Arlington Residence And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arlington, Texas.
- Location
- 405 Duncan Perry Rd, Arlington, Texas 76011
- CMS Provider Number
- 455872
- Inspections on file
- 56
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Arlington Residence And Rehabilitation Center during CMS and state inspections, most recent first.
A resident was discharged to another facility without a completed discharge summary, as required by facility policy. While some documentation such as the face sheet and medication orders was provided, essential elements like the reason for discharge, medication reconciliation, and a final summary of the resident's status were missing. Staff interviews revealed inconsistent practices and uncertainty about discharge documentation responsibilities.
A resident with severe cognitive impairment eloped from a facility twice due to inadequate supervision and environmental hazards. Despite being in a secure unit, the resident broke a window and left the facility, being found by police hours later. On a second occasion, the resident scaled a fence after breaking another window. Staff were aware of the resident's elopement risk but failed to prevent these incidents.
The facility failed to maintain an adequate emergency water supply, leaving 68 residents at risk. Observations revealed no emergency water on site, and interviews with the Dietary Manager and Administrator showed a lack of awareness and responsibility for water storage. The Chief Nursing Officer confirmed the need for a three-day supply, which was not met, as the facility lacked the required 519 gallons of water for residents and employees.
The facility failed to maintain a safe, clean, and homelike environment, with issues such as stained ceiling tiles, a precarious HVAC vent, inadequate clean linens, and a broken room door. These deficiencies affected residents' comfort and safety, with staff and management aware of the issues but unable to resolve them due to various constraints.
The facility failed to conduct EMR/NAR checks for a CNA prior to employment, as required by their Abuse Prevention Program. This oversight was discovered during a review of employment registry screenings, revealing that the HR Manager did not complete the necessary checks before the CNA's hire date. The Administrator confirmed the checks were not monitored, potentially placing residents at risk.
Three residents in an LTC facility did not receive scheduled showers, impacting their hygiene and dignity. A resident with quadriplegia was not bathed due to a lack of clean linens, while another with total paralysis had stained linens and unkempt hair. A third resident refused bed baths when clean linens were unavailable. Staff interviews revealed documentation and communication issues regarding shower refusals.
The facility failed to provide organized activities for residents in a secure unit, as observed over several days. Despite a scheduled activities calendar, no activities were conducted, and residents were left with minimal engagement. Staff interviews confirmed the absence of activities, and the Activity Director cited challenges in managing activities on and off the unit.
The facility failed to verify the certification status of two CNAs, allowing them to provide care without current certifications. The HR Manager did not complete the required EMR/NAR checks upon hire or annually, leading to expired certifications for CNA D and CNA E. Interviews revealed a lack of oversight and awareness of certification requirements, potentially risking resident safety.
A resident with chest pain did not receive her prescribed Ranolazine 1000 mg ER on multiple occasions due to a failure in the facility's pharmaceutical services. The medication aide ordered the medication twice, but it was not delivered, and the issue was not communicated to management in a timely manner. The facility's policy for ordering medication was not followed, leading to missed doses and a breakdown in communication among staff.
The facility failed to maintain kitchen sanitation standards, with dust and fuzz on air vents and grease buildup on the stove backsplash. Staff interviews revealed confusion over cleaning responsibilities, with the stove last cleaned a month ago and vents not cleaned for three months, contrary to the facility's sanitation policy and the Federal Food Code 2022.
The facility failed to maintain essential laundry equipment, resulting in a backlog of laundry and unclean linens for residents. A resident reported having stained sheets for six days and a lack of clean towels for showering. The facility operated with only one residential washing machine, as the commercial machine was broken. The Administrator acknowledged the issue and had requested a new machine from corporate.
The facility failed to provide privacy curtains for several resident rooms, compromising visual privacy. Observations showed missing curtains and window blind slats in multiple rooms. The HR Manager acknowledged responsibility but noted the floor tech responsible for curtains had quit. The Administrator confirmed no specific policy on privacy curtains, but they were covered under Resident Dignity policies.
The facility failed to provide adequate training on dementia and ANE for several CNAs and LVNs, as required by policy. Training transcripts lacked documentation of completed trainings, and there was no monitoring system to ensure compliance. The HR Manager and DON acknowledged the absence of a system to track training completion, which could lead to potential harm due to untrained staff.
A facility failed to ensure a resident was free from physical restraints unless needed for medical treatment. The resident, with severe cognitive impairment, had half bedrails in place without a care plan, safety assessment, or consent. Staff interviews revealed the bedrails were not used for mobility, contrary to the physician's order. The DON was unaware of the bedrail type, and the facility's policy on side rails was not followed.
