Avir At Patriot
Inspection history, citations, penalties and survey trends for this long-term care facility in El Paso, Texas.
- Location
- 11490 Gateway North Blvd, El Paso, Texas 79934
- CMS Provider Number
- 676468
- Inspections on file
- 52
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 39 (1 serious)
Citation history
Health deficiencies cited at Avir At Patriot during CMS and state inspections, most recent first.
A resident with DM and multiple comorbidities was admitted on several oral hypoglycemics and later ordered insulin, but staff did not document routine blood glucose (BG) monitoring from admission. Over days, the resident complained of abdominal pain, nausea, vomiting, diarrhea, and poor intake, with repeated PRN opioid use for pain. A critical WBC of 30.9 K/uL was called in by the lab and handed by one LVN to another, yet there was no documentation that the physician or NP was notified, and the result remained pending review in the EHR. Concerned family members used a home glucometer and found BG values in the 400–500 mg/dL range, prompting calls to the physician, who ordered AC/HS BG checks, sliding-scale insulin, and Lantus; however, nursing staff did not document exact BG check times or insulin administration times, and BG values remained above 500 mg/dL. The resident became clammy, lethargic, then unresponsive with tachycardia, while attempts to reach the physician/NP went unanswered until the DON instructed staff to call 911; EMS found the resident unresponsive and transported her to the ED, where she was treated for severe metabolic derangements and later died.
A resident with multiple comorbidities and a recent below-knee amputation, admitted with a PRN hydrocodone-acetaminophen order for phantom pain, developed new abdominal pain and diarrhea, for which the physician ordered diagnostic tests and GI medications. Despite ongoing complaints of abdominal pain, high pain scores, ineffective Tylenol, refusal to eat, and observations of the resident crying and stating they had not eaten in days, LVNs repeatedly documented the symptoms and administered PRN hydrocodone but did not notify the attending physician or NP, as confirmed by the DON. The facility’s policy required prompt physician notification of significant changes in condition, and the medical director later stated the hydrocodone was intended only for phantom pain and that he should have been called about the abdominal pain. This failure to consult the physician and representative regarding a significant change in condition constituted the cited deficiency.
Two residents experienced multiple failures in clinical documentation, including missing entries for new physician orders, diagnostic tests, lab follow-up, critical lab notifications, and STAT insulin orders and administration. Nursing staff did not consistently record when labs and imaging were ordered, drawn, or communicated to the physician, and a STAT Lantus order and dose were not reflected on the Physician Order Summary or MAR despite being described in a nurse note. In addition, the DON and Dietary Manager did not document family concerns about diet, food portions, and dignity-related grooming practices, nor did they complete or record grievance follow-up regarding meals, dialysis sack lunches, and a missing personal blanket. These omissions show that the facility did not maintain complete and accurate medical records in line with its own charting and documentation policy.
A resident with dementia, ESRD, diabetes, and malnutrition had a family member who raised multiple grievances to nursing and dietary staff about undignified hair styling, inadequate dinner portions, protein intake, uneaten dialysis sack lunches, a missing blanket, and lack of inclusion in care plan meetings. Staff documented some of these concerns in nursing notes and verbally notified the Dietary Manager, but no grievance form was completed, no entry was made in the grievance binder, and the Social Worker and DON were not formally engaged through the facility’s grievance process. The facility’s written grievance policy, which required formal filing, investigation, and written responses to grievances, was not followed, and there was no documentation that the concerns were investigated or resolved per policy.
A cognitively intact, chairbound resident with progressive MS and morbid obesity reported that another cognitively intact, wheelchair-bound resident with a history of verbal aggression repeatedly yelled at her and called her a "cow," causing her anxiety and frustration. The verbally aggressive resident had prior documented incidents of yelling at and insulting peers and a roommate, including a previous episode of calling a female resident a cow. A receptionist directly witnessed the aggressive resident call the other resident a cow while he played dominoes and she sat nearby, acknowledged that this had happened before, and confronted him but did not report the incident to the Administrator, instead deferring to the victim’s preference not to report. This inaction occurred despite the facility’s abuse policy and prior ANE training requiring immediate reporting of any verbal abuse, resulting in a deficiency for failing to protect a resident from abuse and to promptly report allegations to administration.
A resident with diabetes, gangrene, and recent left BKA experienced several days of abdominal pain, nausea, vomiting, and diarrhea, with care plans directing close monitoring and physician notification for changes in condition. The attending physician ordered imaging and labs, but critical lab results, including an elevated WBC, were not reported and remained pending in the EHR. On the day of the event, the resident’s blood glucose rose from the 470s to over 560 mg/dL despite multiple insulin orders and administrations, with the LVN failing to document exact times of blood glucose checks and insulin doses. As the resident became clammy, lethargic, and then unresponsive with HR 194, staff reported making multiple unsuccessful attempts to reach the attending physician and NP, who was out of town and had no alternate physician designated. The DON then instructed staff to call 911, and the resident was sent to the ED, where she arrived unresponsive and later died. Surveyors found that the facility failed to ensure another physician supervised the resident’s care when the attending was unavailable and failed to ensure critical lab values and worsening condition were reported and addressed.
A resident with diabetes and multiple comorbidities experienced significantly elevated blood glucose and abdominal pain. After a family member checked a high blood glucose level, an LVN notified the physician, who ordered blood glucose checks with sliding-scale lispro and later additional STAT doses of lispro plus Lantus. The facility’s emergency insulin kit did not contain Lantus, so the weekend RN supervisor borrowed a new Lantus vial prescribed for another resident, administered it, and discarded the vial, despite training and policy prohibiting borrowing medications and re-use of single-dose vials. The STAT Lantus order and administration were not entered on the physician order summary or MAR, and the LVN did not document the times of blood glucose checks or insulin administration, contrary to facility policy requiring complete medication documentation.
A resident with ESRD, diabetes, and dementia developed a blood-filled blister and ecchymosis near a dialysis access site. Nursing staff notified the NP and initiated wound care, but did not immediately consult the physician or act on the family's and dialysis nephrologist's request to send the resident to the ER. The resident was only sent to the hospital after repeated requests, contrary to facility policy requiring prompt physician notification and action for significant changes in condition.
A resident with multiple medical conditions and cognitive impairment had family members file grievances regarding inconsistent call light placement and lack of staff responsiveness. The facility failed to document grievance resolutions, notify the family, and ensure staff followed procedures for monitoring call light accessibility, resulting in unresolved concerns about the resident's care.
A resident with multiple chronic conditions returned from dialysis with a blood blister and bruising on the chest. The assigned LVN documented only the blister, omitting the ecchymosis, and did not write a required physician telephone order for ER evaluation. The DON assessed the resident but failed to document the assessment. These actions resulted in incomplete and inaccurate clinical records, contrary to facility policy.
A nurse medication cart was found to contain an opened insulin vial that had expired, contrary to facility policy and manufacturer guidelines requiring removal of expired medications. Nursing staff, including an LVN, the DON, and the Administrator, confirmed that it is the responsibility of nurses to monitor and remove expired insulins from medication carts, but this had not occurred in this instance.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
A resident with multiple urological conditions and a risk for impaired skin integrity did not have a weekly skin assessment documented as required by facility policy. Nursing staff either failed to perform or failed to document the assessment, with one LPN admitting to not recording the assessment and another believing an incident-related check was sufficient. The DON acknowledged a lack of quality assurance for verifying completion of these assessments.
A resident with multiple diagnoses, including IDD, received OT and was scheduled for ST after being identified as PASRR-positive, but the facility failed to submit the required NFSS authorization form within the mandated timeframe following the IDT meeting, resulting in a lapse in compliance with PASRR and state requirements despite therapy services being provided.
Two residents with cognitive impairments exited a facility unsupervised after a lab technician inadvertently held the door open. They were outside for 13 minutes before being assisted back inside. The incident highlighted a lapse in supervision and safety protocols.
Two residents with cognitive impairments eloped from the facility after a lab technician inadvertently held the door open for them. They were found unharmed within the premises, but the incident was not reported to the state survey agency as required by the facility's policy. The failure to report constitutes a deficiency in handling elopement risks and reporting procedures.
A resident with severe cognitive impairment and physical dependency was transferred using a mechanical lift without engaging the brakes on the lift and wheelchair, posing a risk of injury. Interviews revealed inconsistent training and understanding of proper procedures among CNAs, with facility policies lacking specific guidance on brake usage.
A facility failed to ensure call light accessibility and timely response, affecting a resident with Alzheimer's and two hallways. A resident's call light was out of reach, and call lights in two hallways were not promptly attended to, despite staff presence. The facility's policies on call light accessibility and response were not followed, leading to prolonged response times.
Two residents in a LTC facility were improperly restrained in their beds using fall mats propped up by furniture, which is considered a restraint. This action was not in line with their care plans or facility policies. Staff acknowledged the practice as inappropriate, and it was not reported or documented as required.
Two residents in an LTC facility were found restrained in their beds using fall mats and furniture, which was not an appropriate intervention for fall prevention. Both residents had significant medical histories that increased their fall risk, and staff acknowledged the setup was inappropriate. The deficiency was identified through observations and interviews, revealing a failure to maintain a safe environment and provide adequate supervision.
A facility failed to investigate allegations of mistreatment involving a resident who reported being pushed in a wheelchair, causing knee pain. Despite the resident's report, the CNA involved was not immediately suspended, contrary to the facility's abuse policy. Interviews with staff and the resident's roommate did not corroborate the mistreatment claims, but the facility's inaction posed a risk of continued abuse.
The facility failed to ensure accurate MDS assessments for two residents regarding their use of bed rails, which were not marked in the assessments despite being indicated in care plans and physician's orders. The MDS Coordinators did not consider bed rails as restraints and did not code them, leading to inaccuracies. The facility's policies did not address the accuracy of MDS assessments, potentially affecting resident care.
The facility failed to assess and obtain informed consent for bed rail use for two residents, leading to a deficiency. One resident, with rheumatoid arthritis and muscle weakness, was unable to use the bed rails and had no ongoing assessments. Another resident, with muscle wasting and a history of falls, also lacked assessments and consent. The facility did not attempt alternatives before installation, violating its policy.
