Arlington Heights Health And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Worth, Texas.
- Location
- 4825 Wellesley St, Fort Worth, Texas 76107
- CMS Provider Number
- 455819
- Inspections on file
- 54
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Arlington Heights Health And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to ensure that an RN was on duty for at least 8 consecutive hours per day on multiple weekend days, as shown by timecard records indicating only partial RN coverage or shifts that crossed midnight so that fewer than 8 hours fell on the same calendar day. The Staffing Coordinator, ADON, DON, and Administrator described a scheduling process in which the Staffing Coordinator created monthly schedules and the DON reviewed them mainly when coverage issues arose, but key staff were unaware that the 8 consecutive RN hours had to occur within the same day. The RCN confirmed there was no specific RN coverage policy, and the report states that this failure could place residents at risk of not having their nursing and medical needs met and improper care.
A resident with bipolar disorder and depression, who was cognitively intact and required substantial ADL assistance, had a PASARR Level 1 (PL1) that inaccurately documented no evidence of mental illness, and no PASARR Level 2 evaluation was completed by the local mental health authority. The care plan showed use of an antipsychotic for bipolar disorder and depression, yet the PL1 did not reflect these conditions. Interviews with MDS coordinators revealed conflicting accounts and confirmed that a referral to the local mental health authority was not made at admission as required, with one coordinator later discovering the omission and attributing it in part to confusion over insurance coverage. This failure to recognize the inaccurate PL1 and to make a timely PASARR referral resulted in the cited deficiency.
Surveyors found that the facility failed to develop and implement comprehensive, person-centered care plans for two residents. One resident with severe cognitive impairment and multiple diagnoses had a history of refusing care, including nail care, which was consistently observed and reported by nursing staff but not documented or incorporated into the care plan. Another resident with severe cognitive impairment and a right-hand contracture had no care plan addressing the contracture, its management, or her refusals to keep a splint in place, despite staff and therapy being aware of the condition. These omissions occurred despite a facility policy requiring comprehensive care plans with measurable objectives and timeframes for all identified medical, nursing, mental, and psychosocial needs.
A resident with COPD, depression, dementia, and diabetes, who required staff assistance for ADLs, was care planned to receive assisted bathing or bed baths on specific days, with documentation in the POC. For two consecutive months, the POC showed "Not applicable" for all scheduled bathing days, and no shower sheets were available to verify care. The resident reported not receiving bed baths on his scheduled days and being told staff were short-staffed when he requested them. CNAs and an LVN gave conflicting accounts about when and how often bed baths were provided and how refusals and care were documented, while the ADON and DON acknowledged that, based on existing records, they could not confirm that the resident’s scheduled bathing/bed baths had been provided.
A resident with severe cognitive impairment, MRSA, and multiple Stage 3 and unstageable pressure injuries was admitted with detailed daily wound care orders, including cleansing, application of Santyl or collagen, and Hydrofera Blue dressings. Review of the eTAR and staff interviews showed that no wound care was provided over a weekend, despite daily orders, and the same dressings applied on Friday remained in place until Monday. The ADON on duty acknowledged she knew of the wounds and her responsibility to perform treatments in the absence of the weekday wound care nurse but missed the treatments, left early, and did not notify relieving nurses. The wound care nurse, ADON, DON, and wound care NP all confirmed that ordered treatments were not followed and that this created a risk for infection and wound deterioration.
A resident with a PICC line for IV medications had a transparent dressing that remained in place beyond the ordered weekly change interval, with no documentation of the scheduled dressing change and no recorded refusal. The dressing was observed to be peeling and dirty on the surface, and an LVN acknowledged knowing the dressing should be changed weekly and PRN but reported not having training on PICC line dressings. In a separate observation, an LVN administering IV antibiotic via the PICC line donned gloves and a gown before hand hygiene, changed gloves without washing hands, and completed the infusion and left the room without performing hand hygiene, later admitting she forgot. Leadership interviews confirmed expectations for weekly and PRN PICC dressing changes and proper hand hygiene, and facility policies addressed central line care and hand washing, but requested training records were not provided.
A resident receiving IV Daptomycin for septicemia via a PICC line had an IV medication bag in use and an additional empty bag in the room that were not labeled with the date, time, or nurse initials, contrary to the care plan and facility policy. An LVN on the earlier shift acknowledged she hung the IV medication but forgot to label the bag and tubing, despite prior IV administration training and skills checks. Another LVN, the ADON, and the DON all confirmed that IV bags and tubing were required to be dated and initialed and that tubing should be changed every 24 hours to prevent medication errors and infection, but this was not done for this resident.
A pharmacist’s recommendation for a gradual dose reduction of an antidepressant was not acted upon when the ADON, who was responsible for reviewing pharmacy consultant recommendations, failed to forward the recommendation to the attending physician. As a result, a resident with depression and intact cognition continued to receive amitriptyline 100 mg daily without a GDR attempt, despite facility policy requiring implementation of GDRs and the pharmacist’s documented request. The DON confirmed expectations that pharmacy recommendations be reviewed monthly and sent to the physician, but this did not occur in this case.
A resident with severe cognitive impairment and multiple chronic conditions had a care plan calling for ongoing discussion of options at each care plan meeting, but there was no documentation in the clinical record that the family/legal representative was invited to participate in quarterly care plan meetings. The Social Worker reported making multiple phone attempts and previously sending letters to invite the family but acknowledged she had not documented these efforts and could not locate any records of contact. The family member stated he had never attended a care plan meeting, did not recall being invited over the past year, and wished to be included. The DON and Administrator confirmed that the Social Worker was responsible for scheduling care plan meetings and documenting all invitation attempts, as required by the facility’s documentation policy, which mandates complete and accurate recording of communications in the clinical record.
The facility failed to ensure full visual privacy for three cognitively intact residents whose beds lacked privacy curtains that fully enclosed the bed area. Each resident required staff assistance with ADLs and had conditions such as stroke, diabetes, cerebral palsy, pressure ulcers, and incontinence. Observations showed that even when curtains were fully drawn, the ends of the beds remained exposed, and residents reported they would not like someone entering while they were being changed. Staff interviews revealed that maintenance hung curtains after being notified, housekeeping was said to monitor and replace curtains, and nurses and CNAs were expected to notify housekeeping when curtains needed attention, but there was no specific policy addressing privacy curtains.