A resident with severe cognitive impairment and multiple health conditions was sent to the hospital, yet her EMR inaccurately showed vital signs and medication refusals documented by LVNs. One LVN was not present, and the other admitted to documenting without verifying the resident's presence. The DON confirmed the resident had passed away at the hospital, highlighting a failure in maintaining accurate records.
A resident was issued an immediate discharge from a facility due to non-compliance with the smoking policy, but the facility failed to provide the required written notification to the resident and the Ombudsman. The resident, who had intact cognition and multiple medical conditions, was sent to a hospital for low sodium and was ready for discharge shortly after. However, the facility refused to readmit the resident, leaving them without a place to go and without proper discharge planning.
A resident with a history of elopement risk managed to leave a secured unit in an LTC facility due to a malfunctioning door alarm. The resident exited through a back door that did not sound an alarm, allowing him to leave unnoticed initially. Staff later found and returned the resident safely, but the incident revealed a significant lapse in safety measures.
Two incidents at the facility resulted in violations of resident rights and dignity. In the first case, a staff member recorded a resident with his cell phone while the resident was agitated, violating privacy policies. The resident had cognitive impairments and a history of behavioral issues. In the second case, a CNA removed a resident's cell phone to prevent him from calling 911 during a care episode, which was against the resident's rights. The resident had multiple sclerosis and cognitive deficits. Both incidents reflect a failure to respect residents' rights to dignity and communication.
The facility failed to serve pureed bread to residents on a pureed diet during a lunch meal. A dietary staff member forgot to prepare the bread, and the DM did not ensure all meal components were served. This oversight affected residents requiring a pureed diet, including one with dementia and malnutrition, as the facility did not follow its policy to meet residents' nutritional needs.
The facility failed to maintain an effective pest control program, leading to the presence of bugs in a resident's room and a dining area. Multiple residents and staff reported frequent sightings of bugs, including cockroaches, throughout the facility. Despite regular visits from a pest control company, the issue persisted, as documented in maintenance logs.
The facility failed to ensure Cook C wore a beard restraint while preparing and serving food, as observed during a lunch meal service. Cook C, with facial hair, was seen using a blender and plating meals without a beard restraint, contrary to the facility's policy and the Federal Food Code. Interviews revealed a lack of awareness and availability of beard restraints in the kitchen.
A resident with moderate cognitive impairment and a history of Alzheimer's was not provided necessary grooming services, resulting in unwanted facial hair. Despite the resident's desire for hair removal, staff did not offer or attempt to shave her chin, and there was no documentation of care refusal. Interviews with facility staff revealed a lack of awareness and action regarding the resident's grooming needs, contrary to the facility's policy requiring daily grooming.
The facility did not update the daily nurse staffing information on one occasion, as required by policy. Observations showed that the staffing information was not updated for the current day, and interviews revealed that the DON, responsible for the update, did not return to the facility. The ADON acknowledged the oversight, and the Administrator confirmed the requirement for daily updates.
A resident with schizoaffective disorder and other health issues was not re-admitted to the facility after being transferred to a behavioral health hospital. Despite the discharge assessment indicating a return was anticipated, the facility did not complete necessary paperwork or communicate effectively with the hospital. The DON and Administrator cited safety concerns and property damage as reasons for not allowing the resident to return.
A resident's urinary catheter was found on the floor, contrary to infection control protocols. The resident, with a complex medical history, was unaware of the catheter's position. The LVN repositioned the catheter after surveyor prompting. The DON and Administrator confirmed the expectation for proper catheter positioning, aligning with facility policy.
A resident in a LTC facility was unable to use a non-functional call light system, impacting her ability to request assistance. Despite being cognitively intact and requiring a wheelchair, she had to self-propel to the nurse's station for help. The LVN was unaware of the issue, and the maintenance log showed no record of the malfunction. The Corporate Maintenance Director and Administrator both emphasized the importance of a functioning call light system, which was not adhered to as per facility policy.
The facility failed to provide adequate supervision and assistive devices to prevent accidents for three residents. One resident experienced a fall resulting in a sacrum fracture, another eloped from a secured unit due to a malfunctioning door, and a third sustained burns from accessing a microwave in an unlocked staff break room.
