Briarcliff Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Carthage, Texas.
- Location
- 4054 Northwest Loop, Carthage, Texas 75633
- CMS Provider Number
- 676051
- Inspections on file
- 30
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Briarcliff Skilled Nursing Facility during CMS and state inspections, most recent first.
Incomplete Comprehensive Care Plans for Hospice, PTSD, Dialysis, and Combative Behavior: A resident on hospice, a resident with a PTSD history, a resident receiving dialysis, and a resident with rejection of care/combative behavior all had MDS findings or orders documenting those needs, but their comprehensive care plans did not include the related services, triggers, or interventions. Interviews with the ADON, family member, MDS Coordinator, DON, and Administrator confirmed these items should have been care planned and that the MDS nurse was responsible for the comprehensive care plans.
Failure to Invite Residents and Representatives to Care Plan Meetings: Two residents were not consistently included in quarterly care plan conferences. One resident with anemia, A-fib, cirrhosis, and moderate cognitive impairment said she had never been invited to a care plan meeting, and a second resident with Parkinson's disease had a family member who said she had not been invited in a while. The SW said she sent invitation letters and that some meetings may have been missed during a period when staffing was limited, while the DON and Administrator stated care plan meetings should occur quarterly with the resident, family, and IDT.
Unsafe and Unclean Resident Room Conditions: A cognitively intact resident with muscle weakness, chronic pain, and liver disease had a damaged bathroom door with black marks on the door and nearby wall, and dirty room windows that staff had noticed but not addressed. The resident said the conditions made her feel staff did not care, while interviews showed CNA, housekeeping, maintenance, LVN, and the DON were aware of the cleanliness and repair concerns or did not know who was responsible for them.
A resident with COPD, Alzheimer’s disease, and anxiety disorder was not kept free from physical restraint when a CNA held both wrists during a brief change after the resident became combative. The resident had moderate cognitive impairment and rejection of care, and bruising was later documented on both forearms. Interviews showed staff continued the care while holding the resident’s wrists in the air, and the DON and ADON stated staff should stop and return later when a resident becomes combative.
Baseline Care Plans Not Completed or Signed by RN: The facility failed to complete baseline care plans within 48 hours for two residents and did not ensure RN involvement in the process. One resident with heart block, atrial flutter, B-cell lymphoma, COPD, and DM2 had a baseline care plan that did not address a catheter, even though a drainage bag was observed and the resident said the catheter came from the hospital. Another resident with anemia, AFib, cirrhosis, and moderate cognitive impairment had no baseline care plan completed by the IDT including a RN, and said no baseline care plan meeting occurred on admission.
A resident with severe cognitive impairment and ADL dependence was not kept clean shaven despite stating that he preferred to be clean shaven. CNA documentation showed bathing/hygiene assistance, but it did not show shaving, and notes did not indicate any refusal. The resident had visible facial hair on repeated observations, and staff confirmed CNAs were responsible for shaving residents during showers as part of routine hygiene care.
A facility failed to prevent accidents and provide adequate supervision, resulting in one resident with severe cognitive impairment assaulting another resident and a separate incident where a resident at high risk for falls was left on the floor for several hours after falling. Both incidents involved lapses in staff monitoring and supervision, leading to resident injuries and distress.
A resident with cognitive impairment and Parkinson's disease suffered second-degree burns after spilling hot coffee served at an unsafe temperature. The facility lacked policies for monitoring hot liquid temperatures and did not conduct risk assessments for residents. Staff interviews revealed inadequate training and awareness regarding the safe serving of hot beverages, contributing to the incident.
The facility's kitchen failed to meet food service safety standards due to inadequate cleaning and maintenance. Observations revealed black carbon buildup on baking sheet pans and the stove top. Staff interviews indicated infrequent cleaning and a lack of clear responsibilities. The Dietary Manager acknowledged the issue, citing short staffing as a challenge. Maintenance records were incomplete, and the facility lacked a specific cleaning policy, leading to potential risks of foodborne illness and contamination.
