Briarcliff Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Mcallen, Texas.
- Location
- 3201 N Ware Rd, Mcallen, Texas 78501
- CMS Provider Number
- 675162
- Inspections on file
- 33
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Briarcliff Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia, diabetes, prior stroke, heart disease, and a documented DNR status in the care plan and physician orders had an OOH-DNR form that was not fully executed because the attending physician had not signed the required sections. The social worker obtained the family’s signature and forwarded the form per facility practice, and another staff member reported emailing the physician for signature, but the physician’s signature was delayed and remained missing at the time of review. This was inconsistent with the facility’s policy and the OOH-DNR instructions, which require the attending physician to sign and document the order in the medical record.
Surveyors found that two residents with dementia-related diagnoses were routinely given antipsychotic medications (including Lurasidone, Haldol Decanoate, and Seroquel) based on orders citing unspecified psychosis, without adequate indication documented in the clinical record. Care plans and MARs showed ongoing use of these psychotropics with black box warnings, while the facility’s own policy required that such drugs be used only for clearly diagnosed and documented conditions and not as chemical restraints. In interviews, a MHNP defended broad antipsychotic use in dementia, an LVN acknowledged limited understanding of appropriate indications and reliance on provider orders and consents, and the DON confirmed that psychosis is not an appropriate indication for antipsychotics in residents with Alzheimer’s or dementia but stated staff still administered medications even when indications were inappropriate.
Multiple residents with severe cognitive and behavioral impairments engaged in physical altercations, resulting in injuries such as lacerations and abrasions. Despite known risks and care plans addressing wandering and aggression, staff did not consistently prevent residents from entering others' rooms or intervening before altercations occurred. There was also inconsistency in recognizing and reporting these incidents as abuse.
The facility did not report a resident-to-resident altercation resulting in minor injuries to local law enforcement and failed to report an allegation of staff-to-resident verbal abuse within the required two-hour timeframe. In both cases, staff either did not recognize the incidents as reportable or assumed others would report them, leading to delays in notifying authorities as required by facility policy and regulations.
A resident with severe cognitive impairment and urinary issues exhibited behaviors of urinating in inappropriate areas, such as trash cans and the floor, over several months. Despite staff awareness and evidence of the behavior, the care plan did not document these behaviors or interventions until after surveyor inquiry. This omission resulted from a lack of timely updates and communication among the interdisciplinary team, contrary to facility policy and training requirements.
A CNA slapped a resident with severe cognitive impairment and a history of aggression after the resident became agitated and struck the CNA during care. The incident was witnessed by staff, confirmed through investigation, and determined to be abuse, placing the resident in Immediate Jeopardy.
Three residents were found to have bathroom sinks with hot water temperatures exceeding the required range, with readings as high as 124°F, while a shower bed used for bathing was observed to have frayed mesh and visible residue. Staff interviews revealed that water temperature checks were performed randomly and documented weekly, but did not identify the elevated temperatures in these rooms. The shower bed's poor condition had not been reported by staff prior to the surveyor's findings.
Two residents did not have comprehensive, person-centered care plans that addressed their specific needs. One resident with severe cognitive impairment required total assistance with feeding, but this was not reflected in her care plan. Another resident with advanced dementia and PTSD did not have identifiable triggers for PTSD documented in his care plan, nor a statement indicating the absence of such triggers. Staff interviews and record reviews confirmed these omissions, resulting in care plans that were not consistent with the residents' current needs.
A resident with moderate cognitive impairment and a need for assistance with personal care was found to have a disposable razor on his sink and a bag of new razors in his dresser drawer, despite facility policy requiring razors to be kept under lock and key. Staff interviews revealed a lack of awareness and adherence to the protocol regarding sharps, resulting in the resident having unsupervised access to razors.
A resident with severe cognitive impairment and multiple comorbidities was receiving oxygen therapy via nasal cannula, but staff failed to post the required oxygen sign on the door to indicate oxygen was in use. Nursing staff acknowledged responsibility for posting the sign and confirmed it was not done due to oversight, despite facility policy and professional standards requiring such signage for safety.
Staff failed to follow infection prevention protocols during care for two residents, including an LVN who did not sanitize hands after touching potentially contaminated surfaces before administering G-tube medications, and a CNA who did not change gloves or perform hand hygiene between catheter care and cleaning a bowel movement. Both staff acknowledged the lapses, and facility policies required proper hand hygiene and glove use.