Failure to Complete Required Discharge Summary for Resident Transfer
Penalty
Summary
The facility failed to complete a required discharge summary for a resident who was discharged to another healthcare facility. Record review showed that while the resident's face sheet, medication orders, and belongings were provided at discharge, there was no comprehensive discharge summary in the clinical records. The available documentation, including the Summary Episode Note, did not address key elements such as the reason for discharge, date of discharge, reconciled medications sent to the new facility, personal belongings disposition, or physician signature. Additionally, the resident's care plan did not address discharge goals. Interviews with facility staff revealed inconsistent understanding and implementation of discharge documentation procedures. The nurse responsible for the discharge documented the transfer in progress notes and provided some information to the receiving facility, but did not complete a full discharge summary as required by facility policy. The DON and Administrator both indicated uncertainty or changes in policy regarding who was responsible for completing the discharge summary, and the process was not followed for this resident. The facility's own policy required a comprehensive discharge summary to be completed by the interdisciplinary team, but this was not done.
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 diagnosed with dementia, managed to leave the facility on two separate occasions. On the first occasion, the resident broke a window in his room and was found by the police after being missing for several hours. The facility's secure unit was not adequately monitored, and the resident's risk of elopement was not sufficiently mitigated. The resident was placed in a secure unit due to his risk of wandering and elopement, yet the interventions in place were insufficient. Despite being on enhanced supervision, the resident was able to break a window and exit the facility. Staff interviews revealed that the resident was known to pack his belongings and stand by exit doors, indicating a desire to leave, but he was usually redirected back to his room. However, on the day of the incident, the staff failed to prevent his elopement. On a subsequent occasion, the resident again managed to elope by breaking a window and scaling a newly constructed fence. The fence was improperly constructed with rails on the inside, facilitating the resident's escape. Staff witnessed the resident climbing the fence but were unable to reach him in time. The facility's failure to provide adequate supervision and secure the environment placed the resident at risk of harm and serious injury.
Inadequate Emergency Water Supply Puts Residents at Risk
Penalty
Summary
The facility failed to ensure an adequate emergency water supply was available, placing 68 residents at risk. During an observation, it was found that the facility had no emergency water on hand. Interviews with the Dietary Manager and the Administrator revealed a lack of awareness and responsibility regarding the storage and management of emergency water supplies. The Dietary Manager admitted to never ordering or being informed about emergency water storage, while the Administrator acknowledged the absence of a policy and the need for corporate guidance. The Chief Nursing Officer confirmed the necessity of having at least one gallon of water per resident for three days, which was not met. The facility's policies indicated a requirement for a three-day supply of water, but this was not adhered to. The record review showed discrepancies in the understanding and implementation of emergency water requirements, with the facility lacking the necessary 519 gallons of water for residents and employees. This oversight could lead to dehydration and other health complications for residents.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. In one instance, ceiling tiles above a resident's bed were stained and had not been replaced for over a month, despite the resident notifying the nursing staff. Additionally, a ceiling HVAC vent in another resident's room was found to be hanging precariously due to a missing screw, posing a potential safety hazard. The facility also failed to provide adequate clean linens for residents, as observed in the case of a resident whose sheets had not been changed for approximately six days due to a shortage of clean linen. The laundry facilities were found to be lacking in clean linens, and the laundry supervisor acknowledged the shortage, attributing it to staff discarding dirty linens and the facility having only one functioning residential washing machine. The administrator was aware of the linen shortage but had not been able to secure a commercial washing machine due to budget constraints. Furthermore, the facility did not ensure that room doors were in proper working condition, as seen in the case of a resident whose door did not latch and remained open unless blocked by a wheelchair. This issue had persisted for a couple of months, and although the maintenance director was aware of the problem, it had not been addressed. The facility's policy on providing a homelike environment was not adhered to, as residents were not provided with a clean, sanitary, and orderly environment, nor with clean bed and bath linens in good condition.