A resident with severe cognitive impairment and a moderate elopement risk was able to leave the facility unsupervised by following a transport company staff member through a secured exit. The door alarm did not sound due to the use of a staff code, and staff were unaware of the resident's departure until she was found outside by a housekeeper and administrator. There was no prior documentation of exit-seeking behavior, and staff interviews confirmed a lack of awareness of the incident until after it occurred.
Two residents with severe cognitive impairment and a history of physical behaviors engaged in a physical altercation after one resident became agitated when a door was closed in her face, resulting in scratches and a bruise to the other resident before staff intervened.
A resident with quadriplegia, neurogenic bladder, and a Stage 2 pressure ulcer did not have a comprehensive care plan addressing their Foley catheter, despite its use and related medical needs. Staff interviews revealed a lack of specific documentation and orders for catheter care, and the interdisciplinary team missed updating the care plan to include this essential aspect of the resident's care.
A resident admitted with a Foley catheter did not have physician orders in place for catheter care, and neither the care plan nor the physician orders addressed the catheter. Nursing staff and facility leadership confirmed that the omission was not identified or corrected during admission or follow-up, despite facility policy requiring review and clarification of orders.
A nurse failed to immediately report an allegation of verbal abuse by a CNA towards a resident with severe cognitive impairment. Instead of contacting the Administrator directly as required, the nurse left a written statement under the Administrator's door, which was not received. This resulted in a delay in the facility's awareness and response to the alleged abuse.
A resident with intellectual disabilities and poor impulse control engaged in multiple aggressive incidents, hitting other residents with a doll and punching another. Despite a care plan addressing potential physical behaviors, the facility failed to prevent these altercations, resulting in an Immediate Jeopardy situation.
A resident with a colostomy experienced a lack of dignified care when her colostomy bag leaked, and staff failed to provide timely assistance. Despite the resident's request for help, a CNA informed her that a nurse was needed, and the nurse, occupied with other duties, left a new bag but did not assist in its application. The resident was left to manage alone, leading to further leakage and embarrassment. The DON noted that staff failed to communicate effectively to ensure the resident's needs were met.
A resident with a colostomy experienced inadequate care when her colostomy bag leaked, and staff failed to provide timely assistance. Despite the resident's need for help due to her cognitive impairment and physical limitations, a nurse left a new bag on the table without assisting or informing another nurse. This led the resident to attempt self-care, resulting in further leakage. The facility's lack of communication and adherence to ostomy care policy contributed to this deficiency.
The facility failed to submit Nursing Facility Specialized Services (NFSS) forms on time for several residents, risking their access to necessary specialized services. The deficiency was due to a lack of training and understanding of the PASRR process by the Director of Rehabilitation, leading to missed deadlines and errors in form submission.
The facility failed to update care plans for two residents, one requiring pleasure feedings and another undergoing dialysis. Despite physician orders and observations confirming these needs, the care plans lacked this information, leading to potential risks in care delivery. Staff interviews revealed a lack of awareness and responsibility for updating care plans, highlighting the importance of comprehensive and current documentation.
A resident with a history of stroke and hemiplegia did not receive timely incontinence care, as required by their care plan. Despite needing assistance every two hours, the resident was left in a soaked state for extended periods, leading to potential risks of skin breakdown and infection. Staff interviews revealed inconsistencies in care provision, and the facility's policy on perineal care was not followed, resulting in a deficiency.
A resident with pneumonia requiring IV access experienced deficiencies in IV fluid administration and PICC line management. The facility failed to label the IV medication bag and tubing and did not change the PICC line dressing for eight days, contrary to the care plan. Interviews revealed that staff were aware of the requirements but did not adhere to them, and management did not catch the oversight.
The facility failed to maintain accurate narcotic logs for two residents, leading to discrepancies between the narcotic administration records and actual pill counts. A medication aide admitted to administering medications without documenting them, despite having attended training on proper procedures. The DON emphasized the importance of immediate documentation to prevent discrepancies.
A resident with severe cognitive impairment eloped from the facility unnoticed, traveling 8 miles before being found. The deficiency occurred because staff failed to conduct regular checks and adhere to elopement prevention policies, despite the resident's known elopement risk.
A facility failed to maintain a safe environment in the south hallway of Zone 3, where a large puddle of water was observed due to a leaking doorway. Four residents were cautioned about the hazard, and Laundry Staff A eventually cleaned the spill. Interviews revealed that the area was known for water issues, and staff emphasized the importance of immediate cleanup to prevent accidents. The ADM was unaware of the problem, and the facility's policy on maintaining nonslip surfaces was not followed.
A resident's Foley catheter bag was found on the floor, contrary to the facility's infection control policy, which requires catheter bags to be kept off the floor to prevent infection. Staff interviews confirmed the oversight, and the facility's policy was not followed despite previous training.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, risking their individualized care. Interviews revealed disorganization in the care planning process and lack of proper oversight.
A resident with multiple diagnoses, including morbid obesity and heart failure, was left in a soiled brief for extended periods due to staff unavailability. The resident's family had to assist with incontinence care, and the facility's care plan was not individualized for the resident's needs. Interviews revealed that call lights were not answered within the expected time frame, and the facility's policy did not define prolonged wait times.
Failure to Ensure Required Daily RN Coverage on Weekends
Penalty
Summary
The deficiency involves the facility’s failure to provide RN coverage for at least eight consecutive hours per day, seven days a week, over multiple weekend days within a review period from early June to mid-December 2025. Timecard reports showed that on 16 specific weekend dates, RN hours worked on those calendar days did not total eight consecutive hours, with RN shifts either starting late in the day, ending before eight consecutive hours were reached, or crossing midnight so that only a portion of the shift fell on the calendar day in question. Examples included days when RNs worked only a few hours in the evening, partial coverage split between different RNs, or coverage that began late at night so that only one to two hours of the shift occurred on that date. On some dates, the ADON provided partial RN coverage, but the total RN time on that calendar day still did not meet the eight consecutive hours required. Interviews with facility staff revealed gaps in understanding and oversight of the RN coverage requirement. The Staffing Coordinator, who had been responsible for creating nursing schedules since July 2025, stated she was aware of the need for eight consecutive hours of RN coverage but did not know that the eight hours had to occur within the same calendar day and believed that any eight consecutive hours, even if crossing midnight, were acceptable. The ADON reported that the Staffing Coordinator completed the schedules and that the DON was responsible for reviewing them, while the ADON only assisted when there were call-offs or coverage issues. The DON stated she reviewed schedules mainly when coverage issues arose and acknowledged she was not aware that the eight consecutive hours had to be on the same day. The Administrator stated he knew of the eight-hour requirement but was unaware it was not being scheduled correctly. The RCN reported that the facility did not have a specific RN coverage policy and that they followed the regulation for eight hours daily. The report notes that this failure could place residents at risk of not having their nursing and medical needs met and improper care.