A resident with cerebral infarction and aphasia reported being hit by nephews while on a pass, but the CNA failed to report the allegation immediately. The delay in reporting violated the facility's protocols, placing the resident in Immediate Jeopardy. Despite training on abuse reporting, the CNA only informed the facility upon returning to work, leading to a police investigation that found no crime.
A CNA in a long-term care facility verbally abused a resident by using a derogatory term in Spanish during a greeting. The resident, who had a history of dementia and was non-verbal, was unable to express if she was offended. The CNA admitted to using the term in a joking manner, but the facility's policy defines such language as verbal abuse.
The facility failed to accurately document significant health events in the MDS for two residents. One resident's fall was not recorded, and another resident's unstageable pressure ulcer was omitted from the discharge MDS. Staff acknowledged these oversights, noting that the MDS was primarily used for billing, while care plans were updated through other assessments. The discrepancies did not have immediate negative outcomes, but could affect communication if residents were transferred.
The facility failed to adhere to physician's orders for oxygen therapy for two residents, leading to incorrect oxygen settings. One resident with COPD had oxygen set at 3 liters per minute instead of the prescribed 2 liters, while another with hypoxia had it set at 1.5 liters per minute. Staff interviews revealed a lack of adherence to orders and absence of a specific policy on oxygen administration.
A resident on anticoagulant therapy experienced a fall, but the facility failed to accurately document the medication and neurological checks. LVN inaccurately noted the resident was not on an anticoagulant, and inconsistent neurological findings were not reported to the NP. The DON acknowledged the documentation errors and potential negative outcomes.
The facility failed to document the risk of elopement and secure unit placement in the care plans of three residents with severe cognitive impairments. Despite being placed in a secure unit due to their conditions, the care plans did not reflect these risks, potentially leading to inadequate care. Errors in completing a new wandering evaluation form led to the resolution of these care plans, removing critical information about the residents' needs.
The facility's pest control program was ineffective, leading to a roach infestation in resident rooms, hallways, and the dining room. Despite monthly pest control services and staff efforts to document and address sightings, roaches were frequently observed alive. Delays in pest control services and insufficient fumigation contributed to the ongoing issue, with residents and staff expressing concerns about the pest presence.
A resident with severe cognitive impairment and diabetes did not receive necessary podiatry services, resulting in overgrown toenails. Despite having an order for podiatry care, the resident was not added to the podiatrist's list, and staff were unaware of the issue until it was highlighted by an investigator. The facility lacked a specific foot care policy, leading to a deficiency in maintaining the resident's foot health.
Failure to Obtain Physician Signature on OOH-DNR for a Resident with DNR Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s Out-of-Hospital Do-Not-Resuscitate (OOH-DNR) order was properly completed in accordance with the resident’s advance directive and the facility’s own policy. The resident was an elderly female with dementia, Type 2 diabetes mellitus, orthopedic aftercare following a nondisplaced fracture of the left femur, cerebral infarction affecting the right dominant side, and heart disease. Her Quarterly MDS showed a BIMS score of 03, indicating severe cognitive impairment. Her comprehensive care plan documented an advanced directive with a DNR code status, including interventions such as ensuring a signed DNR in the medical record, not calling 911 or initiating CPR in the event of cardiac arrest, keeping the resident comfortable, sending a copy of DNR paperwork upon transfer, and consulting social services if the family wished to change code status. The physician’s orders also reflected a DNR status. Record review of the resident’s OOH-DNR form showed that it had been executed by the resident’s adult child as a qualified relative in Section C, but the attending physician had not signed in Section E (Physician’s Statement) or Section F (acknowledgment that the document was properly completed). The OOH-DNR instructions specified that the attending physician must document the existence of the order in the medical record and sign the appropriate sections of the form, along with the required witnesses. Despite the care plan directive to ensure a signed DNR in the medical record, the physician’s signature was missing from the OOH-DNR form at the time of the survey. Interviews with staff clarified the internal process and where it broke down. The social worker stated she was responsible for reviewing advance directives with the family, obtaining the family’s signature, and then giving the OOH-DNR to another staff member, who was responsible for obtaining the physician’s signature. That staff member reported that the social worker would scan OOH-DNRs to her, and she would email the physician for signature, and that the physician typically signed within a day or two; she stated that in this case the physician’s signature was delayed by the physician’s office. The DON acknowledged that the resident’s DNR had been care planned and ordered, but the OOH-DNR form itself had not been signed by the physician as required, despite the facility’s policy to support and facilitate residents’ rights to formulate and implement advance directives and to place copies of existing directives in the chart and communicate them to staff.