Failure to Conduct EMR/NAR Checks for CNA Prior to Employment
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. This deficiency was identified during a review of the employment registry screenings for one of the eight employees, specifically CNA D. The facility did not ensure that a search of the EMR/NAR was completed for CNA D prior to employment and before providing direct patient care. This oversight could place residents at risk for abuse, neglect, exploitation, and misappropriation of property. The HR Manager, who began working at the facility in March 2024, acknowledged that no EMR/NAR checks were completed for CNA D before her hire date of July 7, 2023, nor was an annual EMR/NAR check conducted. The HR Manager stated that it was her responsibility to complete these checks both upon hire and annually. The Administrator confirmed that EMR/NAR checks were supposed to be completed by the HR Manager and that it was his responsibility to monitor their completion. The facility's current, undated Abuse Prevention Program outlines the requirement for conducting employee background checks to prevent employing individuals with a history of abuse, neglect, exploitation, or misappropriation of property.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Specifically, three residents, identified as Residents #29, #48, and #57, did not receive showers as scheduled. This deficiency was observed through record reviews, interviews, and direct observations, which revealed that these residents were not provided with adequate bathing services, leading to poor hygiene and potential risks to their health and dignity. Resident #29, a female with quadriplegia and other significant medical conditions, was dependent on staff for bathing. Her care plan did not address bathing or showering, and records showed she did not receive showers or bed baths during a specified period, with no documented refusals. Interviews revealed that she was told by staff that there were no clean linens or towels available, and she expressed feelings of diminished self-esteem due to the lack of personal care. Resident #48, a male with total paralysis due to multiple sclerosis, was also dependent on staff for ADLs. His care plan was not individualized, and he had a pressure ulcer. Observations noted that his bed linens were stained, and he had not been bathed recently, as confirmed by his statements. Similarly, Resident #57, a male with multiple health issues, required substantial assistance with bathing. He refused bed baths when clean linens were unavailable, citing the futility of washing only to return to a dirty bed. Interviews with staff, including CNAs, LVNs, and the DON, highlighted inconsistencies in documentation and communication regarding shower refusals and the importance of maintaining hygiene for infection control and resident dignity.
Lack of Activities in Secure Unit
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of residents in a secure unit. Observations over several days revealed that no organized activities were conducted as per the facility's activities calendar. On multiple occasions, residents were seen in the dining room with the TV on, but no structured activities were taking place. Staff interviews confirmed that activities listed on the calendar were not being executed, and the Activity Director admitted to difficulties in managing activities both on and off the unit. The facility's policy on activity programs states that activities should be available daily and tailored to individual resident needs. However, the Activity Director acknowledged that none of the scheduled activities were conducted during the observed days, and only minimal engagement, such as painting nails, was attempted. The Administrator was unaware of the complete lack of activities and recognized the importance of activities in preventing resident boredom and potential behavioral issues.
Failure to Verify CNA Certification Status
Penalty
Summary
The facility failed to ensure that two certified nurse aides (CNAs), identified as CNA D and CNA E, had current nurse aide certifications while employed and actively providing care to residents. The facility did not complete the required EMR/NAR checks upon hire or annually for these CNAs. CNA D's personnel file showed no evidence of a completed EMR/NAR check, and CNA E's certification had expired without renewal. The HR Manager, who was responsible for conducting these checks, was unaware of the requirement to update both CNA and MA certifications annually until informed by regional management. The HR Manager had instructed CNA D to renew her certification, but it was not done, and CNA E was under the impression that renewing her MA certification would automatically renew her CNA certification. Interviews with the HR Manager, Director of Nursing (DON), and the Administrator revealed a lack of monitoring and oversight in ensuring that certifications were current. The HR Manager acknowledged her responsibility to conduct annual EMR/ENR checks but stated that it was also the staff's responsibility to keep their certifications current. The DON and Administrator confirmed that the HR Manager was responsible for these checks and that the failure to maintain active certifications could lead to potential harm to residents, including falls, fractures, and incorrect procedures. The facility's policy required all nursing staff to meet specific competency requirements as defined by state law, which was not adhered to in this case.
Failure to Administer Prescribed Medication
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the administration of Ranolazine 1000 mg ER for chest pain. The resident, a female with a diagnosis of chest pain and moderate cognition, did not receive her prescribed medication on several occasions. The medication was not administered on the evenings of February 3rd and 4th, and the mornings of February 4th and 5th, as documented in the Medication Administration Record (MAR). The medication aide (MA) responsible for administering the medication was aware of the shortage and had ordered the medication from the pharmacy twice, but it was not delivered. The MA failed to notify management about the missing medication, although she informed the nurse. The charge nurse was not made aware of the issue until February 5th, and the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were also not informed until later. The facility's policy required medication to be ordered when seven tablets remained, but this was not adhered to, leading to the missed doses. Interviews with facility staff, including the MA, charge nurse, ADON, DON, and the pharmacist consultant, revealed a breakdown in communication and procedure adherence. The pharmacist consultant noted that the facility should have followed up with the pharmacy within 24 hours of ordering and notified the doctor for a substitute medication. The physician assistant was not aware of the issue until February 5th and instructed the facility to hold the medication until it was available. The facility's failure to ensure timely medication refills and communication with the pharmacy and physician led to the resident missing critical doses of her medication.