Failure to Ensure Accurate PASARR Screening and Timely Referral for Mental Health Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate PASARR Level 1 (PL1) screening and appropriate referral for a resident with a documented mental disorder. The resident was an adult male admitted with a diagnosis of bipolar disorder, was cognitively intact with a BIMS score of 15, and required substantial assistance with ADLs. His care plan documented an ADL self-care deficit, use of an antipsychotic medication for bipolar disorder, and depression. However, his PASRR Level 1 screening indicated there was no evidence of mental illness and no primary diagnosis of dementia, and the electronic health record contained no evidence that a PASRR Level 2 evaluation had been completed by the local mental health authority. Interviews revealed conflicting and inaccurate information regarding whether and when the resident had been referred to the local mental health authority. One MDS coordinator stated the resident had been referred in September and evaluated in December, while another MDS coordinator stated the resident had not been referred and that she only initiated the referral in December after discovering the omission. She acknowledged that not having the resident assessed could result in him not receiving services he might qualify for and noted there had been confusion about the resident’s insurance coverage that might have contributed to the lack of referral. The facility’s policy required obtaining a PL1 from the referring entity prior to admission and submitting it via the portal within PASRR regulatory timeframes, but the inaccurate PL1 and failure to coordinate a timely PASRR Level 2 evaluation for this resident with bipolar disorder and depression led to the cited deficiency.
Failure to Care Plan for Care Refusals and Hand Contracture
Penalty
Summary
Surveyors identified a failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents. For one resident, a male with diabetes, seizure disorder, history of TIA, and cerebral infarction, the quarterly MDS showed severely impaired cognition (BIMS score of 5) and a care plan for ADL self-care deficits requiring supervision to limited assistance for personal hygiene. However, the care plan did not address the resident’s pattern of refusing care, including nail care. Observations showed the resident in bed with covers over his head and significantly overgrown fingernails on both hands, despite the resident stating that he had people who cut his nails and indicating he wanted his fingernails cut before again covering his head. Interviews with staff revealed an ongoing pattern of care refusals by this resident that were not reflected in the care plan. An RN reported asking the resident several times for permission to cut his fingernails, with the resident refusing and pulling covers over his head each time. A CNA similarly reported that the resident refused offers for nail care and showers and would always pull the covers over his head. The ADON stated it was normal for this resident to refuse all care, including nail care, and acknowledged that the refusals had not been documented or care planned, despite her belief that refusals should be care planned so staff would understand how to care for the resident. The MDS Coordinator stated she was not aware of the resident’s care refusals, including nail care, and confirmed that nursing staff were responsible for updating care plans or notifying her of issues. For the second resident, an older female with non-Alzheimer’s dementia, reduced mobility, muscle weakness, and a BIMS score of 5 indicating severely impaired cognition, the quarterly MDS and care plan did not reflect the presence of a right-hand contracture. Observation showed the resident’s right hand was contracted, and she was unable to open it, with no device in place for contracture management. Nursing staff and the Director of Rehabilitation confirmed the resident had a right-hand contracture, that therapy had worked with her, and that a splint had been tried but the resident would remove it and complain. The ADON stated the resident had been admitted with the contracture and that there should have been a care plan addressing it, and the MDS Coordinator acknowledged she was unaware of the contracture and that the care plan should have included the contracture, its care, and the resident’s refusals to keep the splint in place. The facility’s policy required a comprehensive person-centered care plan with measurable objectives and timeframes to meet residents’ identified needs, which was not followed in these cases.
Failure to Provide and Document Scheduled Bathing/Bed Baths for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident who was dependent on staff for ADLs received scheduled bathing/bed baths and that this care was properly documented. The resident was an adult male with COPD, depression, non-Alzheimer’s dementia, and diabetes, with an intact BIMS score of 15. His care plan, revised in late September, identified an ADL self-care performance deficit and specified that he required staff assistance for bathing, including provision of a sponge bath when a full bath or shower could not be tolerated. The November and December POC histories showed that the resident was scheduled for bathing/showers on Mondays, Wednesdays, and Fridays on the 6:00 AM–2:00 PM shift, with instructions to turn in a shower sheet to the charge nurse. However, in the Bathing task section for those days, the POC reflected “Not applicable,” and it was unknown from the records whether the resident received showers/bed baths or refused them. During observation and interview, the resident reported that he did not receive showers, preferred bed baths, and that his scheduled days were Monday, Wednesday, and Friday. He stated the last bed bath he recalled was some day the previous week, either Monday or Wednesday, and that he did not receive bed baths on his scheduled days. He further reported that when he requested a bed bath, staff told him they were short-staffed. The facility’s shower binder on the 200 hall contained no shower sheets for this resident, and requested shower sheets were not provided to the survey team before exit. Multiple staff interviews revealed inconsistent information and documentation practices. One CNA stated the resident’s shower days were on the 2:00 PM–10:00 PM shift and that he mostly refused bed baths, and that care was documented on shower sheets and in the POC, yet no shower sheets were found. Another CNA stated that if the POC showed “Not applicable,” it meant the shower was not provided and did not happen, and acknowledged she had not completed any shower sheets for this resident. A third CNA reported giving bed baths, last sometime the previous month, and stated that “Not applicable” in the POC meant the shower was not provided or offered. The assigned LVN stated the resident was provided bed baths on shower days but sometimes refused, and that staff documented on shower sheets and in the POC, though she could not explain the “Not applicable” entries. The ADON stated the facility was no longer using shower sheets and that staff should document in the POC, and acknowledged that based on POC documentation she could not prove the resident received any showers, adding that if it was not documented, it did not happen. The DON similarly stated she could not confirm from documentation that the resident received showers and that nurses in charge and the ADON were responsible for ensuring showers/bed baths were provided. The facility’s bed bath policy stated that complete bed baths are performed for residents on bedrest needing assistive care and may be done daily or alternated with partial bed baths, but the documentation and interviews did not substantiate that this resident’s scheduled bathing care was consistently provided.