The facility failed to maintain a system for the receipt and disposition of controlled drugs, risking medication loss and diversion. Controlled medications were stored in the DON's office without proper logging until destruction, contrary to policy. The Administrator was unaware of the narcotic medication policy, and the last medication destruction was not recent, indicating a lack of regular reconciliation.
A resident was found with unauthorized medications in her room, and two nurses left medication carts unlocked and unattended, violating facility policies. The resident had no order to self-administer, and the carts' unsecured state posed risks of unauthorized access and medication errors.
A facility failed to provide palatable and appetizing food at safe temperatures, affecting four residents. Complaints included bland, cold, and unsuitable food for dietary needs. Despite offering alternatives, dissatisfaction persisted. Staff interviews confirmed frequent resident complaints, and test tray evaluations revealed issues with food quality. The facility's policy on food temperatures was not effectively implemented.
A long-term care facility was found deficient in its infection prevention and control program. Staff failed to perform proper hand hygiene during wound care, used ineffective disinfectants for C. diff, and did not apply enhanced barrier precautions during medication administration and tracheostomy care. These lapses increased the risk of cross-contamination and infection spread among residents.
A resident with severe cognitive impairment and multiple diagnoses was found to be using a lap harness on a Broda chair without proper assessment, monitoring, or documentation as a restraint. Facility staff did not have a clear understanding of the harnesses' use, and there was no physician order or signed consent. Despite justifications for safety and mobility, the lack of documentation and policy on restraints led to a deficiency.
Two residents' MDS assessments failed to accurately reflect the use of restraints. One resident's safety vest and lap belt were not documented as restraints despite being used for positioning due to cerebral palsy. Another resident's limb restraint was not recorded, although it was used for safe positioning due to Rett's Syndrome. Staff and medical professionals considered these devices necessary for safety, but the facility's policy requires accurate assessments to ensure proper care.
A resident with COPD was consistently receiving oxygen at a higher rate than prescribed, contrary to physician orders. Observations showed the resident receiving 3.5 l/min instead of the ordered 2 l/min, and at one point, the setting was at 4 l/min. The LVN and DON confirmed the discrepancy, noting the electronic MAR did not prompt checks for as-needed oxygen settings. The facility's policy requires verification and documentation of oxygen flow rates, which was not followed.
Incomplete Comprehensive Care Plans for Hospice, PTSD, Dialysis, and Combative Behavior
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for four residents whose assessments and records identified specific needs. Resident #2, a female admitted with anemia, atrial fibrillation, and cirrhosis, had an admission MDS showing a BIMS of 12, dependent assistance for bed mobility, personal hygiene, dressing, and transfer, and receipt of hospice services, but her comprehensive care plan dated 03/21/2026 did not include hospice services. Resident #3, admitted with dementia, diabetes type II, and bipolar disorder, had an admission MDS with a BIMS of 10 and a PTSD screen documenting a history of PTSD, but her comprehensive care plan dated 02/27/2026 did not include PTSD, PTSD triggers, or PTSD interventions. Resident #10, admitted with chronic kidney disease, end stage renal disease, and stroke, had a quarterly MDS showing intact cognition with a BIMS of 15 and indicating dialysis services, and an active physician order for dialysis every shift with monitoring of the shunt/graft/fistula for signs or symptoms of infection and adequate circulation, but the care plan dated 03/31/26 did not include dialysis services. Resident #30, admitted with COPD, Alzheimer’s disease, and anxiety disorder, had a quarterly MDS showing a BIMS of 08 and a behavior of rejection of care, but the care plan dated 03/31/26 did not include her history of resisting care or combative behavior. During interviews, the ADON stated Resident #30 refused care and could be combative, and the family member said she became combative if awakened or made to do something she did not want to do. The MDS Coordinator stated care plans were to include all items coded on the MDS, including hospice services, PTSD, dialysis, behaviors, and diagnoses, and that not care planning important items could result in staff not knowing what was needed for management of the resident’s condition. The DON and Administrator stated major diagnoses, conditions, medications, falls, and individualized interventions should be care planned, and the Administrator stated the MDS nurse was responsible for creating comprehensive care plans.