Deficiency in Kitchen Sanitation Standards
Penalty
Summary
The facility failed to maintain kitchen sanitation standards, as observed during a survey. Specifically, three air conditioning vents over the food preparation area and two vents by the dishwasher were found to have accumulated fuzz and dust. Additionally, the stove backsplash was observed to have a buildup of grease. These conditions were noted on two consecutive days, with food being prepared in the kitchen during the second observation. Interviews with staff revealed a lack of clarity regarding cleaning responsibilities. A staff member was unsure who was responsible for cleaning the stove backsplash and could not recall the last cleaning. The Dietary Manager indicated that kitchen staff, particularly cooks, were responsible for cleaning the stove, which was last cleaned about a month ago. The Maintenance Supervisor was uncertain about who should clean the air vents, which had not been cleaned for approximately three months. The facility's sanitation policy and the Federal Food Code 2022 require that food service areas and equipment be maintained in a clean and sanitary manner, free from dust, grease, and other contaminants.
Failure to Maintain Essential Laundry Equipment
Penalty
Summary
The facility failed to maintain essential equipment, specifically a laundry washing machine, in safe operating condition. This deficiency was observed when Resident #37 was found with large brown stains on his bed sheets, which had been unchanged for about six days. The resident also reported being unable to shower due to a lack of clean towels. The facility's laundry area was found to have only one operational residential washing machine, as the commercial washing machine was broken with parts removed and placed on top of it. Interviews with the Laundry Aide and Laundry Supervisor revealed that the facility had been operating with only one residential washing machine for about a month, leading to a backlog of laundry. The Administrator acknowledged the insufficiency of one residential washing machine for the facility's needs and stated that he had requested a new machine from corporate multiple times. The Administrator also mentioned that the facility had sent laundry out for cleaning on a few occasions. The facility's Quality of Life-Homelike Environment policy emphasizes providing residents with a clean and comfortable environment, which was not upheld due to the equipment failure.
Lack of Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to ensure that each bed had ceiling-suspended curtains to provide total visual privacy for residents in several rooms. Observations revealed that multiple rooms lacked privacy curtains at the end of the beds, and some rooms had no privacy curtains at all. Additionally, there were missing slats in the window blinds in one of the rooms. This lack of privacy curtains was noted in rooms #110, #117, #118, #120, #122, #127, and #144, which could compromise the residents' privacy. Interviews conducted with the HR Manager and the Administrator highlighted that the responsibility for changing out the curtains fell to a floor technician who had recently quit and had not been replaced. The HR Manager acknowledged her ultimate responsibility for ensuring privacy curtains were in place. The Administrator confirmed that there was no specific policy addressing privacy curtains, but they were considered under the broader policy of Resident Dignity. The facility's undated policy on Quality of Life-Dignity emphasized respecting residents' private space and property, including knocking before entering rooms and not handling personal belongings without permission.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for eight out of eleven staff members reviewed for training. Specifically, the facility did not provide training on dementia and abuse, neglect, and exploitation (ANE) for CNAs A, B, C, D, E, and LVNs G and H. The training transcripts for these staff members did not indicate when the last ANE or dementia training had been completed, which is a requirement according to the facility's policy. Interviews with the HR Manager and the Director of Nursing (DON) revealed that there was no monitoring system in place to ensure that required trainings were completed and documented in the staff's employee files. The HR Manager stated that all required trainings were to be completed every two years and that staff were directed to complete their trainings online, with completion certificates to be submitted to the DON. However, the DON admitted that some in-service trainings were conducted in person but could not be located during the survey. The Administrator also confirmed the lack of a monitoring system to ensure trainings were completed, acknowledging the potential for harm when staff are not properly trained. The facility's policy requires nursing staff to participate in a competency-based staff development and training program, which includes preventing abuse, neglect, and exploitation, as well as dementia management.
Failure to Properly Assess and Care Plan for Bedrail Use
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints unless required for medical treatment. Specifically, the facility did not care plan for the use of half bedrails for a resident who was at risk for falls and had severe cognitive impairment. The resident's care plan did not address the use of bedrails, and there was no assessment for bedrail safety or consent for their use from the resident's responsible party. The resident had a physician order for bedrails for mobility, but observations indicated that the resident did not use the bedrails for mobility and was unable to follow requests to reposition herself using them. Interviews with facility staff revealed that the resident did not use the bedrails for mobility and would only grab onto them when being turned for incontinent care. The Director of Nursing (DON) was unaware that the resident's bedrails were half rails instead of mobility bars and stated that bedrails should only be used for mobility, not to keep the resident in bed. The facility's policy on the proper use of side rails was not followed, as it requires an assessment for the use of side rails, consent from the resident or legal representative, and inclusion in the resident's care plan.