Missed Weekend Wound Care for Resident With Multiple Pressure Injuries
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatments to a resident with multiple pressure injuries over a weekend. The resident was an elderly male with severe cognitive impairment (BIMS score of 2) and a diagnosis of MRSA infection, who was admitted with multiple pressure injuries, including Stage 3 and unstageable ulcers on the left hip, right gluteal fold, sacrum, left buttock, and both ankles. His care plan and wound evaluation documented specific daily treatment orders for each wound, including cleansing with normal saline or wound cleanser, application of Santyl or collagen, use of Hydrofera Blue, and coverage with bordered gauze or foam dressings, to be done daily and as needed for soiling or dislodgement. Record review of the resident’s electronic treatment administration record (eTAR) for December showed no documentation that any wound care was provided on the Saturday and Sunday in question, despite daily treatment orders. The resident reported that he received wound care Monday through Friday but not on the weekend. When the wound care nurse returned the following Monday, she observed that the resident still had the same dressings in place that she had applied on the prior Friday, indicating that the weekend treatments had been missed. Interviews with staff confirmed that weekend wound care was not completed. The ADON who worked that weekend acknowledged she knew the resident had multiple wounds and that she was responsible for performing wound care because the treatment nurse did not work weekends, but stated she missed the treatments, left early both days, and did not inform the relieving nurses that wound care had not been done. The wound care nurse stated that weekend staff were supposed to provide the treatments and that she did not notify management, expecting them to review treatment records. The ADON and DON both stated they were responsible for ensuring MARs/TARs were checked and that they had not reviewed the wound care TAR for this resident. The wound care NP stated that nurses or the wound care nurse were supposed to follow the treatment orders and that missing treatment placed the resident at risk for infection and worsening wounds.
Failure to Follow PICC Line Dressing Schedule and Hand Hygiene During IV Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe and appropriate administration and management of IV therapy via a PICC line for a resident receiving intravenous medications. The resident was an adult male admitted with septicemia and intact cognition, with physician orders for a PICC line dressing change every seven days on Mondays and as needed. The resident’s care plan included interventions such as administering IV medications as ordered, checking the IV site dressing daily for signs and symptoms of infection, flushing ports/lines as ordered, and changing the dressing every seven days and PRN. Review of the Treatment Administration Record for December showed no documentation that the PICC line dressing was changed on the scheduled date, and there was no documentation of any refusal by the resident. On observation, the resident was found in bed with a PICC line dressing on his right arm dated 11/29/25. The dressing was peeling and dirty on the surface. The resident reported that the dressing had been applied at the hospital and had not been changed since his admission, and that no staff had requested to change it. A subsequent observation with an LVN confirmed the dressing was transparent, peeling, and appeared dirty, and the LVN acknowledged knowing that the dressing should be changed every seven days and as needed when dirty. The LVN stated she had attempted to change the dressing but said the resident refused and that she notified the ADON; however, she also stated she should have changed it earlier since it was due every seven days and reported she had not received training on PICC line dressings. The PICC insertion site itself was observed to be clean with no signs of infection. A separate deficiency was identified during observation of IV medication administration through the same resident’s PICC line. An LVN donned gloves and a gown before washing her hands, prepared and hung the IV antibiotic, labeled the IV bottle and tubing, then removed her gloves and put on new gloves without performing hand hygiene. She cleansed the PICC line tip with an alcohol swab, connected the IV tubing, allowed the medication to infuse, then removed her gloves and left the room, again without washing her hands, and proceeded down the hall with the medication cart. In interview, the LVN admitted she forgot to perform hand hygiene before and after medication administration and stated she understood that failure to wash hands could lead to cross contamination and infection. The ADON and DON both stated their expectations that PICC line dressings be changed every seven days and as needed, and that staff perform hand hygiene before and after resident contact and procedures. Facility policies on central venous catheter dressing changes and hand washing were in place, but training records requested by surveyors were not provided.
Failure to Label IV Medication Bag and Tubing per Policy
Penalty
Summary
The deficiency involves the facility’s failure to ensure parenteral fluids and IV medications were administered in accordance with professional standards, physician orders, and the resident’s care plan. A male resident with septicemia, intact cognition (BIMS score of 14), and an order for daily IV Daptomycin via a PICC line had an IV medication bag in use that was not labeled with the date, time, or initials of the nurse who hung it. An additional empty IV bag in the resident’s room was also unlabeled. The resident’s care plan called for administering IV medications as ordered, monitoring the IV site for infection, flushing ports/lines as ordered, and changing dressings every seven days and as needed. The facility’s IV medication policy required recording the drug name, dose, rate, date, and time on the container label. During observation and interviews, an LVN on duty stated she had not hung the IV bag but confirmed that IV bags and tubing were supposed to be labeled with the resident’s name, date, time, and nurse’s initials, and acknowledged that the unlabeled bag had been hung by the 2:00 PM–10:00 PM nurse. Another LVN later confirmed she was the nurse who administered the Daptomycin during that shift and admitted she knew she was required to label the IV bag and tubing but forgot to do so, despite having completed IV administration training and a skills check the previous month. Both LVNs, as well as the ADON and DON, stated that IV bags and tubing should be dated and initialed to prevent medication errors and infection, and that tubing should be changed every 24 hours. The facility’s failure to ensure labeling of the IV bag and tubing for this resident constituted the cited deficiency in pharmaceutical services and IV administration practices.
