Broadway Nursing & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in San Antonio, Texas.
- Location
- 8223 Broadway, San Antonio, Texas 78209
- CMS Provider Number
- 455467
- Inspections on file
- 39
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Broadway Nursing & Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that front lobby restrooms and a utility hallway were not maintained free of accident hazards. The women’s restroom was open and accessible to residents but lacked grab bars, had no call system, and used an interior latch that prevented staff from opening the door from the outside, with the door also difficult to open from inside. The men’s restroom was similarly open and accessible and, although it had grab bars, it lacked any means for a resident to call for assistance. In addition, an unlocked room off a utility hallway accessible from a resident hallway contained biohazard containers filled with used syringes, contrary to the facility’s own environment and safety policy.
A resident with COPD, diabetes, and fibromyalgia, who was cognitively intact, had a care plan and facility policy requiring that the call light be kept within reach. During observation, the call light was not visible and was found wound around the call light box, and the resident reported not having or knowing the location of the call light. A CNA stated she had wound the cord around the box while making the bed and likely forgot to return it to the resident’s reach, and an LVN confirmed the call light was out of reach and that leaving a resident without a call light was not normal practice and could pose potential harm in an emergency.
A resident with intact cognition, multiple chronic conditions, and a Foley catheter for bladder management was receiving catheter and incontinent care from two CNAs when the privacy curtain at the end of the bed was not fully closed, leaving the resident’s genitals exposed and visible to anyone entering the room. The resident’s MDS documented frequent incontinence, and the care plan addressed Foley catheter care and monitoring for UTI. Both CNAs later acknowledged that the curtain should have been closed, and facility leadership confirmed that resident rights training had been provided and that policy requires privacy and confidentiality during care.
A resident with severe cognitive impairment and multiple psychiatric diagnoses had a PRN order for ABH gel (Ativan/Benadryl/Haldol) written to be applied transdermally every 8 hours as needed for anxiety, agitation, or restlessness, but the order lacked a required 14-day stop date. The DON acknowledged that ABH gel is a psychotropic medication and that PRN psychotropic orders should not exceed 14 days, and facility policy required Medical Records to verify that physician orders are complete and accurate. This failure to time-limit the PRN psychotropic order resulted in a cited deficiency.
A resident with COPD, diabetes, hypertension, and documented bilateral hearing impairment was admitted with hearing aids, as noted in hospital records and the admission MDS. However, the baseline care plan created within 48 hours of admission did not address the resident’s hearing deficit or use of hearing aids. Observation confirmed the resident wore hearing aids and he reported long-term use due to hearing loss. The MDS nurse and DON acknowledged that the baseline care plan was incomplete and did not include all necessary information required by facility policy for proper, person-centered care.
A resident with an indwelling Foley catheter, diabetes, dementia, and other comorbidities was observed receiving perineal and catheter care from CNAs. One CNA used a back-and-forth wiping motion instead of front-to-back and cleaned the penis from base to tip rather than tip to base, contrary to the resident’s care plan and facility policy, which required cleaning around the catheter insertion site and then from the tip of the penis down to the body. The CNA later acknowledged knowing the correct technique, and the DON and Administrator confirmed the proper method and that staff had been trained and competency-checked on incontinent care.
A resident with severe cognitive impairment and diagnoses including renal dialysis dependence, depression, and anxiety was found with a jar of Vicks on the bedside table, despite no physician order for the product and no order to self-administer medications. The resident reported that family had brought the Vicks and that no self-medication assessment had been done. An LVN and the DON confirmed the medication was left at the bedside without secure storage or a self-administration assessment, contrary to the facility’s medication storage policy requiring secure storage of medications.
A resident with intact cognition and multiple medical diagnoses had a personal refrigerator containing an unlabeled, undated container with visibly spoiled contents, which remained in place on repeat observation. The resident reported storing snacks but was unaware of the requirement to date items and did not know about the container. The assigned CNA and LVN both confirmed the presence of the unlabeled, undated food and gave differing or incomplete understandings of responsibility for checking personal refrigerators, while the DON stated that all staff, overseen by charge nurses, were responsible for weekly monitoring and for ensuring perishable items in residents’ refrigerators were labeled and dated per facility policy.
A resident with multiple comorbidities and an indwelling Foley catheter, placed on enhanced barrier precautions, received incontinent and catheter care during which CNAs did not follow required infection control practices. One CNA cleaned the resident’s buttocks and genital area and then handled a clean brief and pad without changing gloves or performing hand hygiene, and two CNAs provided catheter care without donning gowns despite posted enhanced barrier precaution signage and available PPE. Facility policies required gowns and gloves for high-contact care activities and hand hygiene after PPE removal. During the same episode of care, staff did not close the privacy curtain, leaving the naked resident potentially visible from the doorway while a roommate remained in the room.
Surveyors found that multiple residents with dementia, behavioral disturbances, and schizoaffective disorder did not have required face-to-face physician visits documented over an extended period. Facility policy required the attending physician to evaluate residents at specified 30- and 60-day intervals and document these visits, but record review showed no physician progress notes or H&Ps authored by the physician for several residents. An NP completed assessments and H&Ps, with the physician signing but not dating at least one document, and the DON and ADM reported that the physician rounded weekly and signed NP notes, yet they could not produce any physician-written progress notes or H&Ps for the residents involved.
A resident with complex cardiopulmonary conditions had a critical CO2 lab value reported to an LVN, who documented that the NP and DON were informed but did not complete a change-of-condition assessment, did not document vital signs, and did not document any notification to the resident or the resident’s representative. Another LVN later phoned the NP about the critical lab but failed to document that contact. The DON and NP reported that the first LVN used unsecured text/email instead of required phone calls and did not follow established change-of-condition and notification protocols. The resident and the resident’s emergency contact stated they were never told about the abnormal lab result, leading to a deficiency for failure to promptly inform the resident, consult with the practitioner, and notify the resident’s representative of a significant change in condition.