Inadequate Indications for Antipsychotic Use and Chemical Restraint Concerns
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from chemical restraints and unnecessary psychotropic medications, specifically antipsychotics with black box warnings, for two residents reviewed. For one resident with dementia, Alzheimer’s disease, hypertension, and Type 2 diabetes, the facility administered Lurasidone 40 mg daily based on a physician order that cited “unspecified psychosis not due to a substance or known physiological condition (F29)” as the indication. The resident’s care plan documented use of antipsychotic medications for mood disorder and psychosis and included monitoring for adverse reactions and black box warnings, but the record did not show an adequate indication for the use of Lurasidone in the context of dementia-related psychosis. The medication was administered routinely over several days as reflected on the MAR. For another resident with early-onset Alzheimer’s disease, heart disease, Type 2 diabetes, hypertension, bipolar disorder with psychotic features, intermittent explosive disorder, mood disorder due to a known physiological condition, and unspecified intellectual disabilities, the facility administered two antipsychotics—Haldol Decanoate and Seroquel—without an adequate indication documented in relation to dementia. The care plan identified the use of Seroquel and Haldol for psychosis with targeted behaviors of agitation, yelling, and grabbing at others. Physician orders directed monthly intramuscular injections of Haldol Decanoate 50 mg and oral Seroquel 300 mg tablets, initially two tablets at bedtime and later one tablet daily in the morning, all tied to a diagnosis of unspecified psychosis (F29). MARs showed consistent administration of these medications over multiple months. The orders and associated black box warnings noted increased mortality in elderly patients with dementia-related psychosis, yet the indication remained psychosis in residents with dementia diagnoses. Interviews with facility staff and prescribers further illustrated the circumstances leading to the deficiency. A mental health nurse practitioner stated that psychosis was a proper diagnosis for many dementia residents and asserted that more than half of dementia residents in nursing homes are psychotic and need antipsychotics, expressing disagreement with CMS concerns about antipsychotic use and black box warnings. An LVN reported that staff called the provider for behaviors such as crawling on the floor, yelling, aggression, or agitation, and that the provider would order medication; he acknowledged sometimes needing to ask for the indication and stated he did not know that psychosis was not an appropriate indication for an antipsychotic in residents with dementia or Alzheimer’s, adding that nurses followed provider orders as long as consents were signed. The DON confirmed there were numerous active antipsychotic orders, acknowledged that psychosis was not an appropriate indication for antipsychotic use in residents with Alzheimer’s or dementia, and stated that when a doctor or NP wrote an order, staff could not refuse to give the medication even if the indication was inappropriate. The facility’s own psychotropic drug use policy required that psychotropics be used only to treat specific, diagnosed, and documented conditions and not as chemical restraints, underscoring the discrepancy between policy and practice in these cases. The facility’s policy on psychotropic drug use defined chemical restraint as any drug used for discipline or staff convenience and not required to treat medical symptoms, and emphasized that psychotropic medications should only be used when nonpharmacological interventions are clinically contraindicated and when a practitioner determines the medication is appropriate for a specific, diagnosed, and documented condition. Despite this, the records for the two residents showed routine administration of antipsychotics with black box warnings based on indications of unspecified psychosis in the presence of dementia diagnoses, without adequate documentation that the medications were necessary to treat clearly defined medical symptoms as required by the policy. This mismatch between documented indications, resident diagnoses, and policy requirements formed the basis of the cited deficiency.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injuries
Penalty
Summary
The facility failed to ensure that residents were protected from abuse, resulting in multiple resident-to-resident altercations involving five residents. Several incidents occurred where residents with severe cognitive impairments and behavioral issues engaged in physical altercations, leading to injuries such as facial lacerations, abrasions, and scratches. For example, one resident with Alzheimer's disease and severe cognitive impairment wandered into another resident's room, resulting in a physical confrontation where both parties sustained injuries. Another incident involved two residents in a hallway altercation, where one attempted to grab the other, leading to a physical response that caused further injury. The residents involved had significant medical and behavioral histories, including diagnoses of Alzheimer's disease, dementia, mood disorders, and psychosis. Many required extensive assistance with activities of daily living and exhibited behaviors such as wandering, aggression, and rejection of care. Despite these known risks, the facility did not consistently prevent residents from entering others' rooms or from coming into close contact in common areas, which contributed to the altercations. Staff interviews confirmed that some residents were known to wander and had a history of confusion regarding room locations, yet interventions to prevent these interactions were not always effective or timely. Documentation and interviews revealed that staff were aware of the behavioral risks and had care plans in place, but these interventions did not prevent the incidents from occurring. In some cases, staff were not able to intervene before physical contact was made, and there was inconsistency in reporting incidents to local authorities. The facility's approach to determining whether an incident constituted abuse varied, with some staff not initially recognizing resident-to-resident altercations as abuse. This lack of consistent prevention and recognition of abuse led to multiple residents sustaining injuries as a result of altercations.