A resident with dementia and mobility issues was identified as a fall risk, requiring a fall mat next to her bed as part of her care plan. However, during an observation, the mat was found folded behind the headboard, not in use. Interviews with staff revealed that the mat was supposed to be used whenever the resident was in bed, but it was forgotten. The DON confirmed the mat was a necessary intervention to prevent falls.
A resident on continuous oxygen therapy did not have the required oxygen warning signs posted outside their room, as observed during a survey. The facility's policy mandates these signs to ensure safety and proper monitoring. Both a nurse and the DON acknowledged the oversight, which posed a risk of inadequate monitoring and potential harm.
The facility failed to maintain accurate medical records for two residents, leading to potential treatment errors. One resident's diet was incorrectly documented as pureed instead of regular, while another resident's nebulizer treatment was not properly recorded. The DON acknowledged the errors, and staff interviews indicated no complaints from the residents. The facility's documentation policy requires accurate and timely records, which were not adhered to in these cases.
The facility failed to ensure appropriate use of psychotropic medications for two residents. One resident was prescribed Seroquel without a proper diagnosis, and another was given Zyprexa PRN without an end date. The DON acknowledged the lack of documentation for indications and end dates, which should have been addressed during medication audits. Additionally, Olanzapine was prescribed for agitation without a proper diagnosis, contrary to facility policy.
The facility failed to store and handle food according to professional standards, with issues such as an open bag of chips, a box of vegetables on the freezer floor, and condensation-soaked muffins. These practices, confirmed by the dietary manager and DON, risked contamination and bacterial growth, violating the facility's food safety policy.
A resident with severe cognitive impairment and functional limitations was unable to access or use the call light due to it being out of reach and not the preferred type. The facility's staff, including the DON and Therapy Director, failed to assess and accommodate the resident's specific needs for call light accessibility, contrary to the facility's policy.
A resident with limited range of motion did not receive appropriate treatment and services to maintain or improve mobility. Despite having functional limitations and being dependent on others for daily activities, the resident's care plan did not address the need for physical, occupational, or restorative therapies. Therapy services were discontinued due to a change in payment source, and the facility lacked a restorative program, posing risks such as contractures and skin breakdown.
The facility failed to provide adequate supervision and use of assistive devices for two residents. A resident with Alzheimer's and muscle weakness was improperly transferred by staff without using a gait belt, contrary to the care plan and facility policy. Another resident, with a history of falls, had a fall mat placed incorrectly, increasing the risk of injury. These actions did not comply with the facility's policies on fall prevention and safe handling.
A facility failed to properly label the enteral feeding formula for a resident, risking inadequate nutrition. The resident, unable to communicate, relied on a feeding tube due to conditions like cerebral infarction and respiratory failure. An LVN admitted to forgetting to label the feeding bottle, contrary to facility policy requiring specific labeling details.
A resident with dementia and on oxygen therapy was found with a nasal cannula misplaced, contrary to physician orders. Despite staff training, CNAs failed to ensure the nasal cannula was in place during their rounds, leading to a deficiency in care. The resident's oxygen saturation improved only after an LVN corrected the nasal cannula placement.
The facility failed to properly dispose of used cooking oil, leaving a barrel uncovered and nearly full, with trash and debris inside. This oversight was acknowledged by the DM, maintenance director, DON, and administrator, who all recognized the risks of pest attraction and potential spillage. Despite requests, the facility did not provide relevant policies and procedures.
A nursing assistant failed to follow proper hand hygiene and glove-changing protocols during incontinent care for a resident with dementia and muscle wasting, leading to a potential risk of cross-contamination. Despite receiving training, the assistant admitted to forgetting the procedures due to nervousness. The facility's policies emphasize the importance of hand hygiene and appropriate use of gloves, but the incident revealed a deficiency in the infection prevention and control program.
The facility failed to maintain a functioning oven, essential for meal preparation, leading to potential foodborne illness risks. Despite multiple repair attempts, the oven remained non-operational due to a solenoid relay issue and part backorder. The maintenance director and administrator were aware of the problem, but no alternative vendor was sought, and the facility's policy on essential equipment was not provided.
The facility failed to transmit MDS data to the CMS system within the required 14 days for several residents, resulting in significant delays. Residents had various medical conditions, and the MDS data, including discharge and death assessments, were overdue by 76 to 101 days. Interviews revealed confusion among staff regarding transmission responsibilities, and the CMS Submission Report confirmed that the data was only transmitted on the survey day.
A resident with Parkinson's disease and moderate cognitive impairment exited a facility and was left outside overnight due to inadequate supervision and a non-functioning door alarm. The resident was not discovered missing until the following morning, despite a CNA reporting his absence to the charge nurse twice during the night. The charge nurse did not verify the resident's whereabouts, and the incident was not documented in the facility's report log.
The facility failed to ensure adequate supervision and a safe environment, leading to an incident where a resident with a history of aggression was left unattended and hit another resident. Additionally, the Employee Lounge door was left open, posing a risk to residents who might enter and consume unsafe items.
The facility failed to maintain an infection prevention and control program, evidenced by an overflowing trash can at the Hall 100 nurse station and a housekeeper not adhering to COVID-19 protocols. The trash can was full and overflowing with various items, and the housekeeper did not call in sick before coming to work, risking the spread of infection.
A resident with severe cognitive impairment and multiple diagnoses was observed without a privacy cover on his catheter bag, compromising his dignity and privacy. Despite facility policy and staff acknowledgment of the requirement, the catheter bag was visible from the hallway, and the privacy cover was found clipped to the resident's wheelchair instead.
The facility failed to coordinate PASRR services for a resident with intellectual disabilities due to an issue with out-of-state insurance. Despite being PASRR positive and needing specialized services, the resident did not receive the necessary care. The facility's staff and local mental health authority were aware of the issue but did not take steps to resolve it, leading to a significant deficiency in the resident's care.
The facility failed to provide necessary wound care treatment for two residents, including not using gloves while handling gauze and not labeling wound dressings. These actions could lead to infection and improper tracking of wound care.
The facility failed to submit the Payroll Based Journal (PBJ) staffing information to CMS for the 1st quarter of the fiscal year 2023. The HR Coordinator submitted the PBJ to the Corporate Administrator, but it was not sent to CMS on time. This failure could place residents at risk for unmet personal needs and decreased quality of care.
Failure to Monitor Diabetes and Act on Critical Labs Leading to Resident’s Collapse
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services in accordance with professional standards for a resident with multiple comorbidities, including Diabetes Mellitus, coronary artery disease, hypertension, peripheral vascular disease, and a recent left below-knee amputation. The resident was admitted from an acute hospital with multiple oral hypoglycemic medications and later had orders for insulin glargine and insulin lispro with sliding scale coverage. Despite this, there was no documentation that blood glucose monitoring was performed from admission until the day of the acute event, even though the care plan called for diabetes medication as ordered, monitoring for side effects and effectiveness, and education on glucose monitoring. A family member reported that they were concerned that staff were not checking the resident’s blood sugar and brought the resident’s home glucometer to the facility, where they obtained readings in the 400s and 500s. The facility also failed to act on critical laboratory results and to promptly notify the physician or nurse practitioner of significant changes in the resident’s condition. On one date, the physician ordered a CBC with differential, comprehensive metabolic panel, lipase, and amylase, along with abdominal imaging, in response to new complaints of abdominal pain, diarrhea, and low appetite. The labs were collected the following morning, and the lab report later showed a critical WBC of 30.9 K/uL flagged as “CRITICAL HIGH” with a red octagon. A lab monitoring sheet showed the labs were collected, and a witness statement from an LVN indicated that when the laboratory called with the critical WBC result at 6:06 p.m., he answered the phone, wrote the result on a piece of paper, and immediately handed it to the LVN assigned to the resident, emphasizing the critical nature of the result and advising her to verify it in the portal. Video footage corroborated that the LVN received a piece of paper after the lab call. However, there was no documentation that the critical WBC result was reported to the physician or NP, and the lab result remained marked as pending review in the electronic record. In the days leading up to the resident’s decline, the resident repeatedly complained of abdominal pain, nausea, vomiting, diarrhea, and poor intake. Nursing notes documented multiple administrations of PRN hydrocodone for abdominal pain with high pain scores, and a family member reported that the resident had been complaining of stomach pain, throwing up, not eating, and having diarrhea for approximately two weeks. The family stated they had reported these symptoms to an LVN, who allegedly attributed them to dementia and did not assess the resident. On the day of the acute event, the family again found the resident weak, complaining of abdominal pain and nausea, and used their own glucometer to obtain blood glucose readings in the 400s. Nursing staff then notified the physician, who ordered blood glucose checks before meals and at bedtime, a moderate-dose sliding scale, and insulin doses including lispro and later Lantus. The nurse administered insulin but did not document the exact times of blood glucose checks or insulin administration. Subsequent blood glucose readings remained elevated above 500 mg/dL, and the resident became clammy, lethargic, and then unresponsive with a heart rate of 194. Multiple attempts were reportedly made to contact the physician and NP by phone and group text without response. The DON was informed that the resident’s condition was deteriorating, with fixed pupils and increasing lethargy, and instructed that the resident be sent to the ER. EMS was activated, and upon EMS arrival the resident was already unresponsive; she was transported to the hospital, where she was treated for altered mental status, severe acidosis, hypoxia, and hyperkalemia and was pronounced dead later that day. The facility’s failures included not monitoring blood glucose despite diabetes and multiple hypoglycemic medications, not documenting and acting on critical lab results, and not immediately notifying the physician of the resident’s worsening condition and unresponsiveness.