An allegation of resident-to-resident abuse occurred when a cognitively impaired resident with dementia and a known history of throwing objects became upset during care and threw an empty plastic cup at a roommate who repeatedly opened the privacy curtain and made comments about the resident’s mother, causing a small skin tear over the roommate’s eyebrow that was treated on-site and followed by a room change. Despite facility policy and federal requirements mandating that alleged abuse be reported immediately but no later than 2 hours after suspicion, the ADM did not report the incident to authorities until the following day, exceeding the required timeframe and resulting in a deficiency for failure to timely report an alleged abuse incident.
A resident had a critical CO2 lab value, and nursing staff documented only that the NP and DON were informed and that the resident was stable, with no further detail on assessment or follow-up. An LVN later reported calling the NP and receiving no new orders but admitted forgetting to enter a progress note, and another LVN could not recall details of the critical lab or his documentation. The DON stated that an LVN reported assessing the resident and texting the NP and DON but did not document these actions. These omissions failed to meet the facility’s policy requiring detailed documentation of change in condition, provider notification, responses, and related care plan updates.
Two residents were not adequately protected from hazards due to lapses in supervision and environmental safety. One resident with a history of depression and suicidal ideation was able to access a razor and attempted self-injury after returning from a psychiatric hospitalization, without her care plan reflecting her increased risk or need for closer monitoring. Another resident with severe cognitive decline and a known risk for wandering was able to elope from the memory care unit due to ineffective preventive measures.
Two residents did not have their care plans updated by the interdisciplinary team after significant changes in their conditions. One resident's care plan lacked documentation of a history of suicidal ideation and a self-injury attempt, while another resident's care plan did not include the use of a geriatric chair for fall prevention, despite its use by staff. These omissions were confirmed through record reviews, staff interviews, and observations.
A resident who was discharged home with no cognitive impairment did not receive notification or a refund of over $1,000 in personal funds within 30 days, as required. The facility's business office was without a manager at the time, and the resident was unaware of the funds remaining in his account.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Two residents were referred to as 'feeders' by staff, indicating a failure to treat them with dignity and respect. This terminology was used by a MA and LVN during meal service, despite both having received training on resident rights. The DON confirmed that such language was not acceptable, as it did not align with the facility's policy on treating residents with respect and dignity.
The facility failed to obtain informed consent for the administration of Sertraline to two residents. One resident received the medication for several months without a valid consent, while another received it for over four months without any consent. The DON confirmed these oversights, which were against the facility's policy requiring informed consent for psychotropic medications.
The facility's kitchen failed to meet professional food service safety standards, with food boxes stored on the floor, frost and ice on freezer items, and an open jelly container left unrefrigerated. The Dietary Manager confirmed these oversights, which could risk foodborne illness for residents.
A facility failed to maintain proper infection control practices for two residents. An LVN did not wear a gown or gloves while performing an accu-check and administering medication to a resident under contact isolation precautions. Additionally, the LVN did not wear gloves during an accu-check for another resident with diabetes and a foot ulcer. The DON confirmed the need for PPE in these situations, highlighting a lapse in adherence to infection control policies.
The secure unit's lobby area in the facility was found to have a strong urine odor, creating an unpleasant environment for residents, staff, and visitors. Observations confirmed the odor, with no apparent cause identified, and residents appeared clean. LVN C and a frequent visitor acknowledged the smell, while the Housekeeping Supervisor was unaware but planned to address it. The facility's policy on minimizing institutional odors was not followed.
A facility failed to ensure a resident's OOH DNR order was completed and included in the medical record. The resident, with severe cognitive impairment and serious health conditions, was admitted with a DNR status, but the form was missing from the records. Interviews revealed the form might have been misplaced during a hospital transfer, contrary to facility policy requiring advance directives to be readily retrievable.
The facility failed to store controlled medications in a permanently affixed compartment in the A-Hall medication room. A miniature refrigerator contained a lock box with Morphine Sulfate, which was not permanently affixed and could be easily removed. The DON confirmed the oversight, and the facility's policy lacked guidance on permanent affixation, contrary to 42 CFR 483.45 (h)(2) requirements.
A resident's medical records were incomplete, missing documentation of two unwitnessed falls and behaviors requiring PRN medication. Despite facility policies, staff failed to document these incidents, hindering proper care and monitoring.
A resident with severe medical conditions was not monitored for side effects of Aspirin and Ticagrelor, antiplatelet medications, due to a lack of comprehensive care planning. Facility staff, including the LVN responsible for care plans and the DON, failed to include monitoring instructions in the care plan, despite the known risks of bleeding associated with these medications. This oversight was evident during an observation where the resident showed signs of potential bruising or bleeding.
The facility failed to ensure menus met residents' choices and did not have a method to inform them of menu substitutions, leading to dissatisfaction and poor intake. Multiple residents expressed concerns about food quality and lack of notification about changes, and grievances were submitted without noticeable improvements.
The facility failed to provide accessible call lights for two residents, one with severe cognitive impairment and another with moderate cognitive impairment. Both residents' call lights were out of reach, which was confirmed by staff and observed during a survey.
The facility failed to implement written policies and procedures to prevent abuse, neglect, and exploitation by not completing annual Employee Misconduct Registry searches for two staff members, LVN A and CNA B. The HRD and ADM, both new to their roles, discovered missing records and could not locate evidence of the 2023 searches, raising concerns about potential risks to residents.