Failure to Timely Report Alleged Abuse and Resident Altercations
Penalty
Summary
The facility failed to ensure timely reporting of alleged violations involving abuse, neglect, or exploitation, as required by regulations. Specifically, the facility did not report a resident-to-resident physical altercation to local law enforcement, nor did it report an allegation of staff-to-resident verbal abuse within the mandated two-hour timeframe. These failures were identified through interviews and record reviews for two residents out of ten reviewed for abuse/neglect reporting. In the first incident, a male resident with severe cognitive impairment and multiple psychiatric diagnoses was involved in a physical altercation with another male resident who had moderate cognitive impairment. The altercation resulted in minor injuries, including discoloration to the hands and an abrasion to the chin. Although the incident was documented and the residents were monitored, the Assistant Director of Nursing (ADON) did not report the event to local authorities, stating she did not consider it abuse due to both residents' mental illnesses and the belief that the act was not willful. There was no evidence or case number to show that the incident had been reported as required. In the second incident, a female resident with intact cognition and hemiplegia was subjected to inappropriate comments by a nursing assistant, including remarks about her weight and sexual orientation. The certified nursing assistant who witnessed the event did not report it immediately, assuming another staff member present would do so. The Director of Nursing and Administrator confirmed that the incident was not reported to the state agency until several days later, after the ombudsman became involved. The facility's policy requires immediate reporting of all alleged violations, but this protocol was not followed in these cases.
Failure to Include Resident Behaviors in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all identified needs for a resident with severe cognitive impairment and multiple medical diagnoses, including vascular dementia and urinary retention. Specifically, the care plan did not include documentation or interventions related to the resident's behavior of urinating in inappropriate areas, such as trash cans or the floor, despite evidence of this behavior occurring over a period of approximately six months. The omission was identified during a review of the resident's records and interviews with facility staff, who acknowledged awareness of the behavior but had not ensured it was reflected in the care plan. Interviews with the DON, SW, and ADON revealed that although the behavior had been discussed among leadership and was known to staff, it was not documented in the care plan until after the surveyor's inquiry. The DON confirmed that the behavior should have been included to ensure all staff were aware and could implement appropriate interventions, and that the facility's policy required care plans to be updated as needed to reflect changes in resident behavior. The ADON and SW also indicated that the behavior had not been reported or observed directly, but evidence such as urine in trash cans and odor was present, and the issue had been discussed in meetings. The facility's policy and in-service training required comprehensive care plans to describe all services necessary to maintain the resident's highest practicable well-being, including behavioral interventions. However, the failure to update the care plan as required resulted in a lack of communication among staff regarding the resident's behaviors and the necessary interventions, as confirmed by staff interviews and record reviews.