Inaccurate Medical Record Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, leading to a deficiency in accordance with accepted professional standards. The resident, a female with severe cognitive impairment and multiple health conditions including congestive heart failure, diabetes, and chronic kidney disease, was sent to the hospital following a fall. Despite the resident's absence from the facility, her electronic medical records (EMR) inaccurately reflected vital signs and medication refusals, which were documented by two Licensed Vocational Nurses (LVNs). Interviews revealed that LVN B, who was not present on the day in question, had her password saved on the computer, allowing another nurse to document under her credentials. LVN A, who was working that day, admitted to documenting the resident's medication refusals and vitals without verifying the resident's presence in the facility. The Director of Nursing (DON) confirmed that the resident had passed away at the hospital earlier that day, making it impossible for the documented events to have occurred at the facility. The facility's documentation practices were called into question, as the DON and Assistant Director of Nursing (ADON) acknowledged that nurses may have been careless with password security and documentation accuracy. The facility's policy required that all services and changes in a resident's condition be accurately documented by licensed personnel, but this was not adhered to, resulting in the deficiency.
Failure to Notify Resident and Ombudsman of Immediate Discharge
Penalty
Summary
The facility failed to properly notify a resident, their representative, and the Office of the State Long-Term Care Ombudsman of an immediate discharge, as required by regulations. The resident, who had a history of non-compliance with the facility's smoking policy, was issued a 30-day discharge notice due to this non-compliance. However, the facility later decided to issue an immediate discharge notice without providing the required written notification to the resident and the Ombudsman. The resident, who had intact cognition as indicated by a BIMS score of 15, was admitted to the facility with multiple diagnoses, including a fibroblastic disorder, Type II diabetes, muscle weakness, a personality disorder, and an acquired absence of the right leg below the knee. Despite the resident's refusal to adhere to the smoking policy, the facility's documentation did not show that the resident or the Ombudsman received a written copy of the immediate discharge notice. Interviews with the DON and the Ombudsman revealed that the Ombudsman was not aware of the immediate discharge notice, and the resident was not provided with the necessary documentation. The resident was sent to a local hospital due to critical lab results for low sodium and was ready for discharge a few days later. However, the facility refused to readmit the resident, citing the 30-day discharge notice. This left the resident without a place to go, as the facility did not assist in finding alternative placement. The facility's failure to provide proper notification and assistance with discharge planning placed the resident at risk of not having access to advocacy services and discharge options.
Resident Elopement Due to Faulty Door Alarm
Penalty
Summary
The facility failed to ensure adequate supervision and functioning assistive devices to prevent accidents, specifically for a resident who eloped from a secured unit. The resident, who had a history of elopement risk and cognitive impairment, managed to exit the facility through a back door that was not properly secured. The door alarm did not sound, allowing the resident to leave the premises unnoticed initially. The resident, who had been admitted to the secured unit due to his risk of wandering and elopement, was able to leave the facility because the back door was not functioning correctly. Staff interviews revealed that the door alarm did not activate, and the door was found wide open. The resident was eventually found by staff and returned to the facility without injury, but the incident highlighted a significant lapse in the facility's safety measures. The deficiency was identified as past noncompliance, with the immediate jeopardy situation beginning and ending over a two-day period. The facility's failure to maintain a secure environment and provide adequate supervision placed the resident at risk of harm, severe injury, or even death. The incident underscored the importance of ensuring that all exit doors are properly secured and alarms are functioning to prevent similar occurrences.
Violation of Resident Rights and Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with respect and dignity, leading to a deficiency in the care provided to two residents. The first incident involved the Maintenance Director recording a resident with his personal cell phone while the resident was yelling and cursing at the staff. The resident, who had a history of stroke, hemiplegia, and traumatic brain injury, was cognitively impaired and used a wheelchair for mobility. The Maintenance Director claimed he recorded the incident to show management how the resident treated him, but he was unaware that recording residents was against policy. The Administrator confirmed that the Maintenance Director had been trained on managing residents with behaviors and acknowledged that recording the resident was a violation of the resident's rights. The second incident involved a CNA taking away a resident's cell phone when the resident attempted to call 911. This resident had multiple sclerosis, cognitive communication deficit, and muscle weakness, with a moderately impaired cognition. The resident had a history of refusing care and being verbally and physically aggressive. During an episode where the resident was being changed, he became upset and attempted to call 911, prompting the CNA to take his phone away. The CNA stated she was following the DON's orders, although the DON later denied instructing staff to remove the resident's phone. The phone was eventually returned to the resident, but the incident was recognized as a violation of the resident's rights. Both incidents highlight the facility's failure to uphold residents' rights to dignity, self-determination, and communication. The actions of the Maintenance Director and the CNA, whether intentional or due to misunderstanding, resulted in breaches of privacy and autonomy for the residents involved. The facility's policies on electronic devices and resident rights were not adhered to, leading to these deficiencies in care.