Failure to Control Resident Access to Unsafe Restrooms and Biohazard Materials
Penalty
Summary
Surveyors identified that the facility failed to maintain resident-accessible areas as free from accident hazards as possible in the front lobby restrooms and a utility hallway. Observation of the women’s restroom in the front lobby showed it was open, unlocked, and accessible to residents, but lacked grab bars, had no means for a resident to call for assistance, and had an interior latch-type lock that could not be opened from the outside when engaged. The door was also difficult to open from the inside. Observation of the men’s restroom in the same area showed it was also open, unlocked, and accessible to residents, and while grab bars were present, there was no means for a resident to call for assistance. The Maintenance Assistant confirmed these conditions, acknowledged that residents might not be able to use the toilet safely without grab bars, would not be able to call for help if needed, and that staff would not be able to reach a resident if the women’s restroom door latch was engaged. Further observation in a utility hallway revealed a room without a doorknob or any means to lock it, which contained multiple stored items, including three containers labeled biohazard that held used syringes. The utility hallway was accessible from a resident hallway and could be reached by any ambulatory resident. The Maintenance Assistant confirmed that the biohazard containers with used syringes should not have been in an area accessible by residents. Review of the facility’s “Resident Rooms and Environment” policy, revised 08/2020, showed that the facility committed to providing a safe environment and ensuring that the physical layout does not pose a safety risk, which was not followed in these instances.
Call Light Not Kept Within Reach of Resident
Penalty
Summary
The facility failed to reasonably accommodate a resident’s needs by not keeping the call light within reach as required by the resident’s care plan and facility policy. The resident was an older adult female with COPD, diabetes, and fibromyalgia, and her admission MDS showed a BIMS score of 15, indicating she was cognitively intact. Her care plan, dated 3/11/2026, specified that the call light should be kept within her reach. During an observation of her room on 04/14/2026 at 10:30 AM, the call light was not visible, and further observation showed the call light cord was wound around the call light box rather than positioned for her use. The resident stated she did not have a call light and did not know where it was. In an interview at 10:35 AM, a CNA confirmed that the resident’s call light had been on the floor and that she had wound the call light cord around the call light box that morning when making the bed, acknowledging she probably forgot to leave it within the resident’s reach. At 11:00 AM, an LVN confirmed the call light was out of the resident’s reach and stated that it was not normal nursing practice for a resident to be left without a call light, noting that the absence of a call light could constitute potential harm if assistance was needed in an emergency. The DON later confirmed that the facility had a call light policy requiring call cords to be placed within residents’ reach and that the resident’s care plan addressed the need for a call light within reach.
Failure to Maintain Resident Privacy During Incontinent and Catheter Care
Penalty
Summary
The facility failed to ensure a resident’s right to personal privacy during the provision of incontinent and catheter care. A resident with diagnoses including Type 2 diabetes mellitus, dementia, major depressive disorder, and hyperlipidemia was admitted in 2025 with a readmission in early 2026. The resident’s Quarterly MDS showed a BIMS score of 14, indicating intact cognition, and documented that he was always incontinent of bladder and frequently incontinent of bowel. His care plan identified the presence of a Foley catheter to manage bladder function and included monitoring for signs and symptoms of urinary tract infection. On the observed date and time, CNAs D and E provided catheter and incontinent care to this resident without fully closing the privacy curtain at the end of the bed. As a result, the resident’s genitals were fully exposed and he could have been seen by anyone opening the room door. During subsequent interviews, both CNAs acknowledged that the privacy curtain had not been closed and stated it should have been, noting they had received resident rights training from the DON and ADON. The DON and Administrator confirmed that privacy must be provided during nursing care and that the curtain should have been completely closed, and facility policy on resident rights included the right to privacy and confidentiality.
Failure to Limit PRN Psychotropic Medication Order to 14 Days
Penalty
Summary
Surveyors identified that the facility failed to ensure a PRN psychotropic medication order was limited to fourteen days as required. Record review for Resident #5 showed an order summary with a start date of 04/09/2026 for ABH gel (Ativan/Benadryl/Haldol) 1-25-1, to be applied transdermally every 8 hours as needed for anxiety, agitation, or restlessness, but the order had no end date. Resident #5 had diagnoses including generalized anxiety disorder, major depressive disorder, psychotic disturbance, and altered mental status, and a quarterly MDS with a BIMS score of 0 indicating severe cognitive impairment; the care plan documented that the resident required psychotropic medications. During interview, the DON confirmed that ABH gel is a psychotropic medication and that a PRN order for it should have an end date of no more than fourteen days past the start date. The facility’s policy on physician orders stated that the Medical Records Department will verify that physician orders are complete, accurate, and clarified as necessary. This combination of an open-ended PRN psychotropic order, the resident’s severe cognitive impairment and psychiatric diagnoses, and the facility’s own acknowledgment and policy requirements formed the basis of the cited deficiency.
Failure to Include Hearing Needs in Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to develop and implement a complete baseline care plan within 48 hours of admission for a newly admitted male resident with diagnoses including COPD, diabetes mellitus, and hypertension. Record review showed that the resident’s hospital clinicals documented he was hearing impaired and wore bilateral hearing aids, and the admission MDS assessment also indicated the use of hearing aids under section D0300. Despite this information, the resident’s baseline care plan report, printed on the date of admission, did not include any care plan interventions or instructions addressing his hearing deficit or the use of hearing aids. Surveyor observation confirmed that the resident was wearing hearing aids in both ears, and in an interview he stated he had arrived at the facility with his hearing aids and had used them for years due to hearing loss. The MDS nurse stated that a baseline care plan should include anything a resident needs to receive proper care and acknowledged that the current care plan was insufficient for this resident. The DON, after reviewing the baseline care plan, stated that it should have contained additional information such as medications, transfer status, and therapy needs, and reported that insufficient care planning could result in residents not receiving proper care. The facility’s policy on comprehensive person-centered care planning required development of a person-centered base care plan for each resident within 48 hours of admission.