Resident Slapped by CNA Following Agitation and Aggression
Penalty
Summary
A certified nursing assistant (CNA) failed to ensure a resident's right to be free from abuse when she slapped a resident on the face. The incident occurred while two CNAs were attempting to provide care to a resident with severe cognitive impairment, Alzheimer's disease, and a history of physical aggression and agitation. During the care attempt, the resident became agitated and struck the CNA, who then responded by slapping the resident in return. This act was witnessed by another CNA and a registered nurse (RN), who immediately intervened. The resident involved was an elderly female with diagnoses including Alzheimer's disease, cognitive communication deficit, and dementia, requiring moderate assistance with all activities of daily living and exhibiting daily wandering behavior. At the time of the incident, the resident was severely cognitively impaired, as indicated by a BIMS score of 00, and had a documented history of combative behavior toward staff and other residents. The incident was confirmed through interviews, written statements, and review of the facility's incident report, which documented the abuse. The facility's investigation confirmed that the CNA's action constituted abuse. The event was witnessed by staff, and the CNA involved admitted in a written statement to having hit the resident in response to being struck. The incident was reported to the facility administration and was determined to have placed the resident in an Immediate Jeopardy situation.
Removal Plan
- Resident #101 was immediately protected by RN J, who separated Resident #101 and CNA H, instructed CNA H to exit the memory unit and report to the Administrator's office, performed a head-to-toe assessment for any physical injuries, and reported the incident to the Administrator.
- CNA H was immediately removed from the facility, suspended, and terminated.
- A head-to-toe assessment was conducted on Resident #101, revealing no physical harm, pain, or mental anguish.
- The facility's social worker assessed Resident #101 for signs of psychosocial harm and referred Resident #101 for counseling evaluation.
- Staff were in-serviced on the topics of Dealing with challenging residents and Abuse Prohibition Policy.
- All residents in the memory unit were interviewed and observed for abuse with no concerns mentioned.
- Staff in the memory unit were interviewed and all were familiar with the facility's protocol when dealing with residents with cognitive impairment and aggressive behaviors and abuse prohibition policy.
Failure to Maintain Safe Water Temperatures and Shower Bed Condition
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for three residents and one shower bed, as evidenced by observations of excessively high hot water temperatures in resident bathroom sinks and a shower bed in poor condition. During an observation, the hot water temperatures in the bathroom sinks of three occupied rooms were found to be above the facility's required range, with readings of 124, 118, and 116 degrees Fahrenheit. The maintenance director and assistant confirmed that water temperatures are checked daily in one room per hall and documented, but the process did not identify or address the elevated temperatures in these specific rooms. The facility's logs showed that temperatures were generally within range, but the specific rooms in question were not flagged prior to the surveyor's findings. The residents affected included individuals with severe cognitive impairment and limited mobility, as well as a resident with intact cognition but requiring assistance with personal care. Interviews with these residents revealed that they used the sinks regularly but had not sustained burns. Staff interviews indicated that the maintenance team relied on random daily checks and weekly documentation, with alerts set for out-of-range temperatures. However, the system did not prevent the occurrence of excessively hot water in the rooms observed by surveyors. Additionally, the facility failed to ensure that the shower bed in one hall was in good condition. The shower bed was observed to have a white and black film, frayed and worn mesh, and water residue. Staff, including the Central Supply Director and DON, acknowledged the poor condition of the shower bed upon inspection, noting that it needed to be sanitized or replaced. The CNA responsible for using the shower bed stated she had not noticed the need for repair but was trained to report such issues. The facility did not have a policy related to shower beds, and no staff had reported the condition prior to the surveyor's observation.
Failure to Develop and Implement Comprehensive Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as required by policy. For one resident, an elderly female with diagnoses including vascular dementia and Alzheimer's disease, the care plan did not address her need for assistance with feeding. Despite documentation and staff interviews confirming that she required total assistance with feeding at all meals due to severe cognitive impairment, her care plan was not updated to reflect this need. Staff members, including CNAs and nurses, were aware of her dependency but the MDS nurse and DON were not informed, resulting in the care plan lacking accurate and current interventions for feeding assistance. For another resident, an elderly male with multiple psychiatric and cognitive diagnoses including post-traumatic stress disorder (PTSD), bipolar disorder, and advanced dementia, the care plan did not address identifiable triggers for his PTSD. Although the resident had a history of behavioral issues and a complex psychiatric background, staff interviews and record reviews indicated that no specific triggers had been identified or documented in his care plan. The care plan lacked a statement regarding the absence of identifiable triggers, despite staff monitoring his behaviors and acknowledging his advanced dementia and inability to communicate. Observations and interviews with staff revealed gaps in communication and documentation regarding both residents' needs. The facility's policy required care plans to include measurable objectives and timeframes based on comprehensive assessments, but these requirements were not met for the two residents. The lack of accurate and individualized care planning could result in residents not receiving necessary care or services tailored to their specific needs.