Failure to Notify Physician of Ongoing Abdominal Pain and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician and representative of a significant change in condition and ongoing abdominal pain, as required by facility policy. A cognitively intact resident with a history of diabetes mellitus, hypertension, peripheral vascular disease, coronary artery disease, and a recent left below-knee amputation was admitted from an acute hospital and had active diagnoses including post-procedural pain and phantom pain. The resident’s care plan included monitoring and reporting pain, loss of appetite, refusal to eat, weight loss, and signs and symptoms of infection or adverse reactions to analgesic therapy to the physician. The resident had a PRN order for hydrocodone-acetaminophen 7.5-325 mg every six hours as needed for severe pain, with the diagnosis of phantom pain related to the recent amputation. On a medical visit, the attending physician documented a new complaint of abdominal pain and diarrhea with low appetite and ordered diagnostic tests, including abdominal ultrasound, KUB, and laboratory work, as well as medications such as Lomotil, Pepto Bismol, Dicyclomine, and PRN ondansetron. Radiology reports for the abdominal ultrasound and KUB indicated no acute process and no bowel obstruction or ileus, and these results were reported to the physician and nurse practitioner. Subsequent 24-hour report sheets and nursing documentation showed that the resident continued to complain of abdominal pain on multiple occasions. On one night, an LVN documented that hydrocodone was given and that the resident continued to complain of abdominal pain, but the DON stated that the LVN did not notify the attending physician or NP of the ongoing abdominal pain. Further documentation on another date showed that the resident was observed crying, stating that her stomach hurt and that she had not eaten in days, with dry lips noted. The LVN documented that Tylenol was not working, the resident was still in pain, and was refusing to eat, yet the DON reported that the LVN again did not notify the attending physician or NP of the continued abdominal pain. The MAR and administration notes showed multiple administrations of hydrocodone-acetaminophen for high pain levels, including pain scores of 7, 8, and 10, while the 24-hour report sheets continued to reflect that Tylenol was not effective and the resident remained in pain. The facility’s policy on change in a resident’s condition or status required prompt notification of the attending physician and resident representative within 24 hours of a significant change in the resident’s physical or mental condition, but interviews and record review confirmed that the nurses did not contact the physician or NP when the resident’s abdominal pain persisted. In an interview, the attending physician/medical director stated that he had ordered hydrocodone-acetaminophen specifically for phantom pain related to the recent amputation and that the nurses should have called him to report the resident’s abdominal pain. He indicated he would have given a new order and that he would not have approved the use of hydrocodone for abdominal pain because it could worsen the condition due to constipation. He also noted that the problem included the medication order not being entered into the electronic record with the specific indication of phantom pain related to the lower extremity amputation. The survey findings concluded that the facility failed to consult with the resident’s physician and representative when there was a significant change in the resident’s physical, mental, or psychosocial status, specifically by not notifying the physician when the resident continued to complain of abdominal pain on multiple occasions, contrary to facility policy and the resident’s care plan. The report also states that this failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. The facility’s own policy required nurses to make detailed observations and gather pertinent information for the provider and to notify the physician within 24 hours of a change in the resident’s medical or mental condition, except in emergencies. Despite this, the documented ongoing abdominal pain, ineffective pain relief with Tylenol, refusal to eat, and high pain scores treated with hydrocodone were not communicated to the physician or NP by the LVNs involved, as confirmed by the DON. This sequence of inactions and omissions in physician notification and consultation formed the basis of the cited deficiency for failure to immediately tell the resident’s doctor and representative of situations affecting the resident.
Incomplete and Inaccurate Clinical Documentation for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records in accordance with professional standards for two residents. For Resident #1, who had multiple comorbidities including coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, and a recent left below-knee amputation, the attending physician evaluated her for new abdominal pain and diarrhea and ordered abdominal ultrasound (US), KUB, and multiple labs (CBC with differential, comprehensive panel, lipase, amylase). These new orders and subsequent diagnostic activities were not consistently or accurately documented. LVN C did not document on the date of the new orders that the physician had ordered labs and abdominal imaging, nor that labs were pending. RN A, the weekend supervisor, did not document when the abdominal US and KUB results were sent to the attending physician. On the following days, LVN C and LVN D did not document any follow-up on the lab orders that remained pending, and LVN H also failed to document follow-up on these same lab orders. When labs were finally drawn, LVN C did not document that the labs were drawn and that results were pending, and LVN D did not document at shift change that pending lab results had been reported to her. Further documentation failures occurred when critical lab results and insulin orders were communicated. LVN B did not document in Resident #1’s clinical record that he received a telephone call from the lab reporting critical lab results that had been outstanding for two days. He also did not document a telephone order from the physician for a STAT dose of Lantus 10 units when the resident’s blood glucose was elevated to 517 mg/dL, and this STAT Lantus order was not entered on the Physician Order Summary. The Medication Administration Record for the month did not show documentation that the STAT Lantus dose was administered as ordered. A nurse note by LVN B described the resident crying with abdominal pain, receiving PRN hydrocodone, having blood sugars of 473 mg/dL and then 515 mg/dL, and receiving multiple STAT doses of Lispro and Lantus per physician orders, but these insulin orders and administrations were not fully or accurately reflected in the formal order summary and MAR. Additionally, the DON and Dietary Manager did not document in the resident’s electronic record concerns voiced by the resident’s family member regarding the resident’s prescribed diet. For Resident #2, who had dementia, diabetes mellitus, hypertension, end-stage renal disease, adult failure to thrive, and malnutrition, the facility also failed to document family concerns and follow-up actions in the clinical record. The resident had a care plan addressing ADL self-care deficits, impaired cognition, nutritional problems, and a therapeutic diet, including a liberal renal diet with regular texture, health shake, HS snack, and potassium-rich foods for breakfast. The family member reported concerns about the food served for dinner on a specific date, stating the resident received a very small baked potato, small salad, and ice cream, and also raised concerns about how staff styled the resident’s hair with ponytails and bright-colored accessories, which the family felt did not treat the resident with dignity and respect. The family further reported that the resident did not eat the sack lunches sent to dialysis, that staff did not check the reusable blue bag upon return to see if the lunch was eaten, that a long-owned blanket had gone missing without being reported to administration or social work, and that care plan meetings were not consistently scheduled or that the family was not invited after staff changes. The DON acknowledged he did not keep notes and had not documented the family’s dietary concerns in the electronic record. The Dietary Manager acknowledged she had not completed a grievance/concern form, had not documented her follow-up calls to the family, and had not documented in the resident’s clinical record her follow-up on the concerns about the dinner meal. These omissions collectively demonstrate that the facility did not ensure that all services provided, changes in condition, and family concerns were documented in the residents’ medical records as required by the facility’s charting and documentation policy.
Failure to Follow Grievance Policy for Family Concerns About Hair Care and Nutrition
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance/complaint policy and to ensure that a resident’s family grievances were formally recognized, investigated, and documented. A resident with dementia, diabetes mellitus, hypertension, end stage renal disease, adult failure to thrive, and malnutrition had an established care plan addressing ADL self-care deficits, impaired cognition, nutritional problems, and a therapeutic renal diet with supplements. On one evening, the resident’s family member voiced concerns to an LVN about how CNAs were combing the resident’s hair with ponytails, bright-colored ties, ribbons, and barrettes, which the family member felt did not treat the resident with dignity and respect. The same family member also raised concerns about the food served to the resident, including a dinner meal that appeared inadequate and concerns that the resident was not receiving enough protein. Nursing documentation showed that on the date of the complaint, the LVN recorded that the family member called about how CNAs were preparing the resident’s hair and that the LVN explained she would pass the information on to CNAs and nurses. A second nursing note documented that the Dietary Manager was notified that the family had concerns regarding food. However, review of the facility’s grievance binder revealed no grievance report from January onward related to the family’s concerns about the resident’s hair or food. The facility’s grievance policy required that grievances from residents or family members be filed, investigated by a designated grievance officer, and responded to in writing, but the grievance officer line on the policy was left blank, and there was no evidence that the concerns were processed through this system. Interviews further demonstrated that the concerns were not handled through the formal grievance process. The DON stated he had not been informed about the hair-combing concern and was not familiar with the facility’s grievance/concern procedures; he also acknowledged not documenting the family’s concerns about the resident’s diet in the clinical record. The Dietary Manager reported that she was not present when the family voiced concerns about the food, that she attempted to call the family twice, but she did not complete a grievance/concern form or document her follow-up in the resident’s record. The Social Worker, who was responsible for completing grievance/concern forms, stated that no one had reported the family’s concerns about the resident’s hair or food to her. As a result, the family’s grievances regarding the resident’s hair styling, the adequacy and type of food served, the uneaten dialysis sack lunches, the missing blanket, and care plan meeting participation were not entered into the grievance system, not investigated per policy, and not responded to in writing as required. Additional observations and interviews highlighted the underlying events but did not change the fact that no formal grievance process was initiated. Staff reported that the resident did not eat her packed dialysis lunches due to nausea and that the lunches were returned untouched, while the family member believed staff were not checking the bag upon the resident’s return. The resident herself stated she liked the way staff had previously combed her hair with ponytails and accessories but that this stopped after her family member objected; she appeared sad and said she would do whatever her family member wanted. The family member also reported that a long‑owned blanket had gone missing and that staff only replaced it with another blanket and asked if it had been labeled, without escalating the issue to administration or the Social Worker. The family member further stated that she had not been invited to care plan meetings after staff changes and that a scheduled care plan conference had been canceled and not rescheduled. None of these concerns were captured in the grievance binder or processed according to the written grievance/complaint policy, constituting the cited deficiency.