Improper Perineal and Catheter Care Technique for Male Resident
Penalty
Summary
The facility failed to ensure incontinent and catheter care were provided in accordance with appropriate treatment and service practices for one resident. The resident had diagnoses including type 2 diabetes mellitus, dementia, major depressive disorder, and hyperlipidemia, and was occasionally incontinent of bowel with an indwelling catheter. A quarterly MDS showed the resident had a BIMS score of 15, indicating no cognitive impairment. The resident’s care plan documented the presence of a Foley catheter to help manage bladder function and noted that the catheter required regular care to prevent infection, skin problems, or other complications, including monitoring and reporting signs and symptoms of UTI. During an observation of catheter and incontinent care, two CNAs provided care to the resident. While performing perineal and catheter care, one CNA used a back-and-forth wiping motion instead of a front-to-back motion and wiped the resident’s penis from the base to the tip instead of from the tip to the base. In a subsequent interview, the CNA acknowledged that the proper technique was front to back or tip to base and stated she did not realize she was using the wrong motion and that she had received incontinent care training within the year from the DON and ADON. The DON and Administrator confirmed in an interview that the correct motion to clean a resident was front to back to prevent contamination of the urinary tract and that staff received incontinent care training with annual skills checks. Facility policy for indwelling urinary catheter care for males specified washing around the catheter insertion site and then from the tip of the penis down to the body, which was not followed during the observed care.
Unsecured Bedside Medication Without Order or Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and that only authorized personnel had access to medications, as evidenced by an unlabeled medication product being left at a resident’s bedside without a physician’s order or self-administration assessment. Record review showed that the resident, an older female admitted with dependence on renal dialysis, depression, and an anxiety disorder, had an admission MDS with a BIMS score of 3, indicating severe cognitive impairment. Review of the resident’s April 2026 physician orders revealed no order for Vicks VapoRub and no order permitting self-administration of medications. On observation, surveyors noted a jar of Vicks on the resident’s nightstand. In interview, the resident stated that her family had purchased and brought the Vicks to her over the weekend and confirmed that no one had conducted a self-medication assessment. LVN A, who was assigned to the resident, verified the presence of the Vicks jar on the bedside table and acknowledged that the resident had not been assessed for self-administration and should not have access to medications in this manner. The DON also confirmed that the jar of Vicks was found on the bedside table and stated that no medication should be left on a resident’s bedside table without a self-medication assessment. The facility’s “Medication Storage” policy, revised January 2026, required medications to be stored securely to prevent unauthorized access, diversion, loss, contamination, or misuse, which was not followed in this instance.
Failure to Monitor and Label Food in a Resident’s Personal Refrigerator
Penalty
Summary
The facility failed to ensure safe and sanitary storage of food items in a resident’s personal refrigerator, as required by its policy. Record review showed the resident had intact cognition with a BIMS score of 15 and diagnoses including Major Depressive Disorder, Hypertension, and Benign Prostatic Hyperplasia. During observations of the resident’s personal refrigerator, surveyors found an unlabeled, undated storage container with unidentified contents showing fuzzy, slimy patches in shades of green, black, and white. A subsequent observation shortly afterward confirmed the container remained in the refrigerator. In interviews, the resident stated he stored snacks in his personal refrigerator but was unaware that items had to be dated and was unaware of the unlabeled container. The CNA assigned to the resident confirmed the presence of the undated, unlabeled container and stated she did not know who was responsible for checking the resident’s personal refrigerator for expired food. The LVN assigned to the resident also confirmed the presence of the unlabeled, undated container and stated that all staff were responsible for removing such items from residents’ personal refrigerators weekly. The DON confirmed that perishable food and drinks in residents’ personal refrigerators should be labeled and dated, that all staff were responsible for removing undated and unlabeled food items weekly and assisting families with labeling and dating food brought in, and that charge nurses were responsible for overseeing this task in accordance with the facility’s “Personal Refrigerator” policy, which requires weekly monitoring of resident refrigerators.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Catheter and Incontinent Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program involving one resident with an indwelling Foley catheter who was on enhanced barrier precautions. The resident had multiple diagnoses including type 2 diabetes mellitus, dementia, major depressive disorder, and hyperlipidemia, and a quarterly MDS showed no cognitive impairment, occasional bowel incontinence, and use of an indwelling catheter. The resident’s care plan documented the need for Foley catheter care to prevent infection and related complications. During an observation of incontinent and catheter care, a CNA cleaned the resident’s buttocks and genital area and then handled a clean brief and pad without changing gloves or performing hand hygiene in between. The CNA later acknowledged she did not change gloves or sanitize her hands and stated she was nervous and forgot, despite having received infection control training within the year. In the same observation, two CNAs provided catheter care to the resident, who was on enhanced barrier precautions due to the indwelling catheter, without donning gowns before entering the room and performing care, even though enhanced barrier precaution signage was posted at the door and above the bed and PPE was available at the room entrance. Both CNAs stated they forgot the resident was on enhanced barrier precautions and confirmed they had received training on enhanced barrier precautions and had their skills checked. The facility’s policies on Standard and Enhanced Precautions and Hand Hygiene required use of gowns and gloves for high-contact care activities for residents on enhanced barrier precautions, including changing briefs and catheter care, and required hand hygiene after removing PPE. Additionally, during the observed care, the privacy curtain was not closed, and the resident was naked and could have been seen from the doorway while the roommate was present in the room watching television.