Failure to Act on Pharmacist’s Gradual Dose Reduction Recommendation for Antidepressant
Penalty
Summary
Surveyors identified a deficiency in the facility’s management of pharmacy consultant recommendations for gradual dose reduction (GDR) of psychotropic medications. The consultant pharmacist completed a monthly drug regimen review on 08/29/25 and documented a GDR request for a resident’s amitriptyline 100 mg daily, noting that per CMS regulations residents on psychotropic drugs must have GDR attempts unless clinically contraindicated. Record review showed the resident, an adult male with a diagnosis of depression and an intact BIMS score of 15, had been admitted earlier in the year and was receiving amitriptyline for major depressive disorder. His MDS and care plan documented ongoing antidepressant therapy and monitoring for depressive symptoms and adverse reactions. Medication administration records for November and December 2025 showed he continued to receive amitriptyline daily as originally ordered. Interviews and record review revealed that the pharmacy consultant’s August 2025 GDR recommendation for this resident’s antidepressant was not communicated to the attending physician and no action was taken. The ADON, who was responsible for reviewing pharmacy recommendations, acknowledged that the August GDR recommendation for the resident’s antidepressant was missed and was not forwarded to the physician. The DON confirmed that the ADON was responsible for reviewing pharmacy recommendations and stated she was unaware that this GDR recommendation had been missed. The facility’s psychotropic drugs policy, dated 10/25/17, stated that the facility implements GDRs and non-pharmacological interventions, unless contraindicated, for psychotropic medications. Despite this policy and the pharmacist’s documented recommendation, the resident’s drug regimen was not adjusted or reviewed with the physician in response to the GDR request.
Failure to Document Family Invitations to Care Plan Meetings
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with its documentation policy for one resident whose clinical record was reviewed. The resident was an elderly female with sequelae of cerebral infarction, dysphasia, gastrostomy status, anxiety disorder, depression, and schizophrenia, and had a BIMS score of 00 indicating severely impaired cognition. Her care plan indicated she wished to remain for long-term care and included an intervention to discuss options at each care plan meeting unless otherwise notified. During observation, she was in bed and did not rouse when spoken to, preventing direct interview. Her family member reported receiving calls about changes in condition but stated he had never attended a care plan meeting in person or by phone, did not recall being told about or invited to any care plan meetings in the last year, and expressed a desire to be invited so he could be updated on her care. The Social Worker stated it was her responsibility to schedule quarterly care plan meetings and that residents and families were invited. She reported that the resident’s family had been invited several times but did not attend, and that she previously sent letters but now called the family, often making 3–4 attempts and leaving voice messages. However, she was unable to locate any documentation of these attempts and acknowledged she had not documented her efforts to invite the family. The DON and Administrator both confirmed that the Social Worker was responsible for scheduling care plan meetings, that families should be notified by phone or letter and invited to attend, and that all attempts should be documented. The facility’s documentation policy required complete and accurate documentation of all relevant communications in the clinical record. Despite this, there was no documentation in the resident’s clinical record showing that the family/legal representative had been invited to participate in quarterly care plan meetings, resulting in an incomplete medical record for the resident.
Failure to Ensure Full Visual Privacy Due to Inadequate Bed Curtains
Penalty
Summary
The deficiency involves the facility’s failure to provide full visual privacy for three residents whose beds lacked properly installed privacy curtains that extended around the entire bed. For one cognitively intact female resident with bone infection, multiple pressure ulcers, cerebral palsy, bowel and bladder incontinence, and total dependence for ADLs, observation showed that when her privacy curtain was pulled closed, the end of her bed remained exposed. She later stated she did not like the end of her bed being exposed, would be upset if someone entered while she was being changed, and would prefer full curtain coverage but did not know that was an option. A cognitively intact male resident with a history of stroke, diabetes, heart disease, and an ADL self-care deficit was also observed in bed with his privacy curtain pulled, yet the end of his bed remained exposed; he reported that while the exposure did not generally bother him, he would not like someone walking in while he was changing and that the curtain had been that way since admission. A third cognitively intact male resident with stroke, muscle weakness, diabetes, and substantial ADL assistance needs was observed in bed with his privacy curtain partially closed; when fully closed, the curtain still did not wrap around to cover the end of his bed. He stated he was not bothered by the uncovered end but would not like someone entering and seeing him exposed, noting that staff close the door when providing care. Multiple staff interviews revealed that maintenance was responsible for hanging privacy curtains once notified, housekeeping was described as responsible for monitoring and replacing curtains, and nurses and CNAs were identified as primarily responsible for notifying housekeeping when curtains needed placement or replacement, though any staff member could do so. The DON confirmed the importance of privacy for resident dignity during care and stated that nurses and CNAs were responsible for alerting housekeeping when curtains needed attention, with maintenance then hanging the curtains. She also stated there was no policy specifically addressing privacy curtains.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of cerebral infarction, unspecified dementia, psychotic and mood disturbances, and anxiety was not provided with adequate supervision to prevent elopement. The resident, who had been assessed as a moderate elopement risk, was able to leave the facility unsupervised by following a transport company staff member who used a staff-only passcode to open the exit door. The resident was found half a block away from the facility with her walker and was brought back by staff. There was no prior documentation of exit-seeking or elopement attempts for this resident in the days leading up to the incident. The incident was discovered when a housekeeper, after leaving the building, observed an elderly individual with a walker in the street and reported it to the administrator. The administrator and housekeeper located the resident and returned her to the facility. Review of video footage showed that the resident exited through the main door as a transport company staff member entered, without being questioned or stopped. The door alarm did not sound because the staff member used the entry code, and no staff were aware of the resident's departure until after the fact. Interviews with facility staff revealed that they had not previously observed exit-seeking behaviors from the resident and were unaware of her elopement until notified. The facility's policies required all staff to monitor exit doors and report any attempts or suspicions of elopement, but in this case, the procedures were not effectively implemented, allowing the resident to leave the premises without detection.
Resident-to-Resident Physical Altercation Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when two residents with severe cognitive impairment engaged in a physical altercation. One resident, who had a history of physical behaviors directed towards others and was diagnosed with unspecified dementia, entered an empty room with another resident and closed the door. Another resident, also with severe cognitive impairment and a history of physical behaviors, became agitated when the door was closed in her face, pushed the door open, and physically attacked the first resident by grabbing her hair and pulling her out of the room. The altercation escalated, resulting in both residents hitting each other until staff intervened and separated them. The incident resulted in the first resident sustaining scratches to her left cheek and lip, as well as a developing bruise under her left eye. Documentation and witness statements confirmed that staff observed the altercation and responded by running to the scene to separate the residents. Prior to the incident, both residents were known to walk the hallways frequently, and staff were aware of their behavioral triggers and signs of agitation. However, there was no indication that either resident had previously exhibited physically aggressive behaviors towards others, and staff had not anticipated such an incident occurring between them. The deficiency was identified through observation, interviews, and record review, which revealed that the facility did not ensure residents were free from abuse by other residents. The altercation occurred in an unlocked, empty room at the end of the hallway, which both residents attempted to enter. The facility's failure to prevent the altercation and protect the resident from abuse constituted noncompliance with regulatory requirements for resident safety and freedom from abuse.