Failure to Serve Pureed Bread to Residents on Pureed Diet
Penalty
Summary
The facility failed to adhere to the prescribed menu for residents requiring a pureed diet during the lunch meal on September 10, 2024. Specifically, pureed bread was not served to eight residents who required it, including a resident with non-Alzheimer's dementia and malnutrition. This oversight was identified through observation, interviews, and record reviews, which revealed that the dietary staff did not follow the menu that was supposed to meet the nutritional needs of the residents. The deficiency occurred because the dietary staff member responsible for preparing the pureed bread forgot to make it, and the Dietary Manager (DM) did not verify that all meal components were prepared and served. The DM acknowledged that the omission of meal components could lead to missing nutritional values in residents' diets. The facility's policy requires that menus meet the nutritional needs of residents, but this was not followed, resulting in a failure to provide the necessary dietary components to residents on a pureed diet.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of small brown bugs in one resident's room and a dining area. Observations and interviews revealed that multiple residents and staff members noticed bugs throughout the facility, including cockroaches and other insects. Resident #3 reported finding bugs in his room every night, which crawled into his shoes, while Resident #7 observed bugs daily and claimed that staff did not address the issue. On-site observations confirmed the presence of bugs in Resident #6's room and the Sunflower hallway. Interviews with staff, including CNAs, LVNs, and the Maintenance Director, indicated that bugs were frequently seen in various areas of the facility. Staff members reported these sightings to the maintenance department, which logged them in a maintenance book. The Maintenance Director acknowledged the pest issue and stated that a pest control company visited regularly. However, the problem persisted, as evidenced by the maintenance request logs that documented pest control requests and sightings over several months. The facility's policy required immediate communication of pest sightings to management and documentation in the maintenance work order binder.
Failure to Use Beard Restraints in Food Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the actions of Cook C, who did not wear a beard restraint while in the food preparation area and during the lunch meal service. On the specified date, Cook C was seen with facial hair on his chin and was not wearing a beard restraint while using a blender to prepare pureed meat for lunch. Later, during the lunch meal service, Cook C was observed plating meals for residents without a beard restraint, which could potentially lead to food contamination. Interviews conducted with the Dietary Manager (DM) and Cook C revealed a lack of awareness and availability of beard restraints in the kitchen. The DM admitted to not having heard of beard restraints before and confirmed that none were available for staff with facial hair. The facility's policy on preventing foodborne illness requires the use of hair nets or caps and beard restraints to prevent hair from contacting exposed food. This policy aligns with the Federal Food Code 2022, which mandates the use of effective hair restraints where appropriate.
Failure to Provide Necessary Grooming Services
Penalty
Summary
The facility failed to provide necessary grooming services to a female resident with moderate cognitive impairment, as evidenced by the presence of unwanted facial hair. The resident, who had a history of Alzheimer's, myopathies, Type 2 diabetes with neuropathy, and other conditions, required assistance with activities of daily living (ADLs) such as personal hygiene. Despite the resident expressing a desire to have her facial hair removed, staff did not offer or attempt to shave her chin, and there was no documentation of any refusal of care by the resident. Interviews with facility staff, including a CNA, LVN, and the ADON, revealed a lack of awareness and action regarding the resident's grooming needs. The CNA, who had been caring for the resident for two weeks, did not notice the facial hair and had not attempted to shave it. The LVN and ADON were also unaware of the issue, and there was no documentation of grooming refusals in the resident's records. The facility's policy required residents to be groomed daily, but this was not adhered to in the case of this resident, leading to a deficiency in maintaining her dignity and self-esteem.
Failure to Update Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted daily, as required by their policy. On 08/29/24, observations at multiple times throughout the day revealed that the staffing information posted near the facility's entrance was dated 08/28/24, indicating that it had not been updated for the current day. This oversight was confirmed through interviews with the Assistant Director of Nursing (ADON) and the Administrator, who both acknowledged the lapse in updating the staffing information. The ADON stated that the Director of Nursing (DON) was responsible for updating the daily staffing post, but the DON had left the facility at the end of her shift on 08/28/24 and did not return the following day. The ADON admitted that she might have been responsible for updating the post in the absence of the DON but had not done so. The Administrator confirmed that the staffing posting should be updated daily and was unaware of why it was not updated for 08/29/24. The facility's policy requires that the number of nursing personnel responsible for direct care be posted within two hours of each shift's start, but this was not adhered to on the day in question.