Failure to Report and Prevent Ongoing Verbal Abuse Between Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal and physical abuse and to ensure that allegations of abuse were immediately reported to the Administrator. One resident with progressive multiple sclerosis, morbid obesity, and dependence on assistance for ADLs reported that another resident repeatedly called her a “cow” and yelled indirectly at her when passing by her room. She was cognitively intact, oriented, and able to make herself understood. Her care plan documented episodes of adverse behaviors and a potential mood problem related to an incident in which another resident called her a cow, with approaches including behavioral health consultation and monitoring for mood symptoms. The resident alleged that the verbally aggressive resident yelled at others, called her a cow, and made loud, annoying noises when passing her room, which made her feel anxious and frustrated because staff were not stopping him. A friend of this resident stated that the name-calling and yelling had been occurring for approximately a year and a half, including after the verbally aggressive resident was moved to another hall, and that these behaviors occurred more often on weekends. The friend reported that the resident who was being called names had limited physical strength due to multiple sclerosis and that the verbally aggressive resident threatened to hit her. The friend also stated she had reported these concerns to the Administrator the previous year. The resident identified as verbally aggressive was cognitively intact, used a wheelchair, and had documented verbal aggression, including insulting male peers and yelling at a roommate about TV volume. His care plan and psychological assessments noted verbal aggression, anxiety, and depressive disorder, with a risk of verbal aggression. Facility records showed prior incidents of altercations and name-calling involving this resident, including an altercation reported to the state and an incident of calling another resident a cow. Despite this history, multiple CNAs and an LVN reported they had not personally witnessed him insulting or name-calling other residents, though they acknowledged he spoke loudly and made other residents uncomfortable. A key event leading to the deficiency was an incident witnessed by the weekend receptionist approximately one month before her interview. She observed the verbally aggressive resident in the living room playing dominoes and the resident with multiple sclerosis in the reception area when he called her a cow. The receptionist stated this resident had done this before, and she moved the resident with multiple sclerosis at that time. She confronted the verbally aggressive resident and told him not to repeat the behavior, but she did not report the incident to anyone in the facility, despite having been trained via email on abuse, neglect, and exploitation to immediately report verbal abuse to the Administrator. She stated she asked the resident who was called a cow if she wanted it reported, and when the resident said no, she chose not to report it, telling her that if it happened again she would have to report it. The Administrator later stated that staff were expected to immediately report any allegation of abuse, neglect, and mistreatment and that failure to do so placed residents at risk of further abuse. The facility’s written policy on Abuse, Neglect, Exploitation and Misappropriation Prevention Program stated that residents have the right to be free from abuse, including verbal and mental abuse, and that the program includes protecting residents from abuse by anyone, providing staff training on abuse prevention and reporting, and investigating and reporting any allegations within required timeframes. The failure of the receptionist to immediately report the witnessed verbal abuse incident to the Administrator, in the context of a resident with a documented history of verbal aggression and prior incidents of calling another resident a cow, led to the cited deficiency for not protecting the resident’s right to be free from verbal and physical abuse and not ensuring immediate reporting of abuse allegations.
Failure to Ensure Physician Coverage and Response to Critical Labs and Hyperglycemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure that another physician supervised the medical care of a resident when the attending physician was unavailable, and to appropriately act on critical clinical information and worsening condition. The resident was admitted from an acute hospital with diagnoses including coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, gangrene, and a recent left below-knee amputation. The care plan identified diabetes management, infection related to gangrene, and significant pain management needs, with instructions to monitor and report changes in mental status, behavior, appetite, and pain, as well as signs and symptoms of infection and adverse reactions to analgesics. The resident had been complaining of abdominal pain, nausea, vomiting, and diarrhea over several days, and the attending physician ordered a KUB, abdominal ultrasound, and labs, including amylase and lipase. Radiology reports for the KUB and abdominal ultrasound showed no acute process and no bowel obstruction or ileus, and these results were reported to the physician and NP. However, critical lab values, including an elevated WBC indicating possible sepsis, were received on a prior date and remained pending review in the electronic record, meaning they were not reported to the attending physician or NP. The attending physician later stated that if he had known about these lab results, he would have sent the resident to the hospital, and that the critical WBC and rising blood glucose indicated the resident was acutely ill and going into full sepsis. The resident continued to complain of abdominal pain and had poor appetite, and the physician documented follow-up visits and ordered medications such as Bentyl and Zofran PRN, but there is no documentation that the critical lab values were communicated to him or that he was notified of ongoing ineffective pain control or persistent abdominal symptoms over the days in question. On the day of the acute event, the resident’s family checked the resident’s blood glucose with their own glucometer and obtained a reading of approximately 470–495 mg/dL. The LVN notified the RN weekend supervisor and the attending physician, who ordered initiation of a moderate sliding scale insulin regimen, blood glucose checks AC and HS, and 10 units of Lantus. After 10 units of Lispro were given, a recheck about 45 minutes later showed the blood glucose had increased to 517 mg/dL. The LVN reported this to the physician, who then ordered discontinuation of the moderate sliding scale, initiation of a high sliding scale, administration of 14 units of Lispro STAT, and 10 units of Lantus STAT. The LVN did not document the exact times of the blood glucose checks or insulin administrations, although he acknowledged being trained to do so. The facility did not have Lantus in the insulin E-kit, and the RN supervisor borrowed a vial from another resident. Later that afternoon, the resident’s blood glucose was rechecked and found to be 563 mg/dL. The LVN reported that the resident became clammy, increasingly lethargic, and then unresponsive, with a heart rate of 194 and fixed pupils. Multiple attempts were made by the LVN and weekend supervisor to contact the attending physician and NP by phone and group text, but they reported receiving no response. The DON confirmed that the attending physician, who was also the medical director, was out of town on vacation and that the NP assigned to the facility did not answer calls or texts. The DON instructed the nurse to call 911 and send the resident to the ER due to the change in condition. EMS was activated, and the resident was transported to the hospital, where she arrived unresponsive with a blood glucose of 561 mg/dL, hypotension, hypoxia, and required CPR and intubation. Despite resuscitation efforts, the resident expired in the ED. The attending physician later denied receiving calls or texts on the day of the event and stated that he and his NPs were always available and that he did not see a need for an alternate physician when he was out of town. The facility was unable to provide a policy and procedure on physician services to the surveyor prior to exit. The surveyor concluded that the facility failed to ensure another physician was available to supervise the medical care of the resident when the attending physician was unavailable and failed to ensure that critical lab values and ongoing changes in condition were reported and acted upon. This failure occurred for one resident reviewed for physician services and was associated with the resident’s continued worsening condition, severe hyperglycemia, unresponsiveness, transfer to the hospital, and subsequent death. The report states that this failure could place residents at risk of delayed treatment or intervention, decline in health, and/or death.
Failure to Maintain Emergency Insulin Supply and Proper Medication Management
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications, specifically insulin, for a resident with diabetes mellitus. The resident had multiple active diagnoses including coronary artery disease, hypertension, peripheral vascular disease, diabetes mellitus, post-procedural pain, and aftercare following a left below-knee amputation. The care plan identified diabetes mellitus with approaches including diabetes medication as ordered, monitoring for side effects and effectiveness, and monitoring for signs and symptoms of hypoglycemia and infection. The resident was cognitively intact with a BIMS score of 15 and had an existing physician order for insulin glargine (Lantus) 10 units subcutaneously at bedtime and insulin lispro per a sliding scale. On the day of the incident, the resident complained of abdominal pain and diarrhea, and the attending physician had recently evaluated the resident and ordered Bentyl and Zofran PRN. Later, the resident reported abdominal pain rated 8/10, for which PRN hydrocodone was administered. A family member checked the resident’s blood glucose, which was in the 470s mg/dL range, and the physician was notified. The physician ordered blood glucose checks before meals and at bedtime with a moderate sliding scale and a STAT dose of 10 units of lispro, which the LVN reported administering, although he did not document the actual times of the blood glucose checks or insulin administration in the electronic record. A recheck of blood glucose approximately 45 minutes later showed an increase to over 500 mg/dL, and the resident became clammy and reported feeling sleepy. After the blood glucose remained elevated, the physician was notified again and ordered discontinuation of the moderate sliding scale, initiation of a high sliding scale, a STAT dose of 14 units of lispro, and administration of 10 units of Lantus. The facility’s emergency insulin kit did not contain Lantus, so the weekend RN supervisor obtained a new vial of Lantus that belonged to another resident and used it to administer the ordered dose, then discarded the vial in a biohazard container. This borrowing of medication from another resident occurred despite staff training and facility policy stating that medications must be administered as prescribed, that single-dose vials are not to be used for multiple residents, and that medication administration details, including date, time, dosage, route, and results, must be documented. The physician’s STAT order for Lantus and its administration were not entered on the physician order summary or the MAR. Subsequently, the resident’s condition deteriorated, with a blood glucose reading in the 560s mg/dL range, tachycardia, clamminess, and unresponsiveness, leading to EMS activation and transfer to the hospital, where the resident was treated for altered mental status and later pronounced dead. The surveyors concluded that the facility failed to ensure the emergency insulin kit contained Lantus and that staff borrowed insulin from another resident, constituting a failure to provide required pharmaceutical services. The hospital emergency department record documented that the resident arrived unresponsive with a blood glucose of 561 mg/dL, low blood pressure, and oxygen saturation less than 90%, requiring bagging and chest compressions by EMS. The ED course included emergent intubation, CPR, findings of hyperkalemia, severe acidosis, and hypoxia, and eventual cessation of resuscitation efforts at the family’s request, with time of death recorded. Facility nursing notes and interviews confirmed that lab results from a prior day showing rising glucose had not been reported to the physician until the day of the event, that the resident’s glucose continued to trend upward, and that the DON was informed the resident had received 14 units of lispro and 10 units of Lantus per MD order. Interviews with the LVN and RN supervisor confirmed that Lantus was not available in the insulin emergency kit, that a vial was borrowed from another resident, and that this practice was contrary to their training and facility policy. The physician’s STAT Lantus order and its administration were not reflected in the physician order summary or MAR, further evidencing failures in documentation and medication management. Overall, the survey findings show that the facility did not ensure that its emergency insulin kit contained Lantus as needed for STAT administration and that staff resorted to borrowing another resident’s Lantus vial to comply with the physician’s order. Additionally, required documentation of blood glucose checks and insulin administration times, as well as entry of the STAT Lantus order on the physician order summary and MAR, was missing. These actions and omissions were inconsistent with the facility’s own medication administration policy, which requires medications to be administered as prescribed, prohibits using single-dose vials for multiple residents, and mandates complete documentation of medication administration details in the resident’s medical record.