Failure to Ensure Required Physician Face-to-Face Visits and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were seen face-to-face by a physician at the required intervals and that the physician documented these visits in the medical record, as required by facility policy. Surveyors determined that four residents did not have physician progress notes or history and physical (H&P) examinations completed by their physician for a one-year period. Facility policy dated 08/2020 required the attending physician to evaluate residents at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, with documentation of these visits in the health record. One affected resident had dementia with agitation and stimulant-induced anxiety disorder, a BIMS score of 8/15 indicating moderate cognitive impairment, and a care plan addressing cognitive impairment and behavioral issues such as throwing items at others, with interventions including monitoring behavior episodes and documenting potential causes. Another resident had unspecified dementia with behavioral disturbance and a care plan for impaired cognitive function, including using yes/no questions to determine needs. For this resident, an NP completed a history and physical, which was signed but not dated by the physician. A third resident had dementia with anxiety, a BIMS score of 15/15 indicating no cognitive impairment, and a care plan for impaired cognitive function with interventions such as identifying oneself at each interaction and maintaining eye contact. The fourth resident had schizoaffective disorder, bipolar type, with a BIMS score of 15/15 and a care plan for mood problems related to bipolar disorder, insomnia, depression, and anxiety, including risk for mood changes related to pain or discomfort and use of anticonvulsant medications for bipolar disorder. Review of the electronic health records for all four residents showed no physician progress notes, assessments, or H&Ps completed by their physician from 3/27/25 to 3/27/26. During interviews, the DON and ADM stated that the residents’ physician rounded on Wednesdays and signed off on NP notes, but they were unable to provide any written physician progress notes or H&Ps authored by the physician, other than the NP’s H&P for one resident that was signed but undated by the physician.
Failure to Notify Resident, Practitioner, and Representative of Critical CO2 Lab Result
Penalty
Summary
The deficiency involves the facility’s failure to immediately inform a resident, the resident’s practitioner, and the resident’s representative of a significant change in condition related to a critical laboratory result. The resident was admitted with multiple serious cardiopulmonary diagnoses, including heart failure, obstructive sleep apnea, chronic pulmonary edema, and acute and chronic respiratory failure with hypoxia. Her admission MDS showed a BIMS score of 15/15, indicating no cognitive impairment, and her care plan included monitoring for altered respiratory status and reporting signs and symptoms of respiratory distress to the physician as needed. A lab report dated 3/2/26 showed a critical CO2 value of 42 (reference range 21–31), flagged as a critical result, and documentation showed that LVN A was notified of this critical lab in the evening. In response to the critical lab, LVN A entered a progress note in the early morning hours stating that the resident had a critical CO2 result of 42, that the NP and DON were informed, and that the resident was stable at that time. However, there was no further documentation by LVN A describing a change of condition assessment, vital signs, or notification of the resident or her representative, and no change of condition assessment was found in the March assessments in response to the critical CO2 value. The DON later stated that LVN A had notified the NP and DON via text message rather than by phone, and that LVN A should have called the NP and DON for a critical lab, which was considered a change of condition, and should have contacted the on‑call nurse if unable to reach them. The NP reported that LVN A often did not follow protocols and that he texted her about the critical lab via his personal email, which she stated was not secure and violated HIPAA. On the following morning, LVN B documented that the night nurse had sent the results to the NP and was awaiting a response, and LVN B then called the NP to inform her of the critical CO2 value and the resident’s assessment. LVN B did not enter a progress note at that time and later stated she must have forgotten to document the call. When interviewed, the resident and her emergency contact both stated that facility staff had not notified them of any abnormal lab results, and the resident expressed that no one had talked to her about the abnormal lab and that she would have wanted the opportunity to decide whether to go to the hospital. Facility policy on change of condition required prompt notification of the attending physician and the resident or responsible party for significant changes, including serious abnormal labs, and required documentation of the time and method of physician contact and family notification. The survey findings showed that these notification and documentation requirements were not followed for this resident’s critical CO2 lab result. The facility’s own policy defined an acute change of condition as a clinically important deviation from baseline that, without intervention, may result in complications or death, and specified that serious abnormal labs required immediate physician notification, notification of nursing supervision, and prompt notification of the resident and responsible party. Interviews with LVN A confirmed his understanding that a critical lab was considered a change of condition, that he was required to assess the resident, obtain vitals, notify the NP and DON by phone, notify the resident’s representative, and document these actions, and that texting was not sufficient. Despite this, he could not recall what he did in response to this specific critical lab beyond the brief progress note, and there was no documentation that the resident or her emergency contact were informed. These actions and omissions led to the cited deficiency for failure to immediately inform the resident, consult with the physician, and notify the resident representative of a significant change in condition. The NP stated that when she was later contacted by LVN B, she understood the resident’s chronic hypercarbic respiratory failure and elevated CO2 levels and discussed that the resident was on oxygen and needed to be off due to CO2 retention. She noted that the resident was not in distress when assessed by LVN B and during her own rounding. However, the survey focused on the lack of timely, appropriate notification and documentation at the time the critical lab was first reported to LVN A, and on the resident and emergency contact’s report that they were not informed of the abnormal lab result. The combination of failure to follow the facility’s change of condition policy, failure to use appropriate communication methods with the NP and DON, failure to notify the resident and her representative, and incomplete documentation formed the basis of the deficiency.