Failure to Invite Residents and Representatives to Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents and/or their representatives were invited to participate in the development and implementation of person-centered care plans for 2 of 18 residents reviewed. One resident was a female admitted with anemia, atrial fibrillation, and cirrhosis, and her admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment. She required dependent assistance for bed mobility, personal hygiene, dressing, and transfer. Record review showed no documentation of care plan meetings completed prior, and during interview she stated she had not been invited to or participated in a care plan meeting and wanted to attend so someone could explain her medical condition to her. The second resident was a male admitted with Parkinson's disease. His quarterly MDS showed unclear speech, that he was usually understood and sometimes able to understand others, and a BIMS score of 11, indicating moderately impaired cognition. He usually required partial/moderate to substantial/maximal assistance for most ADLs. A quarterly care conference form showed one care conference was conducted and that the resident representative was invited and attended, but no additional care plan conference forms were available. The resident's family member stated she had attended a care plan meeting when he first admitted but had not been invited to a care plan meeting in a while, and she would have liked to attend and participate in his care plan meetings. The Social Worker stated she was responsible for keeping a calendar and ensuring care plan meetings occurred at least quarterly, and that she sent letters to families to invite them. She also stated there was a period when a part-time social worker was trying to do all care plan meetings and that some meetings may have been missed. The DON and Administrator stated care plan meetings should occur quarterly, involve the interdisciplinary team, and include the resident and family, and the facility policy stated the interdisciplinary team would coordinate with the resident and legal representative and review the care plan quarterly and annually.
Unsafe and Unclean Resident Room Conditions
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for Resident #32. The resident’s face sheet showed diagnoses including muscle weakness, chronic pain, and liver disease, and the MDS indicated she was cognitively intact with a BIMS score of 14 and required dependent staff assistance for most ADLs. During observation, the inside of the bathroom door in her room had a deep scrape and black marks along the bottom of the white door and door frame, and there were black marks along the wall near the floor outside the bathroom entrance. Resident #32 stated the bathroom door had been damaged and said it had scrapes and black marks from a wheelchair, although she said her wheelchair had not made the marks and the damage was already present when she was admitted. She said the condition made her feel like staff did not care and that they had problems and did not do anything about it. The Maintenance Request Log at the nurse’s station showed only one maintenance request dated 04/01/26 and did not include requests about the bathroom door, the walls near the bathroom, or the dirty windows. Resident #32 also reported that the windows in her room were dirty on the outside. She said she had reported the windows to the Maintenance Supervisor, who told her he did not do windows, and she said she had also spoken to the Administrator, who told her it was the way the windows were made. Observation showed white coating on the upper panes and a buildup that was black, light brown, and orange on the bottom right pane of the upper portion of the window. Staff interviews confirmed they had noticed the dirty windows, did not know who was responsible for cleaning them, and had not reported them. The Maintenance Supervisor said there was no schedule for cleaning the outside windows and that he had not followed up after the resident raised the concern.
Improper use of wrist holding during resident care
Penalty
Summary
The facility failed to ensure a resident remained free from physical restraints when CNA A held the resident’s wrists during personal care on 03/16/26. The resident had diagnoses including COPD, Alzheimer’s disease, and an anxiety disorder, and her MDS showed a BIMS score of 08 with moderate cognitive impairment and a behavior of rejection of care. Her care plan did not indicate a history of resisting care or being combative with staff. Record review showed the resident’s weekly skin data form for 03/16/26 documented bruising to both forearms, while the prior week’s skin data form did not note bruising to the arms. During interviews, the resident said a CNA held her arms and turned her in bed and that the bruising occurred when staff were trying to care for her. CNA A stated the resident was combative during the brief change and that she held both wrists to keep the resident from hitting staff. CNA B stated the resident was swinging at staff, that CNA A held the resident’s wrists in the air while the brief change was completed, and that the resident was told to stop hitting. The facility’s documentation showed CNA A and CNA B both received one-on-one re-education after the incident, with instruction that if a resident refuses care or becomes combative, staff should step away and try again later or let someone else try later. The ADON and DON both stated that if a resident becomes combative during care, staff should stop and return later. The Administrator stated he was satisfied the aides were in the middle of the brief change and did the best they could to keep the resident safe, and he did not want to second guess them in that situation.