Failure to Secure Disposable Razors in Resident Room
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment, epilepsy, and a need for assistance with personal care was found to have a disposable razor in his restroom and a bag of 18 new disposable razors in his dresser drawer. The resident, who required partial or moderate assistance for personal hygiene due to weakness, history of spinal fractures, and poor balance, stated that he sometimes preferred to shave himself and that CNAs would provide him with a new disposable razor from his drawer when he wished to shave. During observation, a disposable razor was found on the resident's sink, and staff interviews revealed uncertainty about who placed it there and a lack of awareness of the facility's protocol regarding sharps. Further interviews with CNAs and nursing staff confirmed that facility policy required razors to be kept under lock and key in the shower room or medication cart, and that residents were not permitted to keep razors in their rooms. Despite this, the resident had access to multiple razors in his room, and staff were unaware of their presence. The DON and RN both acknowledged that the presence of razors in resident rooms was against facility policy and could result in harm if not properly controlled.
Failure to Post Oxygen Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of acute and chronic respiratory failure, congestive heart failure, hypertension, hyperlipidemia, peripheral vascular disease, and type 2 diabetes mellitus was not provided with appropriate respiratory care signage. The resident, who was severely cognitively impaired, had an active order for oxygen therapy via nasal cannula at 2 liters per minute as needed for hypoxia. During observation, the resident was found receiving oxygen therapy, but there was no oxygen sign posted on the outside of the resident's door or doorframe to indicate oxygen was in use in the room. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that it was the responsibility of nursing staff to post the oxygen sign as soon as possible after receiving the oxygen order. The LVN acknowledged forgetting to post the sign due to being busy, and both the ADON and DON emphasized the importance of the sign for alerting staff and for safety reasons. Review of facility policy and professional standards also indicated the need to post no smoking signs when oxygen is in use.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by improper hand hygiene and glove use by staff during resident care. In one instance, an LVN washed her hands before administering G-tube medications to a female resident with a history of cerebral infarction, dysphagia, and diabetes, but then touched the privacy curtain and bed remote before donning gloves and proceeding with medication administration without sanitizing her hands. The LVN acknowledged the importance of hand hygiene, especially given the resident's G-tube as a potential entry point for infection, but did not follow proper protocol after touching potentially contaminated surfaces. In another case, a CNA provided catheter care to a male resident with chronic kidney disease and an indwelling urinary catheter. After performing initial hand hygiene and donning gloves, the CNA completed catheter care and then, without changing gloves or performing hand hygiene, proceeded to clean a bowel movement and apply a clean brief. The CNA later recognized that gloves should have been changed and hand hygiene performed between these tasks to minimize infection risk, and the DON confirmed that this was the expected standard of care. Record reviews confirmed that the facility's policies required staff to perform hand hygiene in accordance with established procedures and to adhere to standard precautions during resident care. Both staff members involved acknowledged their lapses in following these protocols during interviews, and facility leadership reiterated the importance of proper hand hygiene and glove use as outlined in their infection prevention policies.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, specifically in the case of a resident who was reviewed for abuse. The incident involved a resident who had been admitted with diagnoses including cerebral infarction, aphasia, and mild intellectual disabilities. The resident reported to a CNA that she had been hit by her nephews while out on a pass with her sister. However, the CNA did not report this allegation immediately, as required by the facility's policies. The CNA, who was responsible for the resident's care, did not communicate the resident's allegation of abuse to the appropriate authorities or facility staff in a timely manner. The CNA stated that she was busy and forgot to report the incident, and she was off work following the day of the incident. It was only upon her return to work that she reported the allegation to a nurse, who then informed the facility's Social Services and Administrator. This delay in reporting the allegation of abuse was a significant failure in the facility's duty to protect the resident from potential harm. Interviews with facility staff, including the Social Services, LVN, DON, and Administrator, revealed that the facility had protocols in place for reporting abuse, but the CNA did not follow these procedures. The facility had conducted training on abuse, neglect, and exploitation, emphasizing the importance of immediate reporting. Despite these measures, the CNA's failure to report the allegation promptly placed the resident in an Immediate Jeopardy situation, although no crime was discovered upon investigation by the police.