Failure to Timely Report Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to ensure that an alleged incident of resident-to-resident abuse was reported to the appropriate authorities immediately, but no later than two hours after the allegation was made, as required by regulation and facility policy. Resident #2, who had dementia with agitation, moderate cognitive impairment (BIMS 8/15), anxiety, and a care plan noting behavior problems related to throwing items at other people, threw an empty plastic cup at his roommate, Resident #3, during care on 1/6/26 at 5:45 PM. The incident occurred when Resident #3 attempted to open the privacy curtain while staff were providing care to Resident #2, after having opened the curtain a couple of times before and making comments about Resident #2's mother. The cup struck Resident #3 and caused a small skin tear over his left eyebrow, which was treated in-house, and Resident #3 was subsequently moved to another room. The Provider Investigation Report showed that the Administrator (ADM) did not report this resident-to-resident altercation to the state survey agency until 1/7/26 at 11:04 AM, more than two hours after the allegation and outside the timeframe required for alleged abuse. The facility’s Abuse Prevention and Prohibition Program policy required that allegations involving abuse or resulting in serious bodily injury be reported immediately, but no later than two hours after forming the suspicion, to the state survey agency and other appropriate entities. During interview, the ADM acknowledged reporting the incident within 24 hours and stated she believed the two-hour requirement applied only when serious bodily injury occurred, characterizing the two-hour reporting requirement as a technicality. This failure to follow the regulatory and policy requirement for timely reporting of alleged abuse constituted the cited deficiency.
Failure to Document Nursing Response to Critical Lab Result
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident with a critical laboratory result. A progress note for this resident documented a critical CO2 value of 42 (reference range 21–31) and stated that the NP and DON were informed and that the resident was stable at that time. A subsequent note recorded that the night nurse (LVN A) reported sending the results to the NP and was awaiting a response. However, there was no further documentation by LVN A describing his assessment of the resident, any follow-up actions taken, or additional communication with the NP beyond this brief entry. Record review showed there was no change of condition assessment completed in response to the critical CO2 lab value. LVN B reported in interview that she called the NP around breakfast time regarding the critical lab and that the NP did not provide new orders, but she acknowledged she did not enter a progress note and stated she must have forgotten to document the contact and outcome. LVN A, in a telephone interview, did not remember details about receiving the critical lab or whether he wrote any notes. The DON stated that LVN A told him he had assessed the resident, found her stable, and texted the NP and the DON, but acknowledged he did not document these actions. These omissions were inconsistent with the facility’s Change of Condition Notification policy, which requires licensed nurses to document the date, time, and details of the incident and assessment, the time and method of physician contact, the response and any orders, family notification, care plan updates, and inclusion of the incident in the 24-hour report.
Failure to Prevent Resident Self-Harm and Elopement Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, with a history of depression, anxiety, and a prior hospitalization for suicidal ideation, was able to access a shaving razor and attempted to injure herself by cutting her wrist. Despite her previous hospitalization for suicidal ideation and recommendations from a hospital psychiatrist for closer observation or placement in a secure unit, the resident was returned to the general population without enhanced supervision or environmental controls to prevent self-harm. The care plan did not reflect her history of suicidal ideation or the need for increased supervision, and there was no documentation of interventions specifically addressing her risk for self-injury after her return from the hospital. Staff interviews revealed that the resident's mood and behavior changes were known, and some staff expressed concerns about her safety and the appropriateness of her placement outside of a secure unit. The resident was able to obtain a razor, possibly from personal items brought in by family or from an unlocked utility room containing razors and other potentially hazardous items. The facility's policies required incident reporting for self-inflicted injuries and suicide attempts, but the administrator initially did not believe the incident required reporting. The environment was not adequately controlled to prevent access to dangerous items, and staff supervision and monitoring were insufficient to prevent the resident's self-injury. In a separate incident, another resident with severe cognitive decline and a history of wandering and exit-seeking behavior eloped from the memory care unit. The baseline care plan documented the resident's risk for elopement, but effective measures were not implemented to prevent the resident from leaving the secure area. These failures in supervision and environmental safety placed residents at risk for harm and resulted in the identification of Immediate Jeopardy by surveyors.
Failure to Update and Revise Care Plans Following Significant Changes
Penalty
Summary
The facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, to reflect the current condition of two residents. For one resident with a history of cerebral infarction, anxiety disorder, hemiplegia, and depression, the care plan did not include documentation of a hospitalization for suicidal ideation or a subsequent attempt to injure herself. Despite clear evidence in the medical record and psychiatric evaluation indicating the resident's risk for self-harm and recommendations for closer observation, the care plan was not updated to reflect these significant events or the recommended interventions. Another resident, diagnosed with Alzheimer's disease, dementia, high blood pressure, and anxiety disorder, experienced a significant decline and multiple falls. Although the resident was provided with a geriatric chair by hospice as a fall prevention measure after a hospital visit, this intervention was not added to the care plan. Staff interviews confirmed the use of the geriatric chair for fall prevention, but the care plan only reflected other interventions such as being up at the nurses’ station when anxious and scheduled care planning with family and hospice. The omission of the geriatric chair as an intervention was acknowledged by the MDS nurse, who could not provide a reason for its absence from the care plan. The facility’s policy required that care plans be reviewed and revised upon any status change, with the interdisciplinary team collaborating on intervention options and updating the care plan accordingly. However, in both cases, the care plans were not updated to reflect significant changes in the residents’ conditions or the interventions being used, as evidenced by record reviews, staff interviews, and direct observations.