Baseline Care Plans Not Completed or Signed by RN
Penalty
Summary
The facility failed to ensure the baseline care plan was developed and implemented within 48 hours of admission for two residents, and failed to ensure a RN was part of the baseline care plan process. For Resident #71, the record showed admission to the facility with diagnoses including unspecified heart block, atypical atrial flutter, unspecified B-cell lymphoma, COPD, and type 2 diabetes. The baseline care plan dated 03/26/2026 did not address the resident’s catheter status, even though the resident was observed in bed with a catheter drainage bag attached to the bed frame and stated he had received the catheter in the hospital before admission. The baseline care plan was signed by an LVN, and there was no signature from a RN or other IDT member. For Resident #2, the record showed admission with diagnoses of anemia, atrial fibrillation, and cirrhosis, and an admission MDS reflected a BIMS score of 12 with moderate cognitive impairment. The resident required dependent assistance for bed mobility, personal hygiene, dressing, and transfer. The EHR contained no baseline care plan completed by the IDT including a RN. During interview, the resident stated she did not recall anyone visiting with her about a baseline care plan and said there was no baseline care plan meeting when she first came to the facility. Interviews with facility staff showed the MDS Coordinator stated the baseline care plan was completed by the floor nurse, social worker, department head nurses, and therapy, but not by a RN each time, and that the new EHR had nowhere for the RN to sign. The DON stated the baseline care plan should be completed by the IDT and signed by a RN, and that catheter status and other special care needs should be included. The Administrator stated the baseline care plan was an interdisciplinary form discussed with residents on admit and that it was the responsibility of the team to ensure it was completed and signed properly and a copy was provided to the resident and family. The facility policy stated the baseline care plan was to be initiated and completed within 48 hours of admission based on physician orders and nursing evaluation.
Failure to Provide Shaving as Part of Personal Hygiene Care
Penalty
Summary
The facility failed to provide the necessary services to maintain personal hygiene for Resident #44, specifically failing to ensure he was clean shaven as was his preference. Resident #44 was [AGE] years old, admitted with diagnoses including heart failure, muscle weakness, and anxiety disorder. His quarterly MDS indicated he was sometimes understood and sometimes understood others, had a BIMS score of 2 indicating severely impaired cognition, and required moderate assistance with most ADLs, including bathing and personal hygiene. Record review showed the care plan did not indicate that Resident #44 required assistance with ADLs or identify fall-related risks, although it included an intervention to provide assistance with self-care tasks as appropriate for safety. The CNA flow sheet documented bathing/hygiene assistance on 03/30/26 but did not show whether shaving was provided, and interdisciplinary progress notes did not indicate that he refused shaving. During interviews and observations, Resident #44 stated he preferred to be clean shaven and said no one offered to shave him; he had short white facial hair on repeated observations. Staff interviews confirmed CNAs were responsible for shaving residents during showers, that his shower days were Monday, Wednesday, and Friday, and that he should have been shaved as part of his routine care. The facility policy stated hair care, combing, and shaving would be provided in accordance with standard practice guidelines.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision and assistance to prevent accidents for three residents. In one incident, a male resident with severe cognitive impairment and a history of wandering and behavioral issues entered another resident's room in the memory care unit while unsupervised. He assaulted a female resident, causing multiple bruises to her face and forearm, and also struck a nurse with a plunger and a stethoscope. The incident occurred after a CNA left the unit to seek additional staff assistance, leaving the area unsupervised. The assaulted resident was found crying and distressed, with visible injuries, and required transport to the emergency room for evaluation. Documentation and interviews confirmed that the aggressive resident had not previously exhibited such behavior, but the lack of supervision allowed the incident to occur. In a separate event, another male resident with moderate cognitive impairment and a high risk for falls was left unsupervised for several hours during the night. The resident fell at midnight while attempting to walk unassisted and remained on the floor until nearly 5:00 AM before being discovered by staff. Video evidence showed that no staff checked on him during this period, despite care plans indicating he required assistance with mobility and regular checks. The resident sustained bruising and an abrasion as a result of the fall. Staff interviews revealed that the assigned CNA became overwhelmed with other resident care tasks and failed to check on the resident, while the nurse on duty did not verify the resident's status during the night. Both incidents demonstrate a failure to provide adequate supervision and assistance as required by the residents' care plans and assessments. The lack of timely staff intervention and monitoring directly resulted in resident injuries and distress. The facility's inaction in maintaining appropriate supervision and assistance for residents with known risks contributed to these deficiencies.