Failure to Notify Physician and Act on Family Request for Hospital Evaluation
Penalty
Summary
The facility failed to consult with a resident's physician when there was a significant change in the resident's physical status, specifically the development of ecchymosis and a blood-filled blister near the dialysis access site. The resident, who had a complex medical history including end-stage renal disease (ESRD) on hemodialysis, diabetes mellitus type II, anemia, GI bleed, and dementia, was noted to have a blood-filled blister and maroon ecchymosis on the chest after returning from dialysis. The initial response by nursing staff was to notify the Nurse Practitioner (NP), who ordered wound care and antibiotics, but did not address the request for hospital evaluation made by the dialysis nephrologist and the resident's family. Despite multiple notifications from the dialysis center and the resident's family, nursing staff questioned why the dialysis center had not sent the resident directly to the emergency room and did not immediately act on the nephrologist's recommendation or the family's request. The family member expressed frustration and concern over the staff's reluctance to send the resident to the hospital, as did the dialysis center staff, who clarified that they could not send residents to the ER for non-emergent situations and had communicated the nephrologist's recommendation to the facility. The resident was eventually sent to the emergency room, but only after significant delay and repeated requests from the family and dialysis center. Interviews with facility staff, the NP, the medical director, and the attending physician confirmed that the nurses should have contacted the resident's physician to obtain an order for hospital evaluation as requested by the family and the nephrologist. Facility policy required prompt notification of the physician and resident representative in the event of significant changes in condition or the need for hospital transfer, but this was not followed in this case. The delay in consulting the physician and acting on the family's request constituted a failure to follow policy and could have resulted in delayed medical treatment for the resident.
Failure to Promptly Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to ensure prompt efforts to resolve grievances voiced by a resident's family, as required by both regulation and facility policy. The family filed grievances on two separate occasions regarding the resident's care, specifically about the placement and accessibility of the call light and the conduct of night staff. Documentation revealed that the grievance forms were incomplete, lacking information on the resolution, notification to the family, and signatures. The facility's grievance policy required written responses and notification of findings, but these steps were not followed. The resident involved was an elderly female with multiple complex medical conditions, including recurring urinary tract infections, renal failure, diabetes mellitus, and was on hospice care. She was cognitively moderately impaired and dependent on staff for most activities of daily living, including mobility, hygiene, and toileting. The family reported that the resident was unable to operate the call bell unless it was placed on her chest, and staff were inconsistent in ensuring the call light was within reach. Despite interventions discussed with the clinical team, such as implementing a sign-in log for staff to document call light placement, the log was not consistently posted or used, and staff had not been trained on its use. Interviews with staff and family confirmed that the sign-in log was missing for a period, and staff were not consistently checking or documenting call light placement as required. The family also reported that staff did not check on the resident throughout the night, and that their concerns about staff empathy and visitation were not adequately addressed or documented. The facility's failure to document grievance resolutions and notify the family as per policy contributed to the deficiency.
Incomplete and Inaccurate Clinical Record Documentation for Resident with Chest Injury
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident who returned from a dialysis center with ecchymosis and a blood blister in the middle of the chest. The assigned LVN documented the presence of a blood-filled blister in the Event Report but omitted the ecchymosis surrounding the blister, despite having observed both. The LVN also did not write a physician's telephone order for the nurse practitioner's directive to send the resident to the emergency room for evaluation, as required by facility policy. The Director of Nursing (DON) assessed the resident the following day after being notified of the incident but did not document this assessment in the resident's clinical record, contrary to facility policy and training. Interviews confirmed that both the LVN and DON were aware of the need to document all assessments and physician orders in the electronic clinical record but failed to do so in this instance. The facility's policy requires that all services, changes in condition, and events be documented objectively and completely by licensed personnel. The resident involved had a complex medical history, including end-stage renal disease on hemodialysis, diabetes mellitus type II, anemia, gastrointestinal bleeding, and dementia. At the time of the incident, the resident was alert and able to communicate, reporting no pain from the chest bruise and blister. The lack of complete and accurate documentation regarding the resident's condition and the care provided resulted in a deficiency related to the maintenance of clinical records.
Expired Insulin Vial Found in Medication Cart
Penalty
Summary
A deficiency was identified when a nurse medication cart was inspected and found to contain an opened insulin vial that had exceeded its allowable usage period. The insulin vial was labeled with an open date, and upon review, it was determined that the vial had expired based on the facility's policy and manufacturer instructions, which state that opened insulin vials are only good for 28 to 31 days. The nurse present during the inspection acknowledged that she had not noticed the vial had expired and stated that it was each nurse's responsibility to monitor for expired medications. The Director of Nursing (DON) and the Administrator both confirmed that nursing staff are expected to remove expired insulins from medication carts. Facility policy documents reviewed indicated that outdated or expired medications are to be immediately removed from stock and disposed of according to procedures. Manufacturer instructions for insulin also specify that opened vials should be discarded after 31 days. The failure to remove the expired insulin from the medication cart was observed during the survey, and staff interviews confirmed that the expired medication had not been identified or removed as required by policy.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of an effective program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Failure to Document Weekly Skin Assessment as Required by Policy
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically by not ensuring that a weekly skin assessment was documented in accordance with facility policy. The resident in question was an older male with a history of nephrostomy tube malfunction, bilateral hydronephrosis, left hydroureter, and displacement of a left percutaneous nephrostomy tube. His care plan included interventions for risk of impaired skin integrity and required weekly skin checks. However, review of July 2025 records showed no skin assessment was completed for the week of 07/21-07/25. Interviews with nursing staff revealed that the assigned LVN did not document the required weekly skin assessment, initially stating it was not done because a previous assessment had been completed a few days earlier, and later admitting to having performed but not documented the assessment. Another LVN also failed to complete the scheduled weekly assessment, believing an incident-related assessment was sufficient. The DON confirmed that while weekend audits were being conducted, there was no quality assurance process in place to verify completion of weekly skin assessments. The facility's documentation policy required objective observations and treatments to be recorded, but this was not followed in this instance.
Failure to Submit Timely PASRR NFSS Authorization for Therapy Services
Penalty
Summary
The facility failed to coordinate assessments and submit a complete and accurate request for Nursing Facility Specialized Services (NFSS) in the LTC online portal within 20 days after the Interdisciplinary Team (IDT) meeting for a resident identified as PASRR-positive. The resident, a female with diagnoses including cerebral palsy, non-Alzheimer's dementia, hemiplegia, hemiparesis, traumatic brain injury, anxiety, and depression, was determined to meet criteria for intellectual/developmental disability (IDD) following a PASRR Level 1 screening and subsequent evaluation. The Local Authority Compliance Confirmation indicated the need for PASRR services, including participation in IDT meetings, habilitation services, and monitoring for possible community transition. Despite the resident receiving occupational therapy (OT) and being scheduled for speech therapy (ST), the facility did not submit the required NFSS form within the mandated 20-day period following the IDT meeting. Interviews with facility staff, including the DON, MDS Coordinator, and DOR, revealed that the NFSS forms were left in draft status and never officially submitted, resulting in no authorization for payment for the therapy services provided. The staff indicated that the failure to submit the NFSS was due to a misunderstanding regarding the resident's refusal of services and the continuation of existing therapies, as well as a lack of clarity about staff responsibilities for form submission. The facility's PASRR policy did not reference the 20-day deadline for NFSS submission, and the staff involved at the time of the deficiency were no longer employed at the facility. Documentation confirmed that the resident continued to receive therapy services during the period in question, but the required authorization process was not completed in accordance with state regulations. The deficiency was identified through record review and staff interviews, which confirmed the lapse in compliance with PASRR and NFSS requirements.
Elopement Incident Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and prevent accidents for two residents, leading to an elopement incident. Both residents, who had cognitive impairments and a history of wandering, exited the facility through the front door. The incident occurred when a lab technician inadvertently held the door open for visitors, allowing the residents to leave. The residents were outside the facility for approximately 13 minutes before being assisted back inside. Resident #2, a male with severe cognitive impairment and a history of wandering, was found outside the facility with another resident. His medical history included Parkinson's disease, dementia, and repeated falls. He was unable to recognize stop lights or take necessary precautions when crossing streets. Similarly, Resident #3, who also had cognitive impairments and a history of wandering, was found outside with Resident #2. His medical history included dementia and paranoid schizophrenia, and he was noted to be very confused and unable to respond to questions. The facility's failure to provide adequate supervision and prevent the residents from exiting the facility placed them at risk of injury. The incident was identified as an Immediate Jeopardy, which began and ended on the same day. The facility had corrected the noncompliance before the survey began, but the deficiency highlighted a significant lapse in supervision and safety protocols.
Failure to Report Elopement Incident
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, specifically related to the elopement of two residents, within the required timeframes to the state survey agency. The incident involved two residents who were found outside the facility after a lab technician inadvertently held the door open for them. Both residents were brought back into the facility without injuries, but the incident was not reported to the state survey agency as required by the facility's policy. Resident #2, a male with severe cognitive impairment due to Parkinson's disease, dementia, and other conditions, was assessed as being at risk for elopement. His care plan included interventions to distract him from wandering. On the day of the incident, he was found outside the facility with another resident, Resident #3, who also had cognitive impairments. Both residents were seen on security footage exiting the facility and were later found by a dietary aide within the premises. The Director of Nursing (DON) and the Administrator were informed of the incident, but the decision was made not to report it to the state survey agency, as the residents were found unharmed and within the facility's premises. The facility's policy required reporting such incidents, but the Administrator determined that the situation did not constitute neglect. The failure to report the incident as per the facility's policy and state requirements constitutes a deficiency in the facility's handling of elopement risks and reporting procedures.
Failure to Ensure Competency in Mechanical Lift Use
Penalty
Summary
The facility failed to ensure that nurse aides demonstrated competency in using mechanical lifts for resident transfers, specifically for a resident with severe cognitive impairment and physical dependency. During an observed transfer, two CNAs did not engage the brakes on the mechanical lift and wheelchair, which are critical safety measures to prevent movement and potential accidents. The resident involved was a female with dementia, muscle weakness, and cognitive communication deficit, requiring mechanical lift assistance for transfers. Interviews with the CNAs revealed a lack of consistent training and understanding of the proper procedures for using mechanical lifts, as one CNA believed the lift brakes were only necessary when lowering a resident. The Director of Nursing and Director of Rehabilitation both acknowledged the importance of engaging brakes during transfers to prevent movement and potential safety risks. However, there was uncertainty about the frequency of training, and the facility's policy and the lift's manual did not provide specific guidance on when to engage brakes during transfers.