Failure to Timely Convey Resident Personal Funds After Discharge
Penalty
Summary
The facility failed to convey a resident's personal funds within 30 days of discharge, as required. Record review showed that a male resident, who was cognitively intact at the time of discharge, had a positive balance of $1,030.01 in his personal funds account due to a Social Security deposit. The discharge was processed and accepted by the state, and the resident's account should have been closed with a refund issued within the required timeframe. However, the refund was not processed, and the resident was not notified of the remaining funds in his account. Interviews revealed that the Business Office Manager position was vacant at the time of the survey due to the sudden death of the previous manager. The administrator, who was not in position at the time of the resident's discharge, confirmed that the refund should have been processed but was unsure why it had not occurred. The resident reported being unaware of the funds and stated that he had not been informed by the facility about the deposit after his discharge.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to treat residents with respect and dignity, specifically in the case of two residents who were referred to as 'feeders' by staff members. This terminology was used by a Medical Assistant (MA) and a Licensed Vocational Nurse (LVN) when discussing the residents' needs for assistance during meals. The term 'feeders' was used to describe residents who required help with eating, which was observed during a meal service where a Certified Nursing Assistant (CNA) was assisting these residents. The use of this term was confirmed during interviews with the MA and LVN, who both acknowledged referring to residents in this manner. The deficiency was identified through observations, interviews, and record reviews, which revealed that the staff's language did not align with the facility's policy on resident rights and dignity. The Director of Nursing (DON) confirmed that referring to residents as 'feeders' was not acceptable and did not respect the individuality of the residents. Both the MA and LVN had received training on resident rights, yet the inappropriate terminology was still used, indicating a lapse in the application of this training. The facility's policy emphasizes treating residents with kindness, respect, and dignity, which was not upheld in this instance.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure informed consent for the administration of the psychotropic medication Sertraline for two residents. Resident #38, a man with intact cognition and diagnosed with depression, was prescribed Sertraline. Although verbal consent was reportedly obtained from the resident's representative, the consent was not signed by the LVN until several months later, rendering it invalid. The Director of Nursing (DON) confirmed that the consent process was not properly completed at the time the verbal consent was obtained. Resident #20, who has memory problems and was diagnosed with generalized anxiety disorder and major depressive disorder, was also prescribed Sertraline. The facility's records showed that the resident received the medication daily for over four months without informed consent being obtained. The DON acknowledged that this was an oversight and confirmed that the consent form was only created after a surveyor's intervention. The facility's policy requires that residents or their representatives be informed of the risks and alternatives to psychotropic medications, which was not adhered to in these cases.
Food Storage and Safety Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Boxes of food were improperly stored on the floor in the dry goods pantry, which was confirmed by the Dietary Manager. The manager explained that a recent delivery had not been properly stored due to time constraints. Additionally, frost and ice were found to have accumulated on two boxes of food in the freezer, which the Dietary Manager acknowledged could lead to potential contamination of the food items. Furthermore, an open container of jelly, which was labeled to be refrigerated after opening, was left out on the kitchen counter instead of being stored in the refrigerator. The Dietary Manager confirmed this oversight and stated that all dietary staff are responsible for ensuring proper storage of food items. These deficiencies were identified as potential risks for foodborne illness among residents receiving meals and snacks from the kitchen.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A in handling two residents under specific care precautions. Resident #45, a man with paraplegia, a stage 4 pressure ulcer, and diabetes, was placed under contact isolation precautions due to his chronic wound and indwelling catheter. Despite the presence of a contact precautions sign and available personal protective equipment (PPE) outside the resident's room, LVN A entered the room without wearing a gown or gloves. She performed an accu-check and administered insulin and oral medications without adhering to the required contact precautions, which included wearing a gown and gloves. Similarly, LVN A did not wear gloves while performing an accu-check on Resident #23, a 65-year-old man with type 2 diabetes and a foot ulcer. LVN A stated that she typically does not wear gloves for accu-checks unless the resident has a condition like AIDS, which was not the case for Resident #23. This practice was contrary to the facility's policy, which mandates the use of gloves when there is a possibility of contact with blood or body fluids. The Director of Nursing (DON) confirmed that Resident #45 was under contact precautions and that all staff were required to wear gowns and gloves when entering his room. The DON also stated that gloves should be worn whenever there is a potential for contact with blood or body fluids, including during accu-checks. Despite having received training in infection control, LVN A did not follow the facility's policies, leading to the identified deficiencies in infection control practices.
Unpleasant Odor in Secure Unit Lobby
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in the secure unit's lobby area, which was found to have a strong smell of urine. This observation was made on January 24, 2025, at 10:32 a.m., with no obvious cause for the odor identified. Residents in the unit appeared clean and well-groomed, with no personal odors detected. LVN C confirmed the presence of the unpleasant smell, noting it created an uncomfortable environment for both staff and residents. A visitor, who frequents the facility approximately five days a week, also reported that the lobby area typically had an unpleasant odor. The Housekeeping Supervisor was unaware of the issue but stated she would inspect and clean the area. The facility's policy on maintaining a homelike environment, revised in February 2021, emphasizes minimizing institutional odors, which was not adhered to in this instance.
Failure to Maintain Resident's Advance Directive in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically an Out of Hospital Do Not Resuscitate (OOH DNR) order, was completed and included in the resident's medical record. The resident, an elderly woman with severe cognitive impairment and multiple serious health conditions, was admitted with a DNR status indicated on her profile. However, the facility did not have a copy of the DNR form in the electronic health record or any other files, which was confirmed through interviews with the social worker, Director of Nursing (DON), and MDS coordinator. The absence of the DNR form was attributed to a possible oversight during the resident's transfer to the hospital, where the form might have been included in the transfer packet without a copy being retained at the facility. This oversight was contrary to the facility's policy, which requires that copies of advance directives be maintained in the resident's medical record and be readily retrievable by staff. The failure to have the DNR form on file could lead to confusion regarding the resident's end-of-life wishes.