Failure to Develop and Implement Comprehensive Care Plan for Foley Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical needs, specifically omitting care planning for the resident's Foley catheter. The resident, a male with quadriplegia, neurogenic bladder, and a Stage 2 pressure ulcer, was dependent on staff for toileting hygiene and had a Foley catheter in place throughout the assessment period. Despite these needs, the care plan did not address the Foley catheter, and there were no physician orders related to its care. Nurse Practitioner notes indicated the need for a catheter securement device, but this was not reflected in the care plan or orders. Interviews with nursing staff revealed a lack of clarity regarding the care and documentation of the Foley catheter, with staff relying on general knowledge rather than specific care plans or orders. The Regional Compliance Nurse acknowledged that the interdisciplinary team was responsible for updating care plans and that the omission of the Foley catheter from the care plan and orders was an oversight from admission. The facility's policy required comprehensive care plans to address all medical needs, but this was not followed in this case.
Failure to Obtain Physician Orders for Foley Catheter Care
Penalty
Summary
A deficiency occurred when a resident who was admitted with a Foley catheter did not have physician orders in place to address the treatment and services required for catheter care. The resident, a male with quadriplegia, neurogenic bladder, and a Stage 2 pressure ulcer, was dependent on staff for toileting hygiene and had a catheter in place throughout the assessment period. Review of the resident's care plan and physician orders revealed that neither addressed the Foley catheter, and the only documentation related to catheter care was a nurse practitioner note instructing to ensure catheter securement to prevent pressure. Interviews with nursing staff and facility leadership confirmed that the admitting nurse did not obtain the necessary orders for the Foley catheter, and subsequent follow-up by the ADON and Regional Compliance Nurse failed to identify and correct the omission. Staff acknowledged that the lack of physician orders could result in missed care and increase the risk of infection. The facility's policy required nurses to review and clarify orders as needed, but this process was not followed, resulting in the deficiency.
Failure to Immediately Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to ensure that an alleged incident of verbal abuse was reported immediately, as required by policy, for one resident with severe cognitive impairment and multiple psychiatric diagnoses. An LVN overheard a CNA verbally abusing the resident and wrote a witness statement, which she placed under the Administrator's door while he was out of the building. The Administrator, who was also the facility's abuse coordinator, did not receive the statement and was not made aware of the allegation until later interviews. The LVN did not follow up or attempt to contact the Administrator by phone or other immediate means, as required by the facility's abuse reporting policy. The resident involved was nonverbal and unable to respond to questions due to severe cognitive impairment. The facility's policy required immediate verbal reporting of suspected abuse to the Administrator or designee, including after hours, but this was not followed. The Administrator confirmed that staff were expected to report abuse allegations directly and immediately, typically by phone or text, to ensure resident safety. The failure to report the allegation in a timely manner resulted in a delay in the facility's awareness and response to the alleged abuse.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by incidents involving a resident with a history of aggressive behavior. This resident, who had profound intellectual disabilities and poor impulse control, was involved in multiple altercations with other residents. The resident used a doll to hit two other residents in the face and head and punched another resident in the stomach. These incidents occurred in common areas such as the dining room, where the resident often interacted with others. The resident's care plan noted the potential for physical behaviors and included interventions to analyze triggers and de-escalate situations. However, these interventions were not effectively implemented, as the resident continued to exhibit aggressive behavior. Staff interviews revealed that the resident's actions were known, and attempts to redirect her were often unsuccessful. The resident's behavior was described as territorial, particularly concerning a male friend, which contributed to the altercations. The facility's failure to prevent these incidents resulted in an Immediate Jeopardy situation, indicating a serious threat to resident safety. The facility's policy on abuse and neglect emphasized the right of residents to be free from abuse, yet the incidents demonstrated a lack of effective measures to protect residents from harm. The facility's response included placing the resident on 1:1 supervision and eventually transferring her to another facility, but these actions were taken after the incidents had already occurred.
Removal Plan
- Resident #1 was immediately placed on 1:1 supervision with facility staff.
- Resident #1 discharged to alternate facility with guardians' approval.
- Resident #1's baby doll with the plastic heads were immediately removed from Resident #1's possession and from resident #1's room by regional compliance nurse.
- Resident's #1's care plan was reviewed by Regional Compliance Nurse for appropriate interventions to prevent resident and staff altercations.
- Resident #1's care plan was updated by the Regional Compliance Nurse to reflect additional interventions of 1:1 supervision and removal of baby dolls with hard plastic pieces.
- IDT team will schedule a care plan meeting with Responsible Party, Physician, and Resident to review and evaluate interventions to prevent repeated altercations with staff and residents.
- The Administrator and DON were in-serviced 1:1 by the Regional Compliance Nurse on the following topics: Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented to prevent abuse, Behavior Management Policy- Managing behaviors and intervening appropriately.
- The Medical Director was notified of the immediate jeopardy.
- An ADHOC QAPI was held with the IDT Team to discuss the immediate jeopardy and plan of removal.
- All staff will be in-serviced on the following topics below by the Administrator, Regional Compliance Nurse, DON, and ADON to prevent resident to resident abuse and ensure appropriate response to aggressive behaviors. All staff who are not present will not be allowed to assume their duties until in-serviced. All PRN staff will be in-serviced prior to their next assignments. All new hires will be in-serviced on their date of hire, during facility orientation. All agency staff will be in-serviced prior to starting their shift: Abuse and Neglect- Prevention of abuse/neglect and ensuring interventions listed on the care plan are implemented, Behavior Management Policy- Managing behaviors and intervening appropriately.