Verbal Abuse Incident Involving CNA
Penalty
Summary
The facility failed to ensure that residents were free from verbal abuse, as evidenced by an incident involving a Certified Nursing Assistant (CNA) who verbally abused a resident. The CNA referred to the resident using a derogatory term in Spanish, which translates to 'my stupid pretty,' during a greeting. This incident was reported anonymously to the facility's compliance line, prompting an investigation. The resident involved in the incident was a female with a history of vascular dementia, Parkinson's disease, major depressive disorder, and schizophrenia. She was non-verbal and rarely understood others, as indicated by her quarterly MDS assessment. During an observation, the resident was seen lying in bed, listening to the radio, and not responding to questions, showing no facial expression. The investigation revealed that the CNA admitted to using the derogatory term in a joking and loving manner, believing it was well-received by the resident. However, the facility's policy defines verbal abuse as the use of disparaging and derogatory terms, regardless of the resident's ability to comprehend. The CNA's behavior was deemed inappropriate, and the facility confirmed the allegations of abuse.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care documentation. Resident #4, a male with a history of intervertebral disc disorders, Alzheimer's disease, muscle wasting, and osteoporosis, experienced a fall on 2/28/24. However, this fall was not recorded in the Minimum Data Set (MDS) assessment, which inaccurately reflected zero falls since admission. The MDS coordinator acknowledged the oversight, stating that the fall should have been documented, although it did not affect the resident's care plan or payment level. The Director of Nursing (DON) noted that the MDS was not the primary driver for care plans, but acknowledged that missing information could impact communication if the resident was transferred to another facility. Resident #6, who was admitted with chronic kidney disease, acute pulmonary edema, and vascular dementia, had an unstageable pressure ulcer on the sacrum that was not documented in the discharge MDS. The MDS/LVN responsible for the assessment admitted to omitting this information, explaining that the MDS was primarily used for billing purposes and that the care plan was updated based on other assessments. The DON confirmed the presence of the pressure ulcer, which was attributed to constant diarrhea and skin excoriation, and noted that the facility did not have a specific policy for MDS documentation. The report highlights the facility's failure to accurately document significant health events in the MDS, which could potentially affect resident care and communication between facilities. The discrepancies in the MDS assessments for both residents were acknowledged by the staff involved, but were not seen as having immediate negative outcomes due to the presence of other care planning processes.
Failure to Adhere to Physician's Orders for Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as observed during a survey. Resident #2, diagnosed with chronic obstructive pulmonary disease (COPD), was found with her oxygen set at 3 liters per minute via nasal cannula, contrary to the physician's order of 2 liters per minute. Similarly, Resident #3, who has hypoxia, was observed with his oxygen set at 1.5 liters per minute instead of the prescribed 2 liters per minute. These discrepancies were noted during observations and confirmed through interviews with nursing staff, who acknowledged the deviations from the physician's orders. Interviews with the nursing staff, including an RN, LVN, ADON, and DON, revealed a lack of adherence to the physician's orders for oxygen settings. The RN admitted to noticing the incorrect settings since starting at the facility but was told by a training nurse that it was acceptable. The LVN and ADON confirmed that nurses were responsible for checking oxygen settings at the beginning and end of each shift, yet the facility lacked a specific policy on oxygen administration. The DON also confirmed the absence of a policy and emphasized the importance of following physician orders to prevent adverse reactions. The facility's medication reconciliation policy was reviewed, but it did not specifically address oxygen administration.