Failure to Ensure Call Light Accessibility and Timely Response
Penalty
Summary
The facility failed to ensure that residents had reasonable accommodation for their needs and preferences, specifically regarding the placement and response to call lights. Resident #5, who was diagnosed with Alzheimer's Dementia and other conditions requiring substantial assistance, was found on two occasions with the call light out of reach while in bed. Despite the care plan indicating the necessity for the call light to be within reach, observations showed it was on the floor, and staff interviews confirmed the importance of having the call light accessible to residents. Additionally, the facility did not respond promptly to call lights in two hallways. Observations on Hall 300 revealed that call lights in two rooms were on for 21 and 26 minutes, respectively, without staff entering the rooms, despite staff walking past. Similarly, in Hall 400, a call light was on for 31 minutes without any staff presence in the hallway. Interviews with the DON and staff indicated that call lights should be responded to promptly, and the facility's policy required all staff to respond to activated call lights. The facility's policies on call light accessibility and timely response were not adhered to, as evidenced by the prolonged response times and the failure to ensure call lights were within reach of residents. The DON acknowledged the importance of timely responses and the potential for resident agitation if needs were unmet. However, there was no process in place during shift changes to ensure call lights were attended to, contributing to the deficiency.
Improper Use of Physical Restraints in LTC Facility
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints unless required for medical treatment. Specifically, two residents were restrained in their beds using fall mats propped up by furniture, which is considered a restraint. This action was not in line with the residents' care plans or the facility's policies, which emphasize the importance of treating residents with respect and dignity and ensuring their freedom from unnecessary restraints. Resident #4, a female with dementia and other cognitive impairments, was admitted to the facility with a high risk of falls. On the day of her admission, a fall mat was placed against her bed and held in place by a chair, restricting her movement. This was done without proper justification or documentation, and staff members acknowledged that it was inappropriate and considered a restraint. Interviews with staff revealed that this was done as a temporary measure while waiting for a bed that could be lowered, but it was not an acceptable practice. Similarly, Resident #5, a male with Alzheimer's dementia and a history of falls, was also found to have a fall mat placed against his bed with furniture propped against it. This was not in accordance with his care plan, which required a fall mat to be placed on the floor next to his bed. Staff interviews confirmed that this practice was not reported or documented, and it was acknowledged as inappropriate and a restraint. The facility's policies on incident reporting and fall prevention were not followed, leading to these deficiencies.
Inappropriate Use of Fall Mats as Restraints
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. The deficiency was observed when staff used furniture and fall mats to block residents in bed, which was considered a restraint. Specifically, one resident was found lying in bed with fall mats placed sideways against the bed, with a chair and nightstand pushed up against them. Another resident was similarly restrained with a fall mat and furniture, which was not an appropriate intervention for fall prevention. The residents involved had significant medical histories that increased their risk of falls. One resident was diagnosed with dementia, muscle weakness, and cognitive deficits, requiring substantial assistance for mobility and transfers. The other resident had Alzheimer's dementia and was at risk for falls due to impaired thought processes and lack of coordination. Both residents were assessed as high fall risks, and their care plans included interventions to prevent falls, but the use of fall mats as restraints was not part of these plans. Interviews with staff revealed that the use of fall mats and furniture as restraints was not a standard practice and was not reported to supervisors. Staff members, including CNAs and LVNs, acknowledged that the setup was inappropriate and could be considered a restraint. The Director of Nursing and the Administrator also confirmed that such practices were not acceptable and that better interventions were available. The deficiency was identified through observations, interviews, and record reviews, highlighting a failure in maintaining a safe environment and providing adequate supervision for residents at risk of falls.
Failure to Investigate Allegations of Mistreatment
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for one resident. The incident involved a resident who reported being mistreated by a CNA, specifically stating that her legs were thrown into the bed and that she was pushed in her wheelchair, causing her knee to hit the wall. Despite these allegations, the facility did not immediately suspend the CNA involved, as required by their abuse policy, which could have placed residents at risk of potential continued mistreatment and abuse. The resident in question was an elderly female with diagnoses of muscle weakness, gait abnormalities, and lack of coordination, who required moderate assistance with transfers. The resident's family reported the mistreatment to a nurse, who conducted a physical assessment and found no visible injuries. The nurse then asked the involved CNAs to provide written statements and reported the incident to the Director of Nursing (DON). However, the DON was on vacation at the time and did not address the investigation until her return. Interviews with the involved CNAs and the resident's roommate revealed that the resident did not initially verbalize any pain or injury at the time of the alleged incident. The CNAs denied the allegations, and the roommate did not witness any mistreatment. Despite this, the facility's failure to suspend the CNA immediately after the allegation was reported was a breach of their abuse policy, as confirmed by the DON and the Administrator, who both acknowledged the oversight.
Inaccurate MDS Assessments for Bed Rail Use
Penalty
Summary
The facility failed to ensure accurate assessments for two residents regarding their use of bed rails, which are considered enablers. For Resident #5, the quarterly and annual Minimum Data Set (MDS) assessments did not accurately reflect the resident's use of bed rails. Despite the resident's care plan and physician's orders indicating the use of assist bars for bed mobility, the MDS assessments did not mark the use of bed rails. Interviews revealed that the MDS Coordinator did not consider bed rails as restraints and therefore did not code them in the MDS, despite the resident's inability to use them effectively due to physical limitations. Similarly, Resident #6's quarterly MDS assessment failed to reflect the use of bed rails, even though the resident's care plan and physician's orders indicated their use for bed mobility and positioning. The facility did not conduct any enabler assessments for Resident #6, and the MDS Coordinator stated that bed rails were not coded as they were considered enablers, not restraints. The Director of Nursing acknowledged that the MDS was inaccurate because it did not include the bed rails in Section P. The facility's policies on maintaining MDS assessments and documentation in medical records did not address the accuracy of MDS assessments. The lack of accurate documentation and assessment could potentially affect the care provided to residents who require bed rails for safety and mobility, as the facility did not ensure that the MDS accurately reflected the residents' needs and use of enablers.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to properly assess and obtain informed consent for the use of bed rails as enablers for two residents, leading to a deficiency in care. Resident #5 and Resident #6 were not assessed for the risk of entrapment from bed rails prior to their installation, nor were the risks and benefits reviewed with the residents or their representatives. Additionally, informed consent was not obtained before the installation of the bed rails. This oversight was identified during observations, interviews, and record reviews conducted by surveyors. Resident #5, a male with a history of rheumatoid arthritis, diabetes mellitus, and muscle weakness, did not have a signed consent form for the use of bed rails. The resident required substantial assistance with activities of daily living and was unable to use the bed rails due to weakness in his hands and arms. Despite this, the facility had not conducted ongoing enabler assessments to determine the appropriateness of the bed rails for Resident #5's needs. Interviews with the physical therapist and the director of nursing revealed that no alternatives were attempted before the installation of the bed rails, and there was no physician's order for their use. Similarly, Resident #6, a female with muscle wasting, lack of coordination, and a history of falls, also lacked a signed consent form and had not undergone any enabler assessments. The resident's care plan indicated the use of grab bars to promote independence, but the facility failed to conduct ongoing assessments to ensure the bed rails were appropriate. The director of nursing acknowledged that the facility did not follow its policy of obtaining informed consent and conducting regular assessments, which could lead to the inappropriate use of enablers and increased risk of injury.
Failure to Implement Fall Prevention Measures for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #9, which included measurable objectives and time frames to meet her medical and nursing needs. Resident #9, an elderly female with dementia, muscle weakness, and mobility issues, was assessed to be at risk for falls. Her care plan included the use of a fall mat next to her bed as a safety measure. However, during an observation, it was noted that the fall mat was not in place while the resident was lying in bed, as it was folded and positioned behind the headboard. Interviews with facility staff, including an LVN and a CNA, revealed that the fall mat was supposed to be used whenever Resident #9 was in bed, but it was forgotten on this occasion. The Director of Nursing confirmed that the fall mat was a necessary intervention listed in the resident's care plan to prevent falls. Despite the resident not having any recent falls, the failure to follow the care plan posed a risk of potential injury to the resident.
Failure to Post Oxygen Warning Signs for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, as observed during a survey. A resident, who was on continuous oxygen therapy via nasal cannula, did not have the required oxygen warning signs posted outside his bedroom. This oversight was noted during an observation, and both a registered nurse and the Director of Nursing acknowledged the absence of the sign, which is intended to inform staff and visitors of the oxygen use for safety purposes. The facility's policy mandates that oxygen warning signs must be placed on the door of any resident's room where oxygen is in use. The resident in question was admitted with a diagnosis of pulmonary embolism and was at risk for respiratory infections and distress. The resident's care plan included continuous oxygen therapy to maintain oxygen saturation levels above 90%. Despite these requirements, the absence of the oxygen warning sign posed a risk of inadequate monitoring and potential harm due to unawareness of the oxygen use. The facility's policy also outlines the need for staff to monitor for complications associated with oxygen use, emphasizing the importance of adhering to safety protocols.
Inaccurate Medical Record Documentation for Two Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to potential errors in treatment and services. For one resident, the facility did not document the correct diet texture in the orders and care plan. The resident was admitted with a regular diet from the hospital, but the facility incorrectly documented a pureed texture diet. The Director of Nursing (DON) admitted to making a mistake in entering the order and acknowledged that the error was not addressed during the resident's stay. Interviews with staff indicated that the resident ate well and did not complain about the food. For the second resident, the facility failed to accurately document the administration of a nebulizer treatment in the Medication Administration Record. The record showed missing initials for several days, although the Licensed Vocational Nurse (LVN) responsible claimed the treatment was administered and suggested a computer glitch might be the cause. The DON reviewed the documentation and found no medication errors but emphasized the importance of accurate documentation to verify proper care and treatment. The facility's policy on medical record documentation requires that each resident's record accurately reflects their experiences and includes sufficient details about their care. The policy mandates that documentation be completed at the time of service or by the end of the shift. The deficiencies in documentation for both residents highlight a failure to adhere to these standards, potentially impacting the quality of care provided.