Failure to Re-admit Resident After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after hospitalization or therapeutic leave, violating the bed-hold policy. The resident, a male with schizoaffective disorder, heart failure, hyperlipidemia, mild cognitive impairment, and hypertension, was initially admitted to the secure unit of the facility. He was transferred to a behavioral health hospital following an incident where he expressed suicidal ideation and self-harm. Despite the discharge assessment indicating a return was anticipated, the facility did not re-admit him. The resident's care plan included interventions for behavioral problems, but there was no documentation of his transfer to the hospital or a discharge summary. Interviews with facility staff revealed that the resident exhibited unusual behaviors, such as pacing and attempting to intimidate others. After the incident, emergency services transferred him to the hospital, but the facility did not complete the necessary paperwork or communicate effectively with the behavioral health hospital regarding his return. The Director of Nursing (DON) and the Administrator both indicated that the resident would not be allowed to return due to safety concerns and property damage. The Administrator stated that residents are considered discharged once sent to a hospital, and no discharge documents were sent with the resident. The behavioral health hospital's Program Director confirmed that the facility did not provide the necessary documentation or communication, placing the resident at risk of an unsafe discharge.
Infection Control Deficiency: Urinary Catheter Positioning
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program, as evidenced by the improper positioning of a urinary catheter for a resident. The resident, who was admitted to the facility from an acute care hospital, had a urinary catheter that was observed to be on the floor. This was noted during an observation and interview with the resident, who was unaware of the catheter's position and its significance in infection control. The resident's medical history included encephalopathy, heart disease, hypertension, cerebrovascular disease, hemiplegia following cerebral infarction, and dementia. The resident's nurse, LVN B, confirmed the catheter's position on the floor and repositioned it after being prompted by the surveyor. The Director of Nursing (DON) and the facility Administrator both acknowledged the expectation that urinary catheters should not touch the floor and should be frequently checked by nursing staff. The facility's policy on catheter care also specified that the catheter bag should be positioned below the bladder level and not touch the floor, indicating a lapse in adherence to established protocols.
Deficiency in Call Light System Functionality
Penalty
Summary
The facility failed to ensure that a functional call light system was available for a resident, which compromised the resident's ability to call for staff assistance. The resident, who was cognitively intact and required a wheelchair for mobility, reported that her call light had not been working for an unspecified period. This issue forced her to self-propel to the nurse's station for assistance, which she found inconvenient. The resident's care plan included the need to call for assistance when in pain, highlighting the importance of a functional call light system for her care. During the investigation, it was confirmed that the call light in the resident's room was not functioning, as it did not signal at the nurse's station. The Licensed Vocational Nurse (LVN) interviewed was unaware of the malfunction and could not provide a maintenance log for review. The Corporate Maintenance Director stated that he was not aware of the issue and emphasized the importance of a functioning call light system. The facility's Administrator acknowledged the deficiency and stated that staff should conduct daily rounds to check call light functionality. The facility's maintenance log showed no record of the call light issue, and the facility's policy required prompt reporting and repair of defective call lights.
Failure to Prevent Accidents and Ensure Resident Safety
Penalty
Summary
The facility failed to provide adequate supervision and assistive devices to prevent accidents for three residents. Resident #1, a male with severe cognitive impairment and multiple physical disabilities, experienced an unwitnessed fall resulting in a non-displaced sacrum ring fracture. The fall occurred when a CNA left the resident alone during incontinence care to retrieve more wipes, despite the resident's known impulsiveness and need for constant supervision during such activities. The CNA was later terminated for negligence, and the facility acknowledged that the CNA should have called for assistance instead of leaving the resident alone. Resident #2, a male with severe cognitive impairment and a history of elopement, managed to leave the facility's secured unit without triggering any alarms. The resident was found by a housekeeper outside the facility and brought back. The incident revealed that the back door of the secured unit was not functioning properly, as it did not lock or set off an alarm when the resident exited. The facility's maintenance logs showed that the door had been checked regularly, but the malfunction was not identified until after the elopement. Resident #3, a male with moderate cognitive impairment, sustained burns on his left foot's first and second toes after accessing a microwave in an unlocked staff break room. The resident's care plan noted a risk for skin breakdown, and the burns were treated with various dressings over time. The incident highlighted the facility's failure to secure areas containing potential hazards, such as the staff break room, to prevent residents from accessing dangerous equipment like microwaves.
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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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