Inaccurate Documentation of Anticoagulant and Neurological Checks
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding the documentation of anticoagulant medication and neurological checks following a fall. The resident, an elderly female with vascular dementia, hypertension, muscle wasting, and atrial fibrillation, was on anticoagulant therapy with Xarelto. However, LVN A inaccurately documented that the resident was not on an anticoagulant, which was contrary to the resident's care plan and medication administration records. Following an unwitnessed fall, LVN A documented the resident's neurological checks inaccurately, noting that the resident's pupils were not reactive to light initially, but later documented them as reactive. This inconsistency was not reported to the nurse practitioner, NP C, who stated that had she been informed of the resident being on an anticoagulant, she would have sent the resident to the emergency room for further evaluation. The documentation errors and lack of communication could have led to a failure in providing appropriate care. The Director of Nursing (DON) acknowledged the discrepancies in documentation and the potential negative outcomes due to poor documentation practices. The facility's policy requires accurate and timely documentation, which was not adhered to in this case. The DON admitted to not following up on the documentation regarding abnormal findings, which could have resulted in neurological damage to the resident.
Failure to Document Elopement Risks in Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which did not include measurable objectives and timeframes to address their risk of elopement and wandering. These residents, all with severe cognitive impairments and diagnoses such as dementia and Alzheimer's, were placed in a secure unit due to their behaviors and conditions. However, their care plans did not reflect this placement or the associated risks, which could lead to inadequate care and services. Resident #2, a female with severe cognitive impairment and a history of wandering, was placed in a secure unit due to her dementia-related behaviors. Despite meeting the criteria for secure unit placement, her care plan did not document the risk of elopement or her secure unit status. Similarly, Resident #3, also with severe cognitive impairment and a history of wandering, was placed in the secure unit, but her care plan lacked documentation of her elopement risk and secure unit placement. Resident #10, with Alzheimer's and a history of exit-seeking behaviors, was also in the secure unit, but her care plan did not reflect her risk of wandering or her secure unit status. Interviews with facility staff, including CNAs, RNs, and administrative personnel, revealed that the care plans were not updated correctly due to errors in completing a new wandering evaluation form. This form, when filled out incorrectly, resolved the care plans, removing the documentation of the secure unit placement and elopement risks. Staff acknowledged the importance of having these interventions documented in the care plans to ensure that all staff members were aware of the residents' needs and how to care for them appropriately.
Ineffective Pest Control Program Leads to Roach Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in multiple areas, including resident rooms, hallways, and the dining room. Interviews with residents and staff revealed that roaches were seen alive in various locations, and although some staff attempted to address the issue by killing the roaches and documenting sightings, the problem persisted. The pest control company was contracted to service the building monthly, but there were delays in service, and not all areas were fumigated as needed. Residents reported seeing roaches in their rooms and common areas, with some sightings occurring as recently as a week before the survey. Staff interviews indicated that while there was a process for logging pest sightings, there was uncertainty about the frequency of pest control visits and the effectiveness of the measures taken. Housekeeping staff cleaned daily, but the presence of food and crumbs in resident rooms contributed to the pest issue. The pest control program specifications outlined monthly services for interior and exterior areas, with emergency services available. However, the facility's documentation showed numerous pest sightings over several months, indicating that the pest control measures were insufficient to eradicate the problem. The lack of a comprehensive facility policy for pest control and reliance on a contracted company that did not always respond promptly contributed to the ongoing issue.
Failure to Provide Adequate Foot Care for Resident
Penalty
Summary
The facility failed to provide adequate foot care for a resident, leading to a deficiency in maintaining the resident's foot health. The resident, an elderly female with severe cognitive impairment and multiple diagnoses including diabetes, had an order for podiatry services that was not fulfilled. Her toenails were observed to be overgrown, approximately an inch longer than the nailbed, indicating a lack of proper foot care. Despite having an order for podiatry services, there was no record of the resident being added to the podiatrist's visit list or consent being obtained for such services. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for podiatry services. The CNA assisting the resident with bathing and dressing was unaware of the resident's diabetic condition and had not noticed the overgrown toenails. Similarly, the LVN and other nursing staff did not observe the long toenails and were unsure about the podiatrist's schedule or whether the resident had been added to the list for podiatry care. The ADON and DON acknowledged the oversight and confirmed that the resident's toenails were excessively long, but no action had been taken until the issue was brought to their attention by an investigator. The deficiency was further compounded by the absence of a specific policy for foot care, although the facility's ADLs policy included grooming and nail care. The DON admitted that the resident's foot care needs were missed due to a lack of communication and coordination among staff. The resident's toenails were eventually trimmed by an LVN after the issue was identified, but the initial failure to provide timely podiatry services and foot care represents a significant lapse in the facility's duty to maintain the resident's health and well-being.
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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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