Deficiency in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that residents who had not previously used psychotropic drugs were not administered these medications unless necessary to treat a specific condition, as diagnosed and documented in the clinical record. This deficiency was identified in two residents during a review for unnecessary medications. Resident #111 was prescribed Seroquel without an appropriate diagnosis, and Resident #274 was given Zyprexa PRN without an end date, both of which are antipsychotic medications. Resident #274, who was admitted with diagnoses of altered mental status and cognitive communication, had a physician's order for Seroquel without an indication for use. Additionally, Zyprexa was ordered PRN for acute manic episodes without an end date. The care plan for Resident #274 included goals to remain free of psychotropic drug-related complications, but the necessary documentation and indications for the medications were missing. The Director of Nursing (DON) acknowledged the oversight, stating that the indication for use and end date should have been documented during weekly psychotropic medication audits. Resident #111, who had a history of cerebral infarction, respiratory failure, and was unable to communicate, was prescribed Olanzapine for agitation without a proper diagnosis. The DON confirmed that antipsychotics like Olanzapine should not be used for agitation due to potential long-term side effects and that PRN orders should have a 14-day limit to ensure ongoing appropriateness. The facility's policy on psychotropic medication use requires documentation of specific conditions and non-pharmacological interventions before initiating such medications, which was not adhered to in these cases.
Food Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. The survey revealed multiple instances of improper food storage and handling that could lead to contamination. An open and unsealed bag of chips was found in the pantry, which the cook acknowledged could lead to contamination and potential health risks for residents. Additionally, a box of frozen vegetables was found on the floor of the walk-in freezer, which the dietary manager confirmed posed a risk of contamination. Further observations in the walk-in freezer showed a box of mini muffins soaked with water from condensation on the ceiling, which the dietary manager stated could lead to mold and bacterial growth. Inside the refrigerator, a container of jelly was not properly closed, and a chocolate dessert topping bottle had dry chocolate drippings. The cook and dietary manager both noted that these conditions could lead to bacterial growth and contamination of other food items stored nearby. Interviews with the Director of Nursing (DON) and the administrator confirmed that these practices were unacceptable and posed a risk of cross-contamination and bacterial growth. The facility's policy on food safety, which emphasizes the importance of storing food in a manner that prevents contamination, was not followed. The policy specifically requires that food be stored off the floor and in sealed containers to prevent deterioration and contamination.
Failure to Accommodate Resident's Call Light Needs
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident, specifically regarding the accessibility and usability of the call light system. The resident, who had severe cognitive impairment and functional limitations due to a stroke and vascular dementia, was observed to have a call light that was not within reach and difficult to use. The call light was wedged between the side of the wheelchair and the wheel, lacking a securing device, and was not the type the resident was accustomed to using. The resident expressed difficulty in using the cylindrical call light and preferred a flat, round call light with a red cross, which he found easier to use. Interviews with the Director of Nursing (DON) and the Therapy Director revealed a lack of awareness and assessment regarding the resident's specific needs for a call light. The DON acknowledged the importance of having a call light within reach and suitable for the resident's use, but had not noticed the type of call light the resident had. The Therapy Director mentioned that recommendations for call light assessments could be made during IDT meetings, but no such recommendations had been made for this resident. The facility's policy required evaluation of each resident's unique needs for call light accessibility, but this was not effectively implemented for the resident in question.
Failure to Provide Range of Motion Therapy
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited range of motion, which could potentially lead to decreased range of motion, decreased quality of life, and increased risk of contractures and threats to skin integrity. The resident, who had a history of cerebral infarction, tracheostomy, and feeding tube, was unable to speak or communicate needs and was totally dependent on others for activities of daily living. Despite having functional limitations in range of motion to his arms and legs, the resident did not have a care plan addressing these needs, and no restorative therapy was provided during the 7-day look-back period of the MDS assessment. The resident's physician's orders included evaluations and recommendations for physical, occupational, and speech therapies, but these services were discontinued due to a change in payment source. Interviews with the Director of Rehabilitation and the DON revealed that the facility did not have a restorative program to provide necessary therapeutic interventions, which posed risks such as contractures, increased muscle tone, and skin breakdown. The physical therapist noted that the resident had joint stiffness and would benefit from continued therapy, but no plans were in place to provide additional therapy services.
Inadequate Supervision and Improper Use of Assistive Devices
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistive devices to prevent accidents for two residents. For Resident #103, who has Alzheimer's disease and muscle weakness, the facility's staff did not follow proper transfer procedures. The resident's care plan required extensive assistance from two staff members using a gait belt for transfers. However, during an observation, CNA A and NA B transferred the resident from his wheelchair to the bed by grabbing him from his armpits and the back of his pants, which was not in accordance with the facility's policy. Both aides acknowledged that this method was unsafe but cited the resident's combative behavior as the reason for not using the gait belt. For Resident #15, who has a history of falls and severe impairment, the facility failed to ensure the proper placement of a fall mat. The resident's care plan indicated the use of a fall mat to prevent injury. However, during an observation, the fall mat was found away from the resident's bed, which could lead to potential injury if the resident attempted to get up unassisted. A family member noted that the resident frequently tried to get up without assistance, and the RN confirmed that the mat was not placed correctly. The facility's policies on fall prevention and safe resident handling were not adhered to in these cases. The policy required the use of gait belts for residents who cannot independently ambulate or transfer, and the safe handling policy emphasized the use of mechanical lifts and handling aids. Despite these policies, the staff did not use the gait belt for Resident #103, and the fall mat for Resident #15 was not positioned correctly, leading to potential risks for both residents.
Failure to Label Enteral Feeding Formula
Penalty
Summary
The facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding. Specifically, the facility did not properly label the enteral feeding formula for Resident #111, which put the resident at risk of not receiving adequate nutrition. During an observation, it was noted that the plastic bottle containing the feeding formula was not labeled with any information about the resident, the rate of administration, or other necessary details. Resident #111, who was unable to speak or communicate needs, had a history of cerebral infarction, respiratory failure with hypoxia, and was dependent on a feeding tube for nutrition. The resident's care plan indicated the use of enteral feedings, and a physician's order specified the use of Jevity 1.2 at a rate of 70 ml per hour. However, an interview with LVN J revealed that she had forgotten to label the feeding bottle, which was against the facility's policy requiring labels to include the resident's name, room number, date changed, and the nurse's signature/initials.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, leading to a deficiency in care. The resident, an elderly female with a history of altered mental status, dementia, anxiety, and cognitive communication deficit, was on oxygen therapy as per physician orders. The care plan specified the need for continuous oxygen via nasal cannula to prevent respiratory distress. However, during an observation, the resident was found with the nasal cannula under her chin, not in place as required, although the oxygen tank was not empty. Multiple staff members, including CNAs and an LVN, interacted with the resident without ensuring the nasal cannula was properly placed. CNA F entered the room to comb the resident's hair but did not adjust the nasal cannula. CNA G replaced the oxygen tank but also failed to reposition the nasal cannula. It was only when LVN H assessed the resident that the nasal cannula was placed correctly, resulting in an increase in the resident's oxygen saturation from 71% to 96%. The LVN noted that CNAs were responsible for checking the nasal cannula placement during their rounds. Interviews with the CNAs and the DON revealed that the staff had received training on oxygen therapy and were aware of the importance of ensuring the nasal cannula was in place. However, both CNAs admitted to neglecting this responsibility due to nervousness. The DON confirmed that CNAs and LVNs were expected to ensure proper oxygen therapy administration, including checking the nasal cannula placement during rounds. The facility's policy on oxygen administration emphasized adherence to physician orders and care plans, which was not followed in this instance.
Improper Disposal of Used Cooking Oil
Penalty
Summary
The facility failed to properly dispose of garbage and refuse, specifically regarding a barrel used for disposing of used cooking oil. Observations and interviews revealed that the barrel was left uncovered, nearly full, and contained trash and debris floating on the oil. The Dietary Manager (DM) acknowledged the risk of the uncovered barrel spilling and attracting pests, which could potentially affect the residents and staff by contaminating food from the kitchen. Further interviews with the maintenance director and the Director of Nursing (DON) confirmed the risks associated with the uncovered oil barrel. The maintenance director noted that the barrel should be closed with a lid to prevent overflow during rain and to avoid attracting pests. The DON expressed concerns about the potential health risks to residents due to the attraction of pests like roaches and flies. The facility's administrator also recognized the hazard posed by the exposed container, emphasizing the risk of insect attraction and potential spillage. Despite requests, the facility did not provide policies and procedures for proper storage and disposal of garbage and refuse by the time of the surveyor's exit.
Infection Control Deficiency Due to Improper Hand Hygiene and Glove Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a nursing assistant (NA B) who did not adhere to proper hand hygiene and glove-changing protocols during incontinent care for a resident. The resident, who was admitted with diagnoses including dementia and muscle wasting, was observed to be always incontinent of bladder and bowel. During the care procedure, NA B did not wash her hands before donning gloves and failed to change gloves after they became contaminated, which could lead to cross-contamination and the spread of infections. The incident was observed by a surveyor, and NA B admitted to forgetting the proper procedures due to nervousness. Despite having received training on infection control, NA B did not follow the expected protocols of washing hands before putting on gloves and changing gloves after contamination. The Assistant Director of Nursing (ADON) acknowledged the lapse and noted that she had not yet conducted infection control training for the staff, as she had recently started working at the facility. The Director of Nursing (DON) and the Administrator were informed of the incident and confirmed that the staff were expected to follow hand hygiene and glove-changing protocols to prevent infection spread. The facility's policies on incontinence care and personal protective equipment emphasize the importance of hand hygiene and appropriate use of gloves to prevent transmission of pathogens. However, the failure to adhere to these protocols during the observed incident highlights a deficiency in the facility's infection prevention and control program.
