of his care. Interviews with the ADON and MDS/RN revealed that the responsibility for updating care plans lay with the MDS nurses, and the oversight was acknowledged by the DON. Similarly, Resident #48, a female with severe cognitive impairment and a history of cerebral infarction and dementia, was receiving continuous oxygen therapy at 4L/min via nasal cannula. Despite this, her care plan, dated 5/30/24, lacked any focus, goals, or interventions related to her oxygen therapy. Observations confirmed her use of oxygen, and interviews with the MDS/RN and DON indicated that the care plan had not been updated to reflect her current needs. The MDS/RN acknowledged the potential negative effects of not having oxygen therapy care planned, such as hypoxia and respiratory distress. The facility's Comprehensive Person-Centered Policy, dated December 2023, mandates the development of a comprehensive care plan for each resident, including measurable objectives and timeframes. This policy was not adhered to in the cases of Residents #225 and #48, as their care plans did not include necessary information regarding their oxygen therapy, potentially placing them at risk of not receiving appropriate care.
Failure to Update Resident's Care Plan for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments. Specifically, the care plan for a resident was not updated to reflect a new oxygen order effective on a specified date. The resident, an elderly female with multiple health conditions including respiratory failure, vascular dementia, congestive heart failure, and end-stage renal disease, had a physician's order for oxygen at 2L/min continuous. However, her care plan still reflected an outdated intervention of oxygen therapy at 4L/min. Observations and interviews revealed discrepancies in the oxygen settings being administered to the resident. On one occasion, the oxygenator was set at 3L/min, contrary to the physician's order of 2L/min. The LVN acknowledged the discrepancy and noted that the nursing staff should monitor oxygen settings once per shift, but had not done so since the start of his shift. The MDS/RN confirmed that the care plan was not updated in a timely manner, and the DON acknowledged the oversight, noting that the care plan should have been updated on the day the new oxygen order was received to prevent confusion.
Failure to Check G-Tube Residuals Before Medication Administration
Penalty
Summary
The facility failed to ensure that a nurse, LVN A, demonstrated competency in administering medication via a G-tube for Resident #48. LVN A did not check for gastric residual before administering medication, which is a required procedure according to the facility's protocol. Resident #48, who was admitted with diagnoses including moderate protein-calorie malnutrition, dysphagia, and gastrostomy status, was dependent on staff for all activities of daily living and had a feeding tube for nutritional support. The resident's care plan specifically required checking for tube placement and gastric contents/residual volume before feeding, with instructions to hold feeding if residuals exceeded 150 mL and notify the physician. During an observation, LVN A was seen administering medication without checking for residuals, and she confirmed in an interview that she did not perform this check, believing it was only necessary before feeding. However, the facility's policy and the Director of Nursing (DON) clarified that checking residuals is mandatory before administering medications via G-tube. The DON stated that nurses were trained and evaluated on this skill, and LVN A had been checked off on the competency checklist for enteral med pass, which included checking gastric residuals. Despite this, LVN A did not follow the protocol, leading to the deficiency.
Failure to Label and Date Food in Resident's Mini Refrigerator
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service, as evidenced by the improper handling of food in a resident's mini refrigerator. The resident, who had severe cognitive impairment and multiple health conditions, including chronic obstructive pulmonary disease, dementia, and end-stage renal disease, had a mini refrigerator in his room containing unlabeled and undated food items. These included a plastic container with beans and several mini containers with salsa, which were brought by the resident's daughter. The facility's policy required that all outside food be labeled and dated by the charge nurse to prevent foodborne illnesses. Interviews with various staff members, including the Dietary Manager, LVN, DON, and the Business Office Coordinator, revealed a breakdown in the process of managing outside food brought into the facility. The staff confirmed that the procedure involved the front receptionist handing over the food to the resident's charge nurse, who was responsible for checking the food against the resident's diet plan and labeling and dating it if approved. However, this process was not followed in the case of the resident's mini refrigerator, as the food items were neither labeled nor dated, and the Business Office Coordinator admitted to noticing the unlabeled food but failing to address it. The facility's policy on food brought by family or visitors, revised in 2007, stipulated that non-perishable foods should be stored in plastic containers with tight-fitting lids and that perishable foods must be destroyed daily. Despite this policy, the facility did not maintain a log of outside food, and the oversight in labeling and dating the food in the resident's mini refrigerator posed a risk of foodborne illnesses. The administrator acknowledged the importance of labeling and dating food to track how long it had been stored, but the deficiency in this case highlighted a lapse in the facility's adherence to its own procedures.
Failure to Timely Report Alleged Neglect
Penalty
Summary
The facility failed to report an alleged incident of neglect involving a resident to the State Survey Agency within the required 24-hour timeframe. The incident involved a resident who was reportedly found on the floor by two CNAs, one of whom later alleged that the other CNA had verbally and physically abused the resident. The Director of Nursing (DON) at the time did not report the allegation to the State, and the facility administrator only became aware of the situation upon returning from vacation, at which point she reported it. The resident involved was a male with a history of sepsis, requiring assistance with personal care, and had mild cognitive impairment. During the facility's investigation, the resident denied any abuse from the CNAs involved, and no other staff or residents reported abuse by the accused CNA. The facility's policy mandates that all allegations of abuse, neglect, or mistreatment be reported immediately, but this protocol was not followed, leading to a deficiency in the facility's compliance with reporting requirements.
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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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