Failure to Ensure Safe Serving of Hot Coffee Leads to Resident Burns
Penalty
Summary
The facility failed to ensure an environment free from accident hazards, specifically regarding the serving of hot coffee, which resulted in a resident suffering second-degree burns. The resident, who had a history of chronic obstructive pulmonary disease, Parkinson's disease, and cognitive impairment, was served coffee at a temperature that was not monitored for safety. Despite being advised to wait for the coffee to cool, the resident attempted to drink it and spilled it, causing burns to her thighs and groin area. The facility did not have measures in place to prevent such incidents, as there was no policy for monitoring the temperature of hot liquids before serving them to residents. Additionally, the facility did not conduct hot liquid risk assessments for residents, which could have identified those at risk for burns from hot beverages. The dietary manager confirmed that coffee temperatures were not logged, and there was no policy requiring such logs, despite the potential risk to residents. Interviews with staff revealed a lack of awareness and training regarding the safe serving of hot beverages. The staff did not consistently use cups with lids for residents who might be at risk of spilling hot liquids. The facility's failure to implement adequate safety measures and staff training contributed to the incident, highlighting a significant oversight in ensuring resident safety from hot liquid burns.
Deficiency in Kitchen Cleaning and Maintenance
Penalty
Summary
The facility failed to maintain food service safety standards in its kitchen, as observed during a survey. Approximately six baking sheet pans were found with thick black carbon buildup on their rims, and the stove top was also covered with black carbon buildup. These conditions were noted during initial kitchen observations and subsequent rounds. Interviews with kitchen staff revealed that the cleaning of these items was not performed regularly, with one staff member admitting to cleaning the stove top only once a month. The Dietary Manager acknowledged the presence of carbon buildup and stated that deep cleaning of the stove was conducted monthly, but the kitchen was short-staffed, affecting the completion of cleaning tasks. Interviews with various staff members, including the Nutritional Aide and Maintenance Supervisor, highlighted a lack of clarity regarding responsibilities for cleaning and maintenance. The Maintenance Supervisor mentioned that the stove had been serviced months prior, but no maintenance records were available to confirm this. The Dietary Manager and other staff members expressed concerns about the potential fire hazard posed by the carbon buildup, but there was no specific policy or cleaning schedule in place to address these issues. The Corporate Regional Dietician also noted the absence of a specific policy for equipment cleaning and suggested that some pans could be replaced. A review of facility records showed that the Cooks Daily/Weekly Duties checklist required daily cleaning of ovens, but this was not consistently followed. The U.S. Food and Drug Administration Code mandates that food-contact surfaces of cooking and baking equipment be cleaned at least every 24 hours, a standard that was not met by the facility. The lack of adherence to these guidelines and the absence of proper maintenance records contributed to the deficiency in food service safety, potentially placing residents at risk of foodborne illness and contamination.