Failure to Properly Store Controlled Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments as required, specifically in the A-Hall medication room. During an observation, it was noted that controlled medications were not kept in a separate, permanently affixed compartment. A miniature refrigerator with a locked padlock was found to contain a small red lock box with Morphine Sulfate 100mg containers. Although the lock box was locked, it was not permanently affixed inside the refrigerator and could be easily removed. The Director of Nursing (DON) confirmed during an interview that the lock box containing controlled medications was not permanently affixed, but believed that the double locking mechanism met the requirements. The facility's policy on controlled substances did not include information about the need for controlled medications to be stored in a permanently affixed compartment. A review of the Regulation Text for 42 CFR 483.45 (h)(2) indicated that controlled drugs must be stored in separately locked, permanently affixed compartments, which the facility failed to comply with.
Deficiency in Medical Record Documentation for Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for Resident #4, as required by professional standards. Specifically, the electronic medical record (EMR) did not reflect two unwitnessed falls that occurred on separate occasions. The first incident involved the resident being found lying on the floor beside the bed, and the second incident occurred when the resident was found on the floor after being placed in a chair by a hospice CNA. Despite these falls, there was no documentation in the progress notes regarding these incidents, which is a critical oversight as it prevents staff from being fully informed about the resident's condition and necessary interventions. Additionally, the facility did not document behaviors that warranted the administration of PRN medications for Resident #4. On two occasions, PRN lorazepam and Ativan/Benadryl topical gel were administered without corresponding documentation of the behaviors that necessitated these medications. This lack of documentation is problematic as it hinders the ability of healthcare providers to monitor the resident's condition and the effectiveness of the medication, potentially leading to inappropriate care. Interviews with facility staff, including LVNs and the DON, revealed that there was an expectation for documentation of falls and behaviors requiring PRN medication. However, this expectation was not met, as evidenced by the absence of progress notes and behavior documentation. The DON and other staff acknowledged the importance of such documentation for ensuring accurate resident care and monitoring, yet the oversight persisted, indicating a lapse in adherence to facility policies and procedures.
Failure to Monitor Antiplatelet Medication Side Effects
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding the monitoring of side effects from the use of Aspirin and Ticagrelor, both antiplatelet medications. The resident, who had a history of severe medical conditions including Nontraumatic Acute Subdural Hemorrhage, Major Depressive Disorder, Atherosclerotic Heart Disease, Myocardial Infarction, Hypertension, and Alzheimer's Disease, was not monitored for potential side effects of these medications, which could include significant bleeding. This oversight was identified during a review of the resident's care plan, which did not include any directives for monitoring side effects despite the known risks associated with these medications. Interviews with facility staff revealed a lack of understanding and communication regarding the necessity of monitoring for side effects of antiplatelet medications. LVN B, responsible for the nursing care plans, acknowledged that monitoring for bleeding was not included in the care plan and expressed uncertainty about how such monitoring would be documented. The Director of Nursing (DON) also admitted that the omission of monitoring in the care plan did not stand out during audits, indicating a gap in the facility's care planning process. The deficiency was further highlighted by the resident's condition during an observation, where purple discoloration was noted on various parts of the body, suggesting potential bruising or bleeding. Despite the facility's policy requiring comprehensive, person-centered care plans developed by an interdisciplinary team, the lack of specific monitoring instructions for the resident's antiplatelet medications posed a risk for delayed interventions and potential health decline.
Failure to Inform Residents of Menu Substitutions
Penalty
Summary
The facility failed to ensure that menus were developed and prepared to meet the residents' choices, including their nutritional, religious, cultural, and ethnic needs, while using established national guidelines. The facility did not have a method to inform residents of substitutions to the menu, which could lead to dissatisfaction, poor intake, and diminished quality of life. Record reviews and interviews revealed that residents were not notified of menu changes, and the facility's dietary manager (DM) and administrator (ADM) had differing expectations regarding communication of these changes. The DM stated that substitutions were logged but not communicated to residents, while the ADM believed residents were informed via a whiteboard, which was not present during observation. Multiple residents expressed dissatisfaction with the food quality and lack of notification about menu changes, and grievances had been submitted without resulting in noticeable improvements. The facility's policy on nutritional procedures did not include information on informing residents about substitutions. This lack of communication and failure to meet residents' dietary needs and preferences led to the identified deficiency.
Failure to Provide Accessible Call Lights
Penalty
Summary
The facility failed to provide reasonable accommodation of resident needs for two residents regarding the accessibility of call lights. Resident #16, a severely cognitively impaired [AGE] year-old female with chronic kidney disease, muscle weakness, cognitive communication deficit, and muscle wasting and atrophy, had her call light hanging over the headboard of her bed, out of her reach. This was observed on 02/21/2024 at 2:50 pm. A Certified Medication Aide (CMA) confirmed that the call light should not be over the headboard and acknowledged that the resident could not reach it. Similarly, Resident #17, a moderately cognitively intact [AGE] year-old female with senile degeneration of the brain, cognitive communication deficit, and cerebral infarction, had her call light on the floor under her bed, out of her reach. This was observed on 02/21/2024 at 2:54 pm. The resident confirmed she could not reach the call light, and the CMA and Licensed Vocational Nurse (LVN) both acknowledged that the call light should be within reach. The Director of Nursing (DON) also stated that call lights should be accessible to residents to request assistance, as per the facility's policy dated 09/2022.
Failure to Implement Annual Employee Misconduct Registry Searches
Penalty
Summary
The facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and exploitation for two staff members, LVN A and CNA B, by not completing an annual Employee Misconduct Registry (EMR) search. The last EMR search for LVN A was completed on 02/11/2022, and for CNA B on 01/21/2022. The facility's Abuse and Neglect policy, revised in April 2021, mandates conducting employee background checks and not employing individuals with findings of abuse, neglect, or exploitation. However, no evidence of completed recurring searches of the EMR was found within the facility policy. The HRD, who started in January 2024, discovered many personnel records were missing or misplaced and could not locate evidence of the 2023 EMR searches for LVN A and CNA B. The ADM, also new