Failure to Provide Dignified Colostomy Care
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, specifically in the context of colostomy care. The resident, a female with a history of stroke, legal blindness, and rectal cancer requiring a colostomy, was moderately cognitively impaired and required assistance with toileting hygiene. On a particular evening, the resident's colostomy bag began leaking, and despite her request for assistance, the staff did not provide timely help. A CNA responded to her call light but informed her that a nurse was needed for the task. The nurse, LVN A, who was monitoring the dining area, placed a new colostomy bag on the resident's table but did not assist her in applying it, citing her responsibilities in the dining area. The resident was left to manage the situation herself, leading to further leakage and embarrassment due to the presence of her roommate and the open door to the hallway. LVN A did not communicate the resident's need for assistance to the other nurse on duty, LVN C, who was unaware of the situation until the surveyor's interview. The Director of Nursing (DON) expressed that the expectation was for nurses to communicate with each other to ensure residents receive timely assistance, which did not occur in this instance. This lack of communication and assistance resulted in the resident feeling embarrassed and not treated with the dignity and respect she deserved.
Failure to Provide Adequate Colostomy Care
Penalty
Summary
The facility failed to provide adequate colostomy care for Resident #5, a female resident with a history of stroke, legal blindness, and rectal cancer requiring a colostomy. The resident, who was moderately cognitively impaired, required assistance with toileting hygiene and ostomy care. On the evening of February 7, 2025, Resident #5 experienced a colostomy bag leak and requested assistance. CNA B responded to her call light but informed her that a nurse would need to assist. LVN A, who was monitoring the evening meal, placed a new colostomy bag on the resident's table but did not assist her or inform another nurse to provide the necessary care. As a result, Resident #5 attempted to manage the situation herself, leading to further leakage later that evening. Interviews with LVN A and LVN C revealed a lack of communication and coordination between staff members. LVN A did not notify LVN C, who was responsible for resident care during that time, about Resident #5's need for assistance. The Director of Nursing (DON) stated that the expectation was for nurses to communicate with each other to ensure residents receive timely care. The facility's Ostomy Care policy emphasizes the importance of proper stoma care to prevent skin irritation and breakdown, which was not adhered to in this instance.
Failure to Submit PASARR NFSS Forms Timely
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASARR) Level II determination and the PASARR evaluation report for eight residents. This failure was identified during interviews and record reviews, where it was found that the facility did not submit the Nursing Facility Specialized Services (NFSS) form requests by the specific deadline for these residents. The lack of timely submission of these forms could potentially place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require. The report details the medical conditions and cognitive impairments of the affected residents, who were all PASRR positive and had various diagnoses such as schizophrenia, intellectual disabilities, and anxiety disorders. Each resident's care plan included goals for receiving specialized services as recommended by the local authority per PASRR. However, the facility did not ensure that the necessary NFSS forms were completed and submitted on time, which is crucial for the continuation of these specialized services. Interviews with facility staff, including the Director of Rehabilitation and the Regional Operations Director, revealed a lack of formal training and understanding of the PASRR process. The Director of Rehabilitation, who was new to the position, was responsible for filling out the NFSS forms and ensuring they were signed and uploaded to the portal. However, due to a lack of training, the forms were not uploaded in a timely manner, leading to missed deadlines and errors in the submission process. The Regional Operations Director acknowledged the oversight and was working to correct the errors, but the delay in submission was already noted.
Failure to Update Care Plans for Residents' Specific Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which led to deficiencies in meeting their individual needs. Resident #13, a female with multiple diagnoses including metabolic encephalopathy and Alzheimer's disease, had a physician's order for pleasure feedings that was not included in her care plan. Despite being observed receiving pleasure feedings, the care plan only addressed her tube feeding needs. Interviews with staff revealed a lack of awareness and responsibility for updating the care plan to include pleasure feedings, which could result in staff not knowing the necessary interventions. Resident #63, who has end-stage renal disease and is dependent on dialysis, did not have his dialysis treatment included in his care plan. Although he was observed and interviewed confirming his dialysis schedule, the care plan lacked this critical information. Staff interviews highlighted the importance of an updated care plan for continuity of care and the risk of fluid volume deficit if dialysis was not properly monitored. The MDS Coordinator acknowledged the oversight and the need for care plans to be updated with any changes. The facility's policy requires comprehensive care plans to include measurable objectives and timeframes to meet residents' needs, but this was not adhered to for the two residents. The Director of Nursing emphasized that care planning is a shared responsibility among all staff, yet the care plans for these residents were incomplete, potentially impacting the quality of care provided.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide necessary assistance to a resident who was unable to perform activities of daily living, specifically incontinence care. The resident, a male with a history of cerebrovascular accident and hemiplegia, required substantial assistance with toileting and was at risk for pressure ulcers. Despite the care plan indicating the need for assistance every two hours, the resident reported not receiving a brief change from 4:00 AM until after 12:00 PM on one occasion, and from 4:00 AM until after 9:00 AM on another occasion. Observations confirmed the resident was left in a soaked state, with wet blankets and sheets, indicating a lack of timely care. Interviews with staff revealed inconsistencies in the care provided. CNA H, responsible for the resident's care, admitted to checking the resident less frequently on busier days and acknowledged that the resident was soaked during brief changes. LVN I and LVN F both expressed expectations for CNAs to check and change residents every two hours, but it was evident that this standard was not consistently met. The DON was not informed of the resident's condition during the incontinent care observation, highlighting a communication gap within the facility. The facility's policy on perineal care was reviewed, which outlined the procedure for cleaning after incontinence episodes. However, the failure to adhere to this policy and the care plan interventions resulted in the resident being at risk for skin breakdown and infection. The lack of timely incontinence care and the failure to maintain the resident's hygiene and dignity were significant deficiencies identified during the survey.
Deficiency in IV Fluid Administration and PICC Line Management
Penalty
Summary
The facility failed to ensure the safe and appropriate administration of intravenous (IV) fluids for a resident, leading to deficiencies in labeling and timely dressing changes. Specifically, the facility did not label the IV medication bag and tubing with the date, time, and initials, which is necessary to prevent medication errors. Additionally, the resident's peripherally inserted central catheter (PICC) line dressing was not changed for eight days, despite the care plan indicating a change every seven days. This oversight was observed during a survey, where the dressing appeared dirty, and the IV bag and tubing lacked proper labeling. The resident involved was a female with a diagnosis of pneumonia, requiring intravenous access for medication administration. The resident's care plan included monitoring for signs of infection at the insertion site and specified PICC line dressing changes every seven days. However, there were no physician orders for dressing changes and flushes documented, and the treatment administration records lacked any documentation of PICC line dressing changes. Interviews with the licensed vocational nurses (LVNs) revealed that they were aware of the requirements but failed to adhere to them, citing reasons such as being new to the facility and forgetting to input necessary orders. The Director of Nursing (DON) acknowledged the expectation for staff to date and initial IV bags and tubing and to change dressings every seven days. The DON also noted that the admitting nurse should have entered the orders for dressing changes and flushes, but this was not done. The facility had standard orders for these procedures, and training records indicated that staff had received training on IV therapy competency. Despite this, the oversight in labeling and dressing changes was not caught by management, as the Assistant Director of Nursing (ADON) had assured the DON that all orders for new admissions were up to date, which was not the case for this resident.