Failure to Maintain Accurate Records for Controlled Drugs
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation and maintaining drug records. During an observation and interview, it was found that the controlled medications awaiting disposal were stored in the Director of Nursing's (DON) office behind a double-locked door, with the DON being the only person with access to the keys. The DON's process involved checking the narcotic medication count with a nurse and placing the medications in a basket in the closet without logging them until the pharmacist arrived for drug destruction. This practice did not align with the facility's policy, which requires a controlled medication disposition log to be maintained for documentation purposes. The facility's policy on the disposal of medications, including controlled substances, mandates special handling, storage, disposal, and record-keeping in accordance with federal and state laws. However, the Administrator was unaware of the facility's narcotic medication policy or procedure and could not confirm if the policy was effective in preventing medication diversion. The last medication destruction was recorded on a previous date, indicating a lack of regular reconciliation and documentation of controlled substances awaiting disposal. This deficiency could potentially place residents at risk for loss of prescribed medications, compromise their safety, and lead to drug diversion.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and under proper temperature controls, as required by State and Federal laws. This deficiency was observed in the case of a resident who had medications stored in her room without an order to self-administer. The resident, who had a BIMS score indicating intact cognition, was found with a bottle of Geri Lanta on her bedside table and later in her nightstand drawer. The resident stated that she preferred to have the medication accessible for self-administration, but acknowledged that no assessment had been completed to authorize this. Additionally, a medicine cup with an unknown white powder was found in her room, which the resident could not identify. The facility also failed to secure medication carts properly, as observed with two separate nurse's carts. On one occasion, a nurse left the Hall A cart unlocked and unattended, allowing unauthorized access. The nurse admitted to forgetting to lock the cart after retrieving an item. Similarly, another nurse left the Hall B cart unlocked while attending to a resident's blood sugar check, attributing the oversight to nervousness due to the presence of a state surveyor. Both nurses acknowledged the importance of keeping the carts locked to prevent unauthorized access and potential medication errors. Interviews with the ADON, DON, and the Administrator confirmed that the facility's policy required medication carts to be locked when unattended and medications not to be left at residents' bedsides. The staff members involved were aware of these policies but failed to adhere to them, resulting in the potential for medication errors and unauthorized access. The facility's policy emphasized that only authorized personnel should have access to medications, and all staff were trained to ensure medications were not left at bedsides.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. This deficiency was observed in four residents who were reviewed for palatable food. The residents expressed dissatisfaction with the quality and temperature of the food, with some reporting that the food was bland, cold, or not suitable for their dietary needs. The Dietary Manager and state surveyors also noted that the food sampled during a test tray was not appetizing, with issues such as bland vegetables and overly salty pureed pork chop. Resident #1, a cognitively intact female with peripheral vascular disease and muscle weakness, reported that the food was not good and portions had been cut back. Resident #57, who has Alzheimer's disease and other health conditions, stated that the food was terrible and not suitable for residents with dental issues. Resident #58, who has multiple sclerosis and paraplegia, mentioned that the quality of food had declined significantly in recent weeks. Resident #64, with essential hypertension and other diagnoses, expressed that the food was not good, particularly the supper meals. Interviews with staff members, including CNAs, LVNs, and the Dietary Manager, revealed that residents frequently complained about the food being cold, lacking taste, and not meeting their preferences. Despite the facility's efforts to offer alternative meals and accommodate residents' preferences, the complaints persisted. The facility's policy on food temperatures was not effectively implemented, as evidenced by the lack of regular test tray evaluations and the failure to address residents' concerns adequately.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies observed by surveyors. One significant issue was the failure of a Licensed Vocational Nurse (LVN) to perform proper hand hygiene during wound care for a resident. The LVN did not change gloves or sanitize hands after cleaning a wound and before applying a clean dressing, which could introduce germs into the wound. This oversight was acknowledged by the LVN, who attributed the lapse to nervousness during observation. Another deficiency involved the improper use of disinfectant in a resident's isolation room, which was supposed to be cleaned with a product effective against Clostridium difficile. The facility used a disinfectant that did not kill C. diff spores, potentially allowing the bacteria to spread. The housekeeping staff and infection preventionist were unaware of the disinfectant's ineffectiveness until informed by surveyors, highlighting a gap in the facility's infection control practices. Additional issues included staff failing to perform hand hygiene between feeding two residents, not applying enhanced barrier precautions when administering medications via gastrostomy tube or intravenous line, and not using proper personal protective equipment during tracheostomy care. These lapses in infection control practices placed residents at risk for cross-contamination and infection spread, as staff did not adhere to established protocols for hand hygiene and protective equipment use.