Failure to Maintain Essential Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the stove, in safe operating condition. During an observation and interview, it was revealed that the oven on the right side of the stove was not functioning. The dietary manager (DM) reported the issue to maintenance and documented it in the work order log on 3/24/2024. Despite this, the oven remained unfixed, posing a risk of foodborne illnesses due to improper cooking temperatures. The maintenance director confirmed that the oven was essential for preparing meals for residents and acknowledged the potential risk of illness if food was not cooked properly. The maintenance director explained the process for reporting and addressing maintenance issues, which involved logging requests in a work order binder reviewed daily. He stated that the oven had been repaired multiple times, but continued to malfunction. The initial repair involved replacing parts, but the oven broke down again shortly after. Further inspection revealed a solenoid relay issue, and the necessary part was on backorder, delaying repairs for approximately three months. The maintenance director had not followed up on the status of the part until prompted by the surveyor. The administrator was aware of the ongoing issues with the oven and acknowledged the possibility of using a different vendor for repairs. However, no efforts were made to find an alternative vendor, as they were satisfied with the current service provider. The administrator did not consider the oven essential equipment and did not perceive a risk to residents from the non-functioning oven. The facility's policy on essential equipment was requested but not provided by the time of the survey exit.
Failure to Transmit MDS Data Timely
Penalty
Summary
The facility failed to electronically transmit Minimum Data Set (MDS) data to the CMS system within the required 14 days after the completion of a resident's assessment. This deficiency was identified for five residents who were reviewed for electronic transmission of MDS data. The residents involved had various medical conditions, including severe cognitive impairment, dementia, depression, psychotic disorder, Parkinson's Disease, Chronic Obstructive Pulmonary Disease, epilepsy, diabetes, seizure disorder, and lung cancer. The MDS data for these residents, including discharge and death assessments, were significantly overdue, with delays ranging from 76 to 101 days. Interviews with facility staff revealed a lack of clarity and communication regarding the responsibility for transmitting the MDS data. MDS Nurse D indicated that the discharge MDS for one resident was pending transmission and should have been sent by MDS Nurse E. However, MDS Nurse E stated that she had consulted with the MDS corporate supervisor, who advised that the MDSs did not need modification and had been transmitted. Despite this, the CMS Submission Report confirmed that the MDS records were only transmitted on the day of the survey. The facility's policy required transmissions to be completed within 14 days of completion, which was not adhered to in these cases.
Resident Left Outside Overnight Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and prevent accidents for a resident who exited the building and was left outside overnight. The resident, who had a diagnosis of Parkinson's disease and moderate cognitive impairment, was able to exit the facility through a door in the bistro area. The resident was seen on video footage pushing the door open with his hands and feet while in a wheelchair and subsequently making his way outside. He was not discovered missing until the following morning when a nurse found him outside on the patio. The resident's care plan indicated he was an independent smoker and did not require supervision while smoking. However, the facility's failure to ensure the door alarm was activated allowed the resident to exit unnoticed. Additionally, the staff on duty did not conduct proper rounds or respond to reports of the resident's absence. A CNA reported the resident missing to the charge nurse twice during the night, but the charge nurse dismissed the concerns and continued with her tasks without verifying the resident's whereabouts. The incident was not documented in the facility's incident report log, and the resident was not accounted for during the night shift. The charge nurse was preoccupied with other tasks and did not conduct rounds or respond to the CNA's reports. The facility's lack of supervision and failure to ensure the door alarm was functioning placed the resident at risk of harm, although he did not sustain any injuries or express discomfort from the incident.
Failure to Provide Adequate Supervision and Maintain Safe Environment
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that residents received adequate supervision to prevent accidents. Specifically, Resident #8, who had a history of aggressive behavior and was on 1:1 supervision, was left unattended by the Lead CNA. The Lead CNA left Resident #8 to assist another staff member without ensuring another nursing staff member was available to supervise Resident #8. This lapse in supervision led to Resident #8 hitting another resident, Resident #9, who had multiple medical conditions including muscle weakness and diabetes mellitus. The incident occurred in the morning, and the Lead CNA admitted to leaving Resident #8 unattended for less than 10 minutes, during which the altercation took place. Additionally, the facility failed to keep the Employee Lounge door closed, which posed a potential risk to residents. The Housekeeper left the door open, despite a posted sign instructing that the door should remain closed at all times. The Housekeeping Manager and the DON acknowledged that residents could enter the lounge and consume food or drink that might not be safe for them, particularly for those with conditions like diabetes. The facility did not have a specific policy for keeping the Employee Lounge door closed, although there was a general policy for maintaining a safe environment and preventing accidents. Interviews with various staff members, including the Administrator, Lead CNA, and other nursing staff, confirmed the deficiencies in supervision and environmental safety. The Lead CNA was suspended pending investigation and later received training on 1:1 supervision. The facility's failure to provide adequate supervision and maintain a safe environment for residents was evident in both the incident involving Resident #8 and the open Employee Lounge door, which could have led to further accidents or harm to residents.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by an overflowing trash can at the Hall 100 nurse station and a housekeeper not adhering to COVID-19 protocols. Observations revealed that the trash can was full and overflowing with various items, including fast food bags, paper towels, used gloves, and other debris on the ground. Interviews with the LVN and Housekeeping Manager indicated that the nursing staff were expected to manage the trash if it became overflowing before the housekeeper's scheduled time. The Director of Nursing (DON) confirmed that anyone seeing the trash overflowing was responsible for addressing it to prevent infection risks. Additionally, a housekeeper who felt sick did not follow the facility's COVID-19 policy by calling in before coming to work. The housekeeper exited the employee lounge without keeping the door closed, as required by a warning sign. The Housekeeping Manager and DON confirmed that the housekeeper had been trained on COVID-19 precautions and infection prevention control but failed to follow the protocol, which could risk spreading illness within the facility. The facility's Infection Prevention and Control Program policy mandates that all staff follow procedures to maintain a safe and sanitary environment.
Failure to Maintain Resident Dignity by Not Using Privacy Cover on Catheter Bag
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not ensuring the resident's catheter bag had a privacy cover. Resident #2, who has severe cognitive impairment and multiple diagnoses including Dementia, Diabetes, and a Urinary Tract Infection, was observed on multiple occasions without a privacy cover on his catheter bag. The catheter bag was visible from the hallway and contained dark yellow-brownish urine, which compromised the resident's dignity and privacy. Interviews with the LVN and the DON confirmed that catheter bags should have privacy covers at all times to maintain residents' dignity and privacy. The facility's Catheter Care policy also mandates the use of privacy covers for catheter drainage bags. Despite this policy, Resident #2's catheter bag was observed without a privacy cover, and the privacy bag was found clipped to the back of the resident's wheelchair instead. This oversight indicates a failure to adhere to the facility's own policies and procedures, thereby compromising the resident's quality of life.
Failure to Coordinate PASRR Services for Resident with Intellectual Disabilities
Penalty
Summary
The facility failed to coordinate the assessment following the PASRR Completion PCSP for a resident with intellectual disabilities. The resident, who was PASRR positive, did not receive the necessary PASRR services because the facility did not submit a request to the state agency. This failure was attributed to the resident having out-of-state insurance, which the current state did not accept for PASRR services. The facility's administrator and MDS Coordinator were aware of the issue but did not take the necessary steps to ensure the resident received the required services. The resident, a female with a history of epilepsy, delusional disorders, traumatic brain injury, and seizures, was admitted and re-admitted to the facility. Despite being PASRR positive for intellectual and developmental disabilities, the resident did not receive the specialized services needed. The local mental health authority and the facility's staff acknowledged that the resident required PASRR services, but the out-of-state insurance issue prevented the provision of these services. The facility's records and interviews with staff revealed that no actions were taken to resolve the insurance issue or to submit a request for PASRR services to the state. Interviews with the facility's administrator, MDS Coordinator, and local mental health authority confirmed that the resident was not receiving PASRR services due to the insurance issue. The MDS Coordinator and local mental health authority both stated that the resident needed PASRR services to prevent a decline in health. Despite this, no steps were taken to address the issue, and the resident's care plan did not include the necessary PASRR services. The facility's failure to coordinate the assessment and provide the required services was a significant deficiency that could impact the resident's health and well-being.
Deficient Wound Care Practices
Penalty
Summary
The facility failed to provide necessary treatment and services based on comprehensive assessments and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for two residents. The Wound Care Nurse did not use gloves while handling gauze for Resident #6's right lateral foot wound, which was cleaned and left to air dry. The nurse admitted to the oversight and acknowledged the risk of infection due to not using gloves. The Director of Nursing (DON) confirmed that nurses are trained to use gloves during wound care to minimize infection risks, and the failure to do so could lead to contamination of wound care items and potential infection for the resident. For Resident #3, the Wound Care Nurse did not date or initial the patches after providing wound care for the resident's left hip surgical incisions. The nurse explained that she had lost her marker, which is why the patches were not labeled. The DON emphasized the importance of dating and initialing dressings and patches to ensure proper tracking of wound care and to identify who performed the treatment. The lack of labeling could result in uncertainty about when the dressing was changed and who conducted the wound care. The facility's Wound Treatment Management policy and Clean Dressing Change policy require evidence-based treatments and proper labeling of wound care supplies to prevent infection and ensure accurate tracking of wound care. The failure to adhere to these policies in the cases of Resident #6 and Resident #3 highlights deficiencies in the facility's wound care practices, potentially placing residents at risk for worsening pressure injuries and infection.
Failure to Submit PBJ Staffing Information
Penalty
Summary
The facility failed to follow guidelines for the mandatory submission of staffing information based on payroll data in a uniform format. Specifically, the facility did not submit the Payroll Based Journal (PBJ) staffing information to CMS for the 1st quarter of the fiscal year 2023 (October 1, 2022, to December 31, 2022). This failure was identified through a review of the facility's CMS reports and an email from the Corporate Administrator indicating that the PBJ submission had failed because CMS was no longer accepting submissions for that reporting quarter. The CASPER report also confirmed that no data was submitted for the quarter, triggering a deficiency. Interviews with the facility's Administrator and HR Coordinator revealed that the HR Coordinator was responsible for completing the PBJ and submitting it to the Corporate Administrator for review before it was sent to the state. The HR Coordinator stated that she had submitted the PBJ early to the Corporate Administrator but was unaware of what happened afterward. The Administrator admitted to not being familiar with the PBJ submission process and deferred to the HR Coordinator. This lack of proper submission could place residents at risk for unmet personal needs, decreased quality of care, and a decline in health status.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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