Inaccurate Narcotic Logs and Documentation Failures
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, specifically in maintaining accurate narcotic logs for two residents. The medication aide responsible for the 100 Hall medication cart did not sign off on the narcotic administration record after administering medications to the residents. This resulted in discrepancies between the narcotic administration records and the actual pill counts in the blister packs. For one resident, the narcotic administration record indicated 13 pills remaining, while the blister pack contained only 11 pills. For another resident, the record showed 102 pills remaining, but the blister pack had 101 pills. The medication aide admitted to administering the medications but forgetting to document the administration on the narcotic log. The Director of Nursing (DON) confirmed that staff are expected to document narcotic administration immediately to prevent discrepancies. Despite previous training on narcotic log documentation, the medication aide failed to comply with the facility's procedures. The DON acknowledged the importance of random checks on medication carts and stated that she had conducted such checks two weeks prior to the incident.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and provide adequate supervision to prevent elopement for a resident with severe cognitive impairment. The resident, who had a history of elopement and was at risk due to cognitive deficits and other medical conditions, managed to leave the facility unnoticed. The resident was found 8 miles away at a restaurant, and the facility was only informed of the elopement by a family member after being contacted by a community member. The deficiency was primarily due to the failure of staff to conduct regular rounds and checks on residents, particularly the resident in question. On the day of the incident, staff did not perform the necessary checks at the end of their shifts or upon starting their shifts. The resident was last seen by a nurse at 4:00 AM, and no further checks were made until the elopement was discovered after 7:15 AM. The resident's care plan had identified him as an elopement risk, yet the necessary precautions and supervision were not adequately implemented. Interviews with staff revealed a lack of adherence to the facility's policies on elopement prevention and response. Staff members admitted to not conducting rounds or checking on residents as required, which contributed to the resident's ability to elope. The facility's policies on elopement risk assessment and response were not effectively followed, leading to the resident's unsupervised departure and subsequent risk of harm.
Failure to Address Slip Hazard in Hallway
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards in the south hallway of Zone 3, between the vending machines and the doorway to the smoking courtyard. On July 5, 2024, a large puddle of water was observed in this area, which had entered through gaps in the doorway and a missing threshold during a brief rain shower. Four residents were cautioned about the water on the floor, as they had not noticed it until alerted. Laundry Staff A was asked to get housekeeping or a staff member to clean up the water, and subsequently, they obtained the necessary supplies to address the spill. Interviews with staff revealed that the area was known to have water issues when it rained or when plants were watered outside. Laundry Staff A mentioned that housekeeping typically handled such spills, but they were on break at the time. LVN B and RN E both emphasized the importance of cleaning up spills immediately to prevent slip and fall hazards. The Administrator (ADM) was unaware of the leaking doorway and stated that staff should have put up a caution sign and informed housekeeping. The facility's policy on fall risk and environmental hazards highlighted the need to maintain nonslip surfaces and clean spills immediately, which was not adhered to in this instance.
Infection Control Deficiency: Catheter Bag Placement
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the improper handling of a resident's indwelling urinary Foley catheter. The catheter bag was observed lying flat on the floor, which could lead to cross-contamination and infection. The resident, a male with obstructive and reflux uropathy, had a moderate cognitive impairment and was unaware of the catheter's proper placement. The facility's policy clearly stated that catheter tubing and drainage bags should be kept off the floor, yet this guideline was not followed. Interviews with staff, including an LVN, a CNA, the DON, and the Administrator, confirmed that the catheter bag should not have been on the floor. The LVN acknowledged the oversight and corrected the situation by hanging the catheter bag on the bed railing. The CNA admitted to not noticing the bag's improper placement, and both the DON and Administrator emphasized the importance of keeping the catheter bag off the floor to prevent infection. Despite previous in-service training on catheter care, the staff failed to adhere to the facility's infection control policy.
Failure to Develop Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which could place them at risk of not receiving the individualized care they required. Resident #1, a female with mild cognitive impairment and multiple diagnoses including a leg fracture and heart failure, had a care plan that was not individualized. Similarly, Resident #2, a male with a pacemaker and heart disease, and Resident #3, a male with moderate cognitive impairment and dementia, also had care plans that lacked individualization. The care plans for these residents included generic focuses and interventions that were not tailored to their specific needs. Interviews with the MDS Coordinator and the DON revealed that the facility's care planning process was disorganized, with each department adding their part of the care plan without proper oversight. The MDS Coordinators were responsible for completing the comprehensive care plans but had not individualized them for the residents in question. The DON acknowledged the risk of not having individualized care plans, stating that staff might not know what care the residents needed. The facility's policy required person-centered comprehensive care plans, but this was not being effectively implemented.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to ensure a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, the facility did not ensure that the resident was not left in a soiled brief for an extended period of time. This failure was observed on multiple occasions, with the resident having to wait for assistance for up to 45 minutes. The resident's family had to be called in to assist with incontinence care due to the lack of prompt response from the facility staff. The resident, a [AGE] year-old female with diagnoses including a fracture of the right lower leg, morbid obesity, heart failure, and asthma, was admitted to the facility and required assistance with most of her ADLs. Her care plan was not individualized, and she was not care planned for bowel and bladder incontinence. On the day of the observation, the resident reported being soiled and having called for help at 8:40 AM, but assistance did not arrive until 9:26 AM. This was the second time that morning she had to wait for an extended period to be changed. Interviews with the resident's family and facility staff revealed that the resident's family often had to assist with incontinence care due to the lack of available staff. The family member reported observing nurses sitting at the nurse station not doing anything while the CNAs struggled to find help. The facility's ADON and DON both stated that call lights should be answered within 5-15 minutes, but this expectation was not met. The facility's current Perineal Care Female policy did not reference time frames for care or define what would be considered prolonged wait times.
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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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