Failure to Properly Assess and Document Use of Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, specifically a lap harness on a Broda chair, which was used for purposes of convenience rather than medical necessity. The resident, who was severely cognitively impaired and had multiple diagnoses including Rett's syndrome, epilepsy, and anxiety disorder, was observed multiple times with leg harnesses attached to the Broda chair. These harnesses were not documented as restraints in the resident's care plan, and there was no physician order or signed consent for their use. Interviews with facility staff, including LVNs, CNAs, the ADON, and the DON, revealed a lack of understanding and documentation regarding the use of the leg harnesses. Staff members consistently stated that the harnesses were used to prevent the resident from falling out of the chair due to her condition, but they did not consider them restraints. However, it was noted that the resident could not remove the harnesses independently, indicating that they functioned as restraints. The facility also lacked a policy on restraints, further complicating the situation. Additional documentation from the resident's MD and PASRR Habilitation Coordinator suggested that the harnesses were necessary for the resident's safety and mobility, allowing her to participate in activities and interact with her community. Despite these justifications, the lack of proper assessment, monitoring, and documentation of the harnesses as restraints constituted a deficiency in the facility's care practices.
Inaccurate MDS Assessments for Restraints
Penalty
Summary
The facility failed to ensure accurate assessments for two residents regarding the use of restraints. For Resident #2, the quarterly MDS assessment did not accurately reflect the use of a safety vest (trunk harness) or lap belt as a restraint. Despite the care plan indicating the use of these devices for positioning and safety due to the resident's profound intellectual disabilities and cerebral palsy, the MDS assessment did not list them as restraints. Observations showed Resident #2 using a trunk harness and lap belt, which restricted forward motion, but staff and medical statements indicated these devices were necessary for mobility and did not restrict freedom of movement. Similarly, for Resident #5, the quarterly MDS assessment failed to indicate the use of a limb restraint. The care plan noted the need for a lap harness for safe positioning due to the resident's Rett's Syndrome and epilepsy, but there was no order or consent for the harness. Observations confirmed the use of leg harnesses, and staff interviews revealed that the harness was used to prevent the resident from falling out of the chair. Despite this, the harness was not documented as a restraint in the MDS assessment. The facility's policy requires accurate assessments to develop a comprehensive care plan, but the inaccuracies in the MDS assessments for both residents could lead to a lack of appropriate care and services. The RAI manual defines restraints as devices that restrict movement and cannot be easily removed by the resident, which was applicable in these cases. However, the facility staff and medical professionals viewed the devices as necessary safety measures rather than restraints.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for a resident with chronic obstructive pulmonary disease (COPD) and other health conditions. The resident, who was cognitively intact and required assistance with daily activities, had a physician's order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. However, observations over several days revealed that the resident was consistently receiving oxygen at 3.5 liters per minute, and at one point, the oxygen concentrator was set at 4 liters per minute. This discrepancy was not documented in the medication administration record, indicating a failure to administer oxygen as ordered. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the oxygen settings were not in compliance with the physician's orders. The LVN acknowledged that the electronic medication administration record did not prompt checks for the oxygen settings since it was prescribed on an as-needed basis. Both the DON and the facility Administrator emphasized the responsibility of nursing staff to ensure that oxygen is set at the prescribed rate. The facility's policy on applying oxygen delivery devices requires staff to verify the flow rate and document the procedure, which was not adhered to in this case.
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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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