Baybrooke Village Care And Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mckinney, Texas.
- Location
- 8300 Eldorado Parkway West, Mckinney, Texas 75070
- CMS Provider Number
- 676096
- Inspections on file
- 43
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Baybrooke Village Care And Rehab Center during CMS and state inspections, most recent first.
A facility failed to keep accurate resident records when a resident’s hand splint was documented as applied even though staff observed it was not on and the nurse admitted the charting was incorrect. The facility also entered multiple med orders for another resident as PO despite NPO status and G-tube dependence, with staff noting the mismatch and the NP stating PO meds could cause aspiration. Conflicting staff roles and failure to verify orders contributed to the deficient documentation.
PASRR screening was not coordinated correctly for a resident with PTSD and intact cognition. The resident's PASRR Level I form showed no mental illness despite hospital records documenting PTSD, and staff gave conflicting accounts of who entered and corrected PASRR information in the facility software. The DON stated she was responsible for overseeing PASRR completion, and the Administrator said the facility followed Texas PASRR guidelines without a PASRR policy.
A resident admitted with cancer, HTN, DM, respiratory failure, septic pulmonary embolism, and polyneuropathy did not have a completed baseline care plan within 48 hours of admission. The resident had a BIMS of 15, required supervision for ADLs, and was on a pain regimen. Staff interviews showed confusion about who was responsible for completing the baseline care plan, and the facility policy required it to be initiated and completed within 48 hours based on physician orders and nursing evaluation.
Failure to care plan oxygen use: A resident with DM2, dementia, HF, HTN, and cancer had an MDS showing SOB when lying flat and oxygen therapy, but the current care plan did not address oxygen. Orders included O2 sat checks every shift, oxygen via NC, and weaning while maintaining O2 > 90%, yet the order did not specify liters. Staff observed the resident using oxygen at 1.5L at times and without oxygen at other times, and interviews confirmed the oxygen need was not included in the care plan.
Failure to provide nail care for a resident with dementia, anxiety, depression, and weakness. The resident's care plan directed extensive assistance with personal hygiene, but staff observed black substance under each fingernail on multiple occasions. CNAs and the Restorative Aide said nail care was their responsibility, and one aide noted the resident sometimes refused cleaning, while the RN said no one had reported the issue. The facility policy included hand hygiene and nail care during bathing.
Failure to Apply Ordered Hand Splint for Contracture Management: A resident with hemiplegia, hemiparesis, and a contracted left hand was repeatedly observed without her ordered left hand splint in place, despite a physician order for day-shift use for 6 hours per day. Staff gave conflicting accounts about who was responsible for applying the splint, and interviews showed the RN, restorative staff, and rehab staff were not consistently ensuring the splint was worn as ordered.
A resident with diabetes, stroke, aphasia, hemiplegia, seizure disorder, severe cognitive impairment, and no speech received nutrition via g-tube at 82 mL/hr. Her weight increased from 146.4 lbs to 164.6 lbs over a short period, but staff did not recognize or report the significant gain in a timely manner. Interviews showed the RD, RN, Restorative Aide, ADON, and DON were unaware of the extent of the weight change, despite the facility’s weight monitoring policy requiring routine monitoring and notification for significant weekly gains or losses.
Improper Administration of G-Tube Medications: An RN administered crushed baclofen and oxycodone together through a resident’s g-tube after mixing both meds with water in one cup and pushing the mixture in with a syringe plunger. The resident had a g-tube and multiple complex diagnoses, and the NP, ADON, DON, and facility policy all indicated that enteral meds should be given separately and allowed to flow by gravity rather than being pushed.
A resident with dementia, HF, HTN, cancer, and SOB when lying flat was receiving O2 therapy, but the physician orders did not specify how many liters to administer. Staff observed the resident on and off O2 via nasal cannula, and an RN adjusted the concentrator based on a mistaken interpretation of the order. The ADON and DON stated O2 orders should specify the liters to provide, but the resident's care plan did not address O2 use and the order remained unclear.
Failure to complete post-dialysis assessments for a resident receiving HD. The resident had ESRD, HTN, HF, DM, and HLD, and his care plan and MD orders required dialysis with monitoring of the access site and VS. Dialysis communication forms showed blank post-dialysis sections on multiple treatments. RN and DON interviews confirmed that the assigned nurse was responsible for completing the pre- and post-dialysis documentation, but the post-assessments were not done.
Expired Fast Acting 40% Glucose Gel was found in two medication carts, one on the 100 hall and one on the 200 hall. RN F and RN G both acknowledged the gel was expired and did not know where it came from, while the ADON, DON, regional nurse consultant, and NP confirmed expired meds should be removed from carts and that glucose gel is used for low blood sugar emergencies.
Surveyors found that two residents requiring oxygen therapy did not receive respiratory care consistent with physician orders and facility policy. One resident with severe cognitive impairment and shortness of breath had an active order and care plan for continuous O2 at 2 LPM via NC, but was observed in bed without the cannula in place, with the tubing buried under bed linens while the concentrator ran. The CNA in the room acknowledged knowing the resident was supposed to be on continuous O2 and that he often removed his cannula but had not informed the nurse, and the assigned RN stated she had not checked on him for hours despite knowing of the continuous O2 order. Another resident with COPD and acute respiratory failure with hypoxia had a care plan directing O2 administration but no active O2 order in the chart, yet was observed on 2 LPM O2; the RN confirmed there was no order and stated O2 should not be given without one. The Regional Nurse Coordinator and facility policies confirmed that O2 use requires a physician order, review of the care plan, and documentation in the eMAR/eTAR.
A resident with severe cognitive impairment and diabetes had a Stage 4 sacral pressure ulcer with orders and a care plan requiring cleansing, application of Santyl and calcium alginate, and coverage with a dry dressing on a scheduled and PRN basis. A CNA removed the sacral dressing after it became soiled with feces, despite knowing she was not permitted to remove dressings and was required to notify nursing staff. During incontinence care, surveyors observed the sacral wound open, uncovered, and draining onto the brief, with the CNA completing care and applying a clean brief without ensuring the wound was redressed. The RN and wound care nurse reported they were not informed the dressing had come off, despite expectations that CNAs report soiled or dislodged dressings so nurses could follow PRN wound orders, and there was no documentation in the record noting the missing dressing.
A resident with a history of hypertension and hypotension experienced multiple episodes of low blood pressure over several days, leading staff to withhold prescribed medication. Despite these significant changes, staff did not notify the physician or responsible party as required by policy. The deficiency was confirmed through interviews and record review, revealing a lack of timely communication regarding the resident's condition.
A resident with epilepsy and severe cognitive impairment did not receive approximately 10 scheduled doses of prescribed Lamotrigine due to medication unavailability, which was caused by an outstanding pharmacy balance. Medication aides reported the issue to charge nurses, but the nurses did not escalate the problem or notify the physician as required by facility policy, resulting in a significant medication error.
A resident with epilepsy missed approximately 10 scheduled doses of Lamotrigine due to medication unavailability, and staff failed to notify the physician as required. Medication aides reported the issue to charge nurses, but the nurses did not escalate the concern or inform the provider, contrary to facility policy and expectations. The physician was only made aware of the missed doses after the issue was resolved.
A resident with severe cognitive impairment and mobility needs eloped from the facility undetected during the night, despite being assessed as low risk for wandering. The resident was found at a nearby hospital and returned without injury. The incident revealed a lapse in supervision and monitoring, as the resident was able to leave the premises without staff awareness until discovered missing during routine rounding.
A resident who required nebulizer treatments did not have her breathing mask properly stored after use, as it was left on her bedside table instead of being placed in a plastic bag according to facility policy. Staff interviews confirmed the mask should have been bagged to prevent infection, and the responsible LVN acknowledged forgetting to do so after the previous treatment.
A CNA failed to change gloves and perform hand hygiene at appropriate times while providing incontinent care to a resident with a UTI, including after contact with soiled items and before handling clean supplies, contrary to facility infection control policy.
The facility failed to provide meals that matched the preferences and dietary needs of three residents. A resident with specific dietary orders often received incorrect meals, leading to reliance on outside food. Two other residents also experienced discrepancies between their meal selections and what was served, with staff interviews revealing systemic issues in meal ticket accuracy and communication. The facility's policy on selective menus was not effectively implemented.
The facility's kitchen was found to have multiple deficiencies in food storage and labeling, including unlabeled, undated, and expired items in the dry storage, refrigerator, and freezer areas. Staff interviews revealed a lack of awareness and adherence to established food safety procedures, despite having received training. These practices pose a risk of cross-contamination and airborne illnesses to residents.
A LTC facility failed to maintain an effective infection prevention and control program, as staff did not adhere to proper hand hygiene and enhanced barrier precautions. An ADON did not change gloves between wound care for two residents, while CNAs failed to don gowns during care for two other residents on enhanced barrier precautions. These lapses increased the risk of infection spread, despite regular staff training on infection control protocols.
A resident with severe cognitive impairment and limited mobility was transferred from a wheelchair to a bed without the use of a gait belt or Hoyer lift, as required by their care plan. LVN and CNA involved in the transfer acknowledged the oversight, which was against facility policy and placed the resident at risk for falls and injuries.
A facility failed to ensure proper enteral feeding protocols were followed for a resident with a feeding tube. The LVN did not check the tube's placement or residual before starting the feeding and used a plunger to flush the tube instead of allowing water to flow by gravity, contrary to facility policy. These actions could lead to resident discomfort and complications.
A facility experienced a 15% medication error rate due to RN G's failure to administer medications as scheduled for three residents. Errors included administering Acetaminophen at the wrong time, omitting Olmesartan, and delaying other medications. The residents had various medical conditions requiring precise medication management. RN G cited workload as a reason for the errors, and the DON confirmed the importance of adhering to medication schedules.
The facility failed to maintain an effective Infection Prevention and Control Program, with staff neglecting proper hand hygiene and equipment sanitation. An RN did not sanitize hands between glove changes during wound care for two residents, and an MA did not clean the blood pressure cuff between uses for three residents. Additionally, a CNA did not change gloves or perform hand hygiene during incontinent care for a resident, potentially leading to cross-contamination.
A facility failed to securely store medications, as a bottle of Nystatin topical powder was found in a resident's room. The resident, who was cognitively intact, stated the medication was discontinued and was unsure how it ended up on his table. Staff interviews confirmed that medications should be stored in medication carts and administered by nurses or medication aides, as per facility policy.
A resident with anxiety and chronic pain did not receive proper respiratory care, as their nasal cannula was improperly stored and the humidifier lacked water. Staff interviews revealed a lack of awareness and adherence to procedures, with the CNA and LVN failing to follow facility policies on oxygen therapy. The ADON and DON confirmed the importance of these practices to prevent respiratory infections and irritation.
A resident with severe cognitive impairment was sexually abused by a CNA, as captured on camera footage. The incident was reported by the family member of the resident's roommate, leading to a police investigation and the CNA's termination. The resident was assessed and sent for a SANE exam, which revealed an abrasion. The facility confirmed the abuse and had previously in-serviced staff on abuse prevention.
Incomplete Records and Incorrect Medication Route Orders
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for two residents. For one resident, the record showed an order for a left hand splint to be applied on day shift for 6 hours per day, and the care plan included use of the splint for pain management and limited range of motion. The April MAR documented the splint as in place on two first shifts, but observations on both days showed the resident was not wearing the splint. During interview, RN D stated she had documented that the splint was on even though she had not asked the resident or attempted to place it, and she acknowledged the documentation was incorrect. Other staff interviewed gave conflicting statements about who was responsible for applying the splint, including nursing, therapy, and restorative staff. For the second resident, the record showed NPO status and dependence on a feeding tube, oxygen therapy, suctioning, and tracheostomy care. The physician orders included eight medications written as to be given by mouth, including gabapentin, hyoscyamine, Miralax, senna-lax, aspirin, Cymbalta, buspirone, and methocarbamol, despite the resident’s NPO status. RN G stated she had never given the resident anything by mouth and had not noticed the orders that said by mouth, and she indicated the chart showed NPO. The NP stated that all G-tube residents are nothing by mouth and that if medications were ordered and given by mouth the resident could aspirate. The facility policy stated that licensed nursing staff are to receive and transcribe physician orders, clarify and reconcile orders that may lead to an administration error, and that medication via feeding tube must specify the route of administration. The DON stated the admission nurse entered orders when a resident admitted and that the next nurse and ADON were supposed to verify them, but she did not know why the orders were not reviewed before. The report also states that the incorrect documentation and incorrect medication route orders could affect any resident and result in inaccurate information and inappropriate care.
PASRR Screening Not Corrected for Resident with PTSD
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to the maximum extent practicable for 1 of 2 residents reviewed for PASRR. Resident #2 was an older male admitted with a diagnosis of post-traumatic stress disorder (PTSD), and his most recent MDS showed a BIMS score of 15, indicating intact cognition. His PASRR Level I screening form dated 03/20/26 showed that the question asking whether there was evidence or an indicator of mental illness was answered "no," despite hospital paperwork dated 03/08/26 through 03/16/26 documenting PTSD. During interviews, the MDS nurse stated she only entered PASRR information for residents admitted from home, while the Admissions Coordinator stated he entered PASRR information into the facility software from the hospital paperwork exactly as received. He showed the surveyor the hospital PASRR screening form with no mental illness noted and said nurses could edit the information if they found an error. The DON stated the Admissions Coordinator should facilitate corrections and that if a resident admitted with a qualifying condition and the hospital paperwork was not corrected, the facility would have to correct it; she also stated she was responsible for overseeing PASRR completion. The Administrator stated the facility did not have a PASRR policy and followed Texas PASRR guidelines.
Baseline Care Plan Not Completed Within 48 Hours
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for Resident #102. Record review showed the resident was a [AGE]-year-old male admitted with diagnoses including cancer, hypertension, diabetes, respiratory failure, septic pulmonary embolism, and polyneuropathy. His 5-day MDS assessment reflected a BIMS score of 15, indicating intact cognition, that he required supervision for ADLs, and that he was on a pain regimen. Review of the clinical record showed Resident #102 did not have a completed care plan that included a baseline care plan. The resident’s progress notes reflected discharge home with stable vital signs and discharge instructions. During interviews, the ADON stated baseline care plans were not being completed correctly and said the admitting nurse was responsible for opening and completing them from hospital orders and documentation, while the MDS Nurse said baseline care plans were a group effort between nursing management and the DON. The DON stated the admitting nurse should complete the baseline care plan and the ADONs should review it for accuracy. The facility policy titled Care Plan-Process required initiation and completion of a baseline care plan within 48 hours of admission based on physician orders and nursing evaluation.
Failure to Care Plan Oxygen Use
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #56 that addressed oxygen use. Resident #56 was a [AGE]-year-old female admitted on [DATE] with diagnoses including Type 2 diabetes mellitus without complications, Non-Alzheimer's Dementia, heart failure, hypertension, and cancer. Her quarterly MDS dated 02/09/26 reflected a BIMS score of 09, indicating moderate cognitive impairment, and noted shortness of breath or trouble breathing when lying flat as well as oxygen therapy under special treatments, procedures, and programs. Record review showed that the care plan dated 03/17/26 did not address the resident's oxygen use. Physician orders dated 01/28/26 directed O2 SAT checks every shift and monitoring for signs and symptoms of shortness of breath, and orders dated 04/05/26 and 04/06/26 reflected oxygen every shift via nasal cannula and weaning off oxygen slowly while maintaining O2 greater than 90%. The orders did not specify how many liters of oxygen the resident should receive. The April 2026 MAR showed the resident's O2 sats were within normal limits. During observation on 04/07/26, the resident was seen in her room with oxygen via nasal cannula set at 1.5L and stated she was having a hard time breathing, though the nurse had just checked her oxygen levels and they were normal. Later that day, she was observed in the hallway without oxygen and stated she was feeling better and that oxygen was now only provided as needed. On 04/08/26, she was observed in bed sleeping with oxygen set at 1.5L and no distress noted. Staff interviews confirmed that oxygen should have been care planned, that the care plan had not been updated after a system change, and that the resident's oxygen use was not included in the current care plan.
Failure to Provide Nail Care
Penalty
Summary
The facility failed to ensure Resident #28, a female with diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression, received needed assistance with personal hygiene related to weakness. Her care plan dated 02/10/26 directed staff to provide extensive assistance with personal hygiene, but during an observation on 04/07/26, her fingernails were noted to have a black substance underneath each one. When asked if staff cleaned her nails, the resident said yes, and when asked if she would like them cleaned, she said yes. A later observation on 04/09/26 showed the black substance was still present under each fingernail. CNA C stated aides were responsible for cleaning resident fingernails and said she had not noticed the resident's nails were dirty, while the Restorative Aide said she had noticed the day prior that the nails were dirty but the resident had refused cleaning at times. RN D said no one had reported the dirty fingernails to her, and the ADON and DON stated nail care should be done by aides or nurses during showers or as needed. The facility policy titled Bathing included performing hand hygiene and nail care.
Failure to Apply Ordered Hand Splint for Contracture Management
Penalty
Summary
The facility failed to ensure Resident #50 received her left hand splint per physician order for contracture management. Resident #50 was an older female with diagnoses including diabetes mellitus, hemiplegia, and hemiparesis following a nontraumatic intracerebral hemorrhage and cerebral infarction. Her quarterly MDS reflected intact cognition with a BIMS score of 15, and her care plan included interventions for pain, limited ROM of the left upper extremity related to contracture, and the need for assistance with a left hand splint. The physician order directed that the left hand splint be applied on the day shift for 6 hours per day and that skin around the splint be monitored for redness or breakdown. During observation, Resident #50 was seen sitting in her wheelchair with her left hand contracted and without the splint in place. She gestured that she had a splint but had not been asked to wear it, and no splint was observed in the room. Additional observations later that day and on the following day showed she still did not have the splint on her left hand. The MAR reflected the splint was in place on two first-shift dates, but the resident was repeatedly observed without it during the survey. Interviews showed staff were unclear about who was responsible for applying the splint. RN D stated nurses or therapy were responsible and said she had not attempted to apply it on either of the two survey days, while the Director of Rehab stated the resident was not receiving therapy services and that the Restorative Aide was responsible. The Restorative Aide stated she had not applied the hand splint in months and was not responsible for putting it on. The DON and ADON stated nurses and CNAs were responsible for applying hand splints and following the physician order.
Failure to Monitor Significant Weight Gain in a Tube-Fed Resident
Penalty
Summary
The facility failed to ensure that Resident #53 maintained acceptable nutritional status based on her comprehensive assessment. Resident #53 was a female with diagnoses including diabetes, stroke, aphasia, hemiplegia, and seizure disorder. Her MDS reflected severe cognitive impairment, no speech, and dependence on a feeding tube for nutrition because of coughing and choking during meals or when swallowing medications. Her care plan stated that she required total assistance with tube feeding and that she was to be weighed per facility protocol with follow-up as indicated. Record review showed Resident #53’s weights increased from 146.4 pounds on 03/03/26 to 148 pounds on 03/19/26, 152.6 pounds on 03/25/26, and 157.8 pounds on 04/02/26. On 04/09/26, she was observed being weighed on a Hoyer lift scale, which showed 164.6 pounds. During observation on 04/07/26, she was sitting in a geri-chair in the TV room with a g-tube running Glucerna 1.2 Cal at 82 mL/hr. She made short eye contact but was unable to speak and did not appear to be in discomfort or distress. Interviews showed that the RD, RN, Restorative Aide, ADON, and DON were not aware of the extent of the weight gain at the time it occurred. The Restorative Aide stated she obtained resident weights and noticed the resident’s weight increase in about the last month, but the nurse she told no longer worked at the facility. The RD stated no one reported weight concerns and that she had not pulled the resident’s weights during her last visit. The facility’s Weight Monitoring policy stated resident weights were to be recorded and monitored at least monthly, and if weekly weights showed more than a 2% gain or loss, the resident was to be reweighed within 24 hours and the resident, family, physician, and RD were to be notified.
Improper Administration of G-Tube Medications
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident receiving enteral feeding when RN G administered crushed g-tube medications in a manner that did not follow the facility’s enteral tube medication procedure. Resident #9 was a [AGE] year-old female with diagnoses including aphasia, paraplegia, malnutrition, and respiratory failure. Her record showed she was dependent for ADLs and required a feeding tube, oxygen therapy, suctioning, and tracheostomy care. Her care plan included g-tube use for nutrition and enteral feeding with the goal that nutritional needs would be met with no signs or symptoms of aspiration. During observation, RN G crushed baclofen and oxycodone, mixed both medications together with water in one cup, and administered the combined mixture through the resident’s g-tube. She first flushed the tube with water, then used a syringe plunger to push the medication mixture into the tube. She then used additional water from cups on the bedside table to rinse the medication cup and continued pushing fluid through the tube with the syringe. RN G stated she mixed the medications together and pushed them because she believed the resident’s medications and food were thick and would not flow by gravity, and she said she used her nursing judgment rather than a physician order. Interview and record review showed the facility expected a different method. The NP stated g-tube medications should be given by gravity. The ADON stated giving two medications at the same time was inappropriate, each pill should be separated and mixed typically with 30 mL of water, and g-tube medications should be administered by gravity. The DON stated staff were expected not to mix medications together, to give one medication at a time, and to allow medications to flow by gravity rather than pushing them with a syringe. The facility policy also stated crushed medications are not to be mixed together, each medication is to be administered separately, and medication should be allowed to flow down the tube via gravity.
Missing Oxygen Order Details for a Resident Receiving Respiratory Care
Penalty
Summary
The facility failed to ensure respiratory care was provided consistent with professional standards of practice for one resident who was receiving oxygen therapy. Resident #56 was a [AGE]-year-old female with diagnoses including type 2 diabetes mellitus, non-Alzheimer's dementia, heart failure, hypertension, and cancer. Her quarterly MDS reflected shortness of breath when lying flat and that she received oxygen therapy, but her care plan did not address oxygen use. Her physician orders included oxygen saturation checks every shift and later an order for oxygen every shift for shortness of breath via nasal cannula, followed by an order to wean off oxygen slowly and maintain oxygen saturation above 90%, but the orders did not specify how many liters of oxygen to administer. During observation, Resident #56 was seen using oxygen via nasal cannula with the concentrator set at 1.5 liters, and at another time she was observed without oxygen while in her wheelchair. She stated she had been having a hard time breathing, then later said she was feeling better and that oxygen had recently been provided only as needed. RN D stated she had mistaken the order and adjusted the concentrator to 2 liters per minute, even though the order did not indicate the amount to administer. The ADON and DON both stated that oxygen orders should specify the number of liters to provide, and the DON stated she did not know the prior oxygen settings or liters being administered before the weaning process.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that Resident #58 received post-dialysis assessments after dialysis treatments. Resident #58 was admitted with diagnoses including end-stage renal disease, hypertension, heart failure, diabetes mellitus, and hyperlipidemia, and his MDS reflected that he received dialysis. His care plan included dialysis-related interventions such as dialysis as ordered, frequent weight checks, checking the shunt or access port, and checking vital signs as ordered and as needed. The physician order directed dialysis every shift and dialysis on Mondays and Fridays, with monitoring of the shunt/graft/fistula for signs of infection and adequate circulation. Review of the resident’s dialysis communication forms showed that the post-dialysis sections were left blank on multiple dates, with no information documented in the resident assessment and observation post-dialysis sections. During interview, the resident stated he went to dialysis twice weekly and had not missed treatment, and nursing staff confirmed that pre- and post-dialysis assessments were expected to be completed on the dialysis communication forms. RN D stated the post-dialysis assessments were not completed, and the DON stated the assigned nurse was responsible for completing pre- and post-assessments and sending the communication form with the resident to dialysis and back.
Expired Glucose Gel Left in Medication Carts
Penalty
Summary
The facility failed to provide pharmaceutical services to meet resident needs when two medication carts, the Hall 100 cart and the Hall 200 cart, each contained an unopened box of Fast Acting 40% Glucose Gel with an expiration date of 04/2025. During observation, the expired glucose gel was found in the 100-hall cart with RN F and in the 200-hall cart with RN G. Both nurses stated they were not sure where the glucose gel came from and acknowledged that it was expired and should not have remained in the carts. Interviews with RN F, RN G, the ADON, the DON, the Regional Nurse Consultant, and NP E showed that staff understood expired medications should be removed from medication carts and that glucose gel was used for low blood sugar emergencies. The facility’s Medication Storage policy, revised January 2026, stated that outdated medications are to be immediately removed from stock and disposed of according to procedure. The report also noted that the ADONs, nurses, medication aides, and pharmacist all had roles in reviewing medication storage, but the expired glucose gel remained in both carts at the time of survey observation.
Failure to Follow Oxygen Therapy Orders and Obtain Physician Orders for Respiratory Care
Penalty
Summary
The deficiency involves the facility’s failure to provide respiratory care consistent with physician orders and professional standards for two residents requiring oxygen therapy. For the first resident, an older male with severe cognitive impairment (BIMS score of 4), shortness of breath, and an order for continuous oxygen at 2 LPM via nasal cannula, surveyors observed him lying in bed without oxygen in place. The oxygen concentrator was running at 2 LPM, but the tubing was covered by bed sheets and not connected to the resident. His care plan included a problem of respiratory diagnosis with an intervention to administer oxygen as ordered, and active physician orders specified oxygen at 2 LPM every shift for shortness of breath. During observation and interview in the room, the CNA providing incontinent care stated she had not noticed that the resident was not on oxygen. She reported that the resident was known for removing his cannula but acknowledged she had not reported this behavior to the nurse, despite knowing he was supposed to be on continuous oxygen at 2 liters. The RN assigned to the resident stated she was aware of the continuous oxygen order but was not aware the resident was not receiving oxygen and reported she had not been to his room for hours. She stated that nurses were responsible for checking residents on oxygen to ensure they were receiving it and identified difficulty breathing as a possible negative outcome of not receiving oxygen. For the second resident, an older female with moderately impaired cognition (BIMS score of 10), COPD, and acute respiratory failure with hypoxia, the care plan documented a respiratory diagnosis with an intervention to administer oxygen as ordered. However, review of her physician order summary did not show an active order for oxygen. Surveyors observed her in the dining room with a portable oxygen tank set at zero LPM and tubing not connected, and she stated she was on oxygen and received it when provided by nurses, while her family member could not recall her being on oxygen. Later, the resident was observed on oxygen at 2 LPM. The RN caring for her confirmed the resident was on 2 LPM oxygen but could not find an order in the chart and stated there should be an order and that residents should not receive oxygen without one. The Regional Nurse Coordinator stated that residents receiving oxygen should have physician orders, that the charge nurse or person applying oxygen was responsible for obtaining orders, and that nurses were responsible for monitoring and evaluating residents on oxygen. Facility policies on oxygen administration and oxygen therapy via concentrator required verification and review of physician orders and documentation of ordered oxygen therapy in the eMAR/eTAR.
Uncovered Stage 4 Sacral Pressure Ulcer Not Reported or Redressed
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a Stage 4 sacral pressure ulcer received necessary treatment and services consistent with professional standards of practice. The resident was an elderly male with severe cognitive impairment, a BIMS score of 4, and diagnoses including diabetes mellitus. His entry MDS documented a Stage 4 pressure ulcer on the sacrum present on admission, and his care plan identified this ulcer with goals for healing and being free from infection, with interventions including treatment as ordered and monitoring. Physician orders directed staff to cleanse the sacrum and bilateral buttocks Stage 4 wounds with wound cleanser, pat dry, apply Santyl and calcium alginate, and cover with a dry dressing daily, with additional PRN orders if the dressing became soiled or dislodged. On the day of the surveyor’s observation, the treatment administration record showed the last wound treatment had been administered two days earlier, before the order was changed to three times weekly. During incontinence care, a CNA was observed cleansing the resident and turning him using a draw sheet. The resident’s sacral wound was observed to be open, uncovered, and draining onto the brief, and the CNA completed care by applying a clean brief and leaving the resident in bed without a dressing over the wound. There was no documentation in the resident’s March progress notes indicating that the wound dressing had been missing earlier that day. In interviews, the CNA stated she had removed the resident’s dressing that morning because it was peeling off and had fecal matter on it, acknowledged she was aware she was not allowed to remove dressings, and admitted she failed to notify the nurse or treatment nurse to replace it, despite prior training to do so. The charge RN and the wound care nurse both reported they had not been informed that the dressing had come off and stated their expectation that CNAs notify nursing staff so the dressing could be replaced per scheduled and PRN orders. The wound care nurse confirmed she had applied a dressing at the last treatment and expected nurses to monitor the dressing each shift and follow PRN orders if it became soiled or dislodged. The facility’s wound dressing change policy stated that dressings should be changed if feces seep beneath the dressing, but no training records were provided to support staff education on these procedures.
Failure to Notify Physician of Resident's Change in Condition
Penalty
Summary
Facility staff failed to promptly notify a resident's physician and responsible party of significant changes in the resident's condition, specifically regarding multiple episodes of low blood pressure. The resident, an older male with a history of hypertension, hypotension, heart failure, and other complex medical conditions, experienced several consecutive low blood pressure readings over multiple days. Despite these abnormal vital signs and the withholding of prescribed blood pressure medication due to the low readings, staff did not inform the physician or nurse practitioner as required by facility policy. Documentation showed that the resident's blood pressure was repeatedly below normal, with readings such as 85/59, 70/53, 73/55, and as low as 62/50 over a span of days. These findings were recorded by medication aides and nurses, who also withheld the resident's blood pressure medication in response to the low readings. However, there was no evidence that the physician or nurse practitioner was notified of these changes until the resident was being evaluated for an unrelated hospital transfer. Interviews with the physician and nurse practitioner confirmed that they were not made aware of the resident's ongoing low blood pressure, and both stated that notification should have occurred, especially given the need to withhold medication and the potential for underlying causes. The DON acknowledged that staff did not notify the physician, attributing the oversight to the resident's history of low blood pressure, but facility policy required notification for acute changes in condition. The deficiency was identified through interviews, record reviews, and policy examination.
Failure to Ensure Resident Received Prescribed Seizure Medication
Penalty
Summary
A deficiency occurred when a male resident with diagnoses of encephalopathy and epilepsy, who was severely cognitively impaired and dependent on staff for care, did not receive his prescribed Lamotrigine 250 mg twice daily for epilepsy management. Over a specified period, approximately 10 scheduled doses were missed, as documented in the Medication Administration Record (MAR) and confirmed by multiple medication aides. The medication was not available during this time, and the aides reported the issue to the charge nurses on duty. Despite being informed by the medication aides, the charge nurses did not escalate the issue to the Director of Nursing (DON) or notify the resident's physician about the missed doses. The physician was only informed after the issue was resolved, and she stated that consistent administration of the medication was critical for the resident's health and quality of life. The DON also confirmed that she was not notified of the medication issue until after several doses had been missed and that the nurses failed to follow the facility's policy regarding notification and escalation of medication availability issues. The underlying cause of the medication unavailability was an outstanding balance with the pharmacy, which resulted in the pharmacy withholding the medication until payment was received. The facility's policy required staff to notify the charge nurse, attempt to obtain the medication from an emergency kit, contact the pharmacy for a STAT delivery if needed, and inform the physician of any missed doses due to medication availability. These steps were not followed, leading to the resident missing multiple doses of a critical medication.
Failure to Notify Physician of Missed Epilepsy Medication Doses
Penalty
Summary
Facility staff failed to ensure timely physician notification when there was a significant change in a resident's physical status, specifically regarding missed doses of a prescribed epilepsy medication. The resident, an older adult with diagnoses including encephalopathy and epilepsy, was re-admitted to the facility and required supervision for care. Physician orders indicated the resident was to receive Lamotrigine 250 mg twice daily for epilepsy management, but approximately 10 scheduled doses were missed over a documented period. Medication aides reported that the medication was not available in the cart and stated they informed the charge nurses (LVNs) on duty about the issue. However, the charge nurses did not escalate the matter or notify the resident's physician about the missed doses. The physician later confirmed she was not informed of the medication disruption until after the issue was resolved, despite her expectation to be notified of any missed medications for prompt intervention and resident safety. The Director of Nursing (DON) and the facility administrator both stated that their expectations for staff conduct were not met, as the nurses failed to notify the provider of the missed medication doses. The issue with medication availability was related to an outstanding pharmacy balance, which delayed access to the medication. The facility's policy required notification of the physician when medications were unavailable and missed doses occurred, but this protocol was not followed in this instance.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent an elopement for one resident. The resident, an elderly male with diagnoses including encephalopathy and epilepsy, had severely impaired cognition as indicated by a BIMS score of 05. He required supervision and/or set-up assistance for care and used a walker and wheelchair for ambulation. Despite being assessed as low risk for wandering or elopement, the resident was able to leave the facility undetected between 11:30 PM and 12:00 AM. The resident was discovered missing during routine rounding at midnight by a CNA, who then alerted the nurse and initiated the facility's elopement protocol. The resident was found approximately 0.1 miles away at a nearby hospital and was returned to the facility by an LVN around 12:30 AM. Upon return, the resident was assessed and reported no pain or injuries. There was no documentation of previous wandering behaviors or prior elopement attempts for this resident. Interviews with facility leadership confirmed that all residents were expected to remain in the building for safety reasons, but it was unclear how the resident was able to elope. The facility's records indicated that doorways were checked and that the resident was subsequently placed on 1:1 monitoring. The incident was discussed among the physician, administrator, and DON, and the facility's policies on elopement management and abuse prevention were reviewed.
Improper Storage of Respiratory Equipment
Penalty
Summary
A deficiency occurred when a resident who required respiratory care, including nebulizer treatments, did not have her breathing mask properly stored according to professional standards and facility policy. The resident, who was cognitively intact and had a diagnosis of cough and anemia, was observed with her breathing mask left on top of her bedside table after use, rather than being placed in a plastic bag as required. The resident reported that she had not yet received her morning breathing treatment and was unsure where the nurse placed the mask after previous treatments. Later, the mask was observed inside a plastic bag, but it was not clear when this occurred. Interviews with staff confirmed that the expectation was for the breathing mask to be bagged when not in use to prevent cross-contamination and infection. The nurse responsible for the resident's care acknowledged that she had likely forgotten to bag the mask after the previous treatment and confirmed that the mask should be placed in a bag when not in use. Facility policy also required that respiratory equipment be bagged and labeled if it was to be used again. This lapse in following proper storage procedures for respiratory equipment constituted a failure to provide safe and appropriate respiratory care consistent with professional standards and the resident's care plan.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent care for a male resident diagnosed with a urinary tract infection. The resident was cognitively intact and dependent on staff for toilet hygiene. During the observed care, the CNA washed her hands and donned gloves and a gown before beginning care. However, she did not change her gloves or perform hand hygiene after touching the trash can, after cleaning the resident's perineal area, or after cleaning the resident's bottom, and before handling a new brief. The CNA continued to use the same gloves throughout the care process, including after contact with soiled items and before touching clean supplies. The facility's policy required hand hygiene after contact with soiled or contaminated articles and after removal of gloves. The CNA acknowledged during an interview that she should have changed gloves and performed hand hygiene at several points during the care. The Assistant Director of Nursing (ADON) and the Administrator both confirmed that the expectation was for staff to change gloves and perform hand hygiene as outlined in the facility's infection control policy.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that residents received meals that accommodated their preferences and dietary needs, as evidenced by the experiences of three residents. Resident #40, who was cognitively intact and had specific dietary orders for large portions of protein, frequently received meals that did not match his selections. Despite circling his choices on the menu, he often received incorrect items, such as a hamburger instead of a pork chop, and was missing items like potato salad and extra protein portions. This led him to rely on food brought by his family and to stop complaining about the discrepancies. Confidential Resident #1 also experienced issues with meal preferences not being honored. Despite selecting specific items and indicating dislikes, such as pasta and salad, the resident received meals that included these disliked items and were missing selected items like potato salad. The resident expressed dissatisfaction with the meals and felt that complaints were not understood by the staff, leading to a cessation of complaints. Confidential Resident #2 reported similar issues, noting that while breakfast was correct, other meals often did not match their selections. Staff interviews revealed that there were systemic issues with meal ticket accuracy and communication between kitchen and nursing staff. The kitchen staff sometimes substituted items without informing residents, and there were reports of rudeness towards nursing staff when corrections were requested. The facility's policy on selective menus was not effectively implemented, leading to residents not receiving meals according to their preferences and dietary needs.
Improper Food Storage and Labeling in Facility 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, including unlabeled and undated food items in the dry storage, refrigerator, and freezer areas. Additionally, there were several open and unsealed food packages, which were not stored in airtight containers as required. Expired food items were also found in various storage areas, indicating a lack of proper inventory management and rotation. During interviews, staff members, including the Regional Dietary Manager and other kitchen staff, acknowledged the presence of expired and unsealed items. They confirmed that all staff were responsible for ensuring proper storage and labeling of food items, as well as checking expiration dates. Despite having received in-service training on these procedures, staff were unaware of the existing deficiencies, suggesting a gap in the implementation of training and oversight. The facility's policy on food storage, dated 2018, outlines specific procedures for maintaining food safety, including the use of airtight containers, proper labeling, and the First In, First Out method for stock rotation. However, the observed practices in the kitchen did not align with these guidelines, posing a risk of cross-contamination and airborne illnesses to residents consuming meals from the facility's kitchen.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and failure to implement enhanced barrier precautions. Specifically, ADON A did not perform hand hygiene between cleaning Resident #39's wounds and applying clean dressings, and similarly failed to change gloves and sanitize hands between wound sites during care for Resident #40. These actions were acknowledged by ADON A, who admitted to not following proper infection control protocols, thereby increasing the risk of infection spread. Additionally, CNA B did not don a gown while providing incontinent care to Resident #34, who was on enhanced barrier precautions due to a urinary tract infection and other conditions. Despite being aware of the need for enhanced barrier precautions, CNA B prioritized quick care over proper PPE use, which she later recognized as a mistake. This oversight was compounded by the fact that Resident #34 was on contact precautions, further emphasizing the need for strict adherence to infection control measures. Similarly, CNAs C and D failed to wear gowns while transferring and providing care to Resident #52, who was also on enhanced barrier precautions due to her medical condition. Both CNAs acknowledged their lapse in judgment, attributing it to a momentary oversight. The facility's infection preventionist, ADON E, confirmed that staff were regularly trained on infection control protocols, including hand hygiene and enhanced barrier precautions, yet these lapses occurred, highlighting a significant deficiency in the facility's infection control practices.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure that Resident #38 received adequate supervision and assistance devices during a transfer from a wheelchair to a bed. On the specified date, LVN F and CNA J did not use a gait belt or a Hoyer lift, as required by the resident's care plan, when transferring the resident. Resident #38, a severely cognitively impaired male with limited range of motion and a history of falls, required total assistance for transfers and was at high risk for falls. The care plan specifically indicated the use of a gait belt during transfers to prevent falls and injuries. During the incident, LVN F and CNA J transferred the resident without the necessary equipment, despite the availability of gait belts in storage. LVN F acknowledged that the transfer was inappropriate and that the absence of a gait belt placed the resident at risk for falls and injuries. CNA J also admitted to not using the gait belt, which was against the facility's policy and the resident's care plan. The Director of Nursing confirmed that the staff was expected to use a gait belt for transfers due to the resident's condition, and failure to do so could result in falls or dislocation.
Failure to Follow Enteral Feeding Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a feeding tube. Specifically, the Licensed Vocational Nurse (LVN) did not follow proper procedures for checking the placement and residual of the feeding tube before starting the feeding. During an observation, the LVN connected the feeding tube and started the feeding without verifying the tube's placement or checking for residual, which is necessary to ensure the feeding tube is correctly positioned and that the resident is not retaining too much in the stomach. Additionally, the LVN did not adhere to the correct method of flushing the feeding tube. Instead of allowing water to flow by gravity, the LVN used a plunger to push water through the tube, which is against the facility's policy and can cause discomfort to the resident. The Director of Nursing (DON) confirmed that the staff is expected to follow physician orders and facility policies, which include checking tube placement and residual and allowing water to flow by gravity to prevent discomfort and potential complications.
Medication Administration Errors Result in 15% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 15% error rate during the survey. This was observed in the administration of medications to three residents. RN G administered Acetaminophen 500 mg to a resident at 09:30 AM, although it was scheduled for 12 PM. Additionally, RN G did not administer Olmesartan to another resident during the scheduled 8 AM medication round. Furthermore, medications scheduled for 8 AM were administered at 11:15 AM to a third resident. The residents involved had various medical conditions requiring precise medication management. One resident had a history of femur fracture, chronic obstructive pulmonary disease, and acute respiratory failure, among other conditions. Another resident had a fracture of the left lower leg, hypothyroidism, and depression. The third resident had a history of gait abnormalities, hyperlipidemia, and Type 2 diabetes mellitus. These conditions necessitated strict adherence to medication schedules to ensure therapeutic effectiveness and prevent adverse reactions. Interviews with RN G and the Director of Nursing (DON) revealed that RN G was aware of the medication administration guidelines, which require medications to be given within one hour before or after the scheduled time. However, RN G cited a high workload as a reason for the delays and omissions. The DON confirmed that medications should be administered within the specified time frame and that any unavailability should be reported to the primary care provider. The facility's policy mandates that medications be administered as prescribed, within 60 minutes of the scheduled time, unless otherwise specified by the prescriber.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by multiple instances of improper hand hygiene and equipment sanitation. RN B did not perform hand hygiene between glove changes during wound care for two residents, despite removing soiled dressings and applying new ones. This oversight occurred during the treatment of wounds on the coccyx and back, where RN B failed to sanitize her hands before donning new gloves, potentially leading to cross-contamination. Additionally, MA E did not sanitize the blood pressure cuff between uses for three residents, despite having disinfectant wipes readily available on the medication cart. After taking blood pressure readings, the cuff was placed back on the cart without being cleaned, which could facilitate the spread of germs between residents. MA E acknowledged the importance of hand hygiene and equipment sanitation but did not adhere to these practices during the observed medication administration process. CNA F also neglected proper infection control procedures while providing incontinent care to a resident. After cleaning the resident, CNA F did not change gloves or perform hand hygiene before handling a new brief, which could lead to contamination of clean items. The facility's Director of Nursing and Assistant Director of Nursing both emphasized the importance of hand hygiene and glove changes in preventing cross-contamination, yet these practices were not consistently followed by the staff.
Medication Storage Lapse in Resident's Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored securely, as evidenced by a bottle of Nystatin topical powder being left inside a resident's room. The resident, a cognitively intact male with a history of gastro-esophageal reflux disease, was observed with the medication on his overbed table. The resident stated that the medication was for a rash on his groin but had been discontinued, and he was unaware of how it ended up on his table. This oversight was confirmed by LVN C, who acknowledged that medications should not be left in residents' rooms and should be returned to the medication cart after administration. Further interviews with facility staff, including LVN D, the DON, and ADON A, revealed that the medication was indeed discontinued and should not have been in the resident's room. The staff emphasized that all medications, regardless of their form, should be stored in the medication carts and administered by nurses or medication aides. The facility's policy on medication storage, revised in 2016, supports this practice to ensure safe and effective drug administration. Despite the in-service training conducted by the DON to address this issue, the incident highlighted a lapse in adherence to the facility's medication storage protocols.
Deficiency in Respiratory Care Management
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, leading to deficiencies in the management of oxygen therapy. The resident, an elderly female with anxiety and chronic pain, was observed using a nasal cannula connected to a humidifier that lacked water, which is essential to prevent nasal and throat irritation. Additionally, the nasal cannula used with the resident's portable oxygen tank was improperly stored, hanging on the backrest of the wheelchair without being bagged, posing a risk of contamination and potential respiratory infection. Interviews with staff revealed a lack of awareness and adherence to proper procedures for handling respiratory equipment. A CNA assigned to the resident admitted to not knowing the correct storage method for the nasal cannula and typically hung it on the wheelchair. The LVN responsible for transferring the resident acknowledged overlooking the need to bag the nasal cannula and failing to check the humidifier's water level. The ADON and DON confirmed the importance of these practices to prevent respiratory infections and irritation, emphasizing the staff's responsibility in maintaining these standards. The facility's policies on oxygen therapy, which require nasal cannulas to be bagged when not in use and humidifiers to be filled with water, were not followed. This oversight in adhering to established procedures resulted in the resident's respiratory care needs not being met according to professional standards and the comprehensive care plan, potentially compromising the resident's health.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse. Resident #1, who had severe cognitive impairment and was unable to consent, was sexually abused by CNA A. The incident was captured on camera footage, showing CNA A engaging in inappropriate, sexually oriented activity with Resident #1. The resident's medical history included unspecified dementia, severe cognitive impairment, and total dependence on staff for personal care and hygiene. The abuse was reported by the family member of Resident #1's roommate, who observed the incident on camera footage and reported it to the local police department. The police initiated an investigation, and the facility suspended CNA A. Resident #1 was assessed by the Director of Nursing (DON) and sent to the hospital for a Sexual Assault Nurse Examiner (SANE) exam, which revealed an abrasion of the labia. The resident returned to the facility with no new orders. The facility's investigation confirmed the abuse, and CNA A was terminated. Interviews with staff and review of CNA A's personal file showed no prior complaints or barriers to employment. The facility had in-serviced staff on abuse and neglect reporting and prevention before the incident. The facility's policy on abuse, neglect, and exploitation was reviewed, and it was found that the facility had failed to protect Resident #1 from sexual abuse. The Immediate Jeopardy (IJ) situation was determined to have existed from the date of the incident until the facility implemented corrective actions. The police investigation concluded with the arrest of CNA A, who admitted to the attempted sexual assault. The facility's failure to protect Resident #1 placed residents at risk for serious injuries, abuse, and serious psychosocial harm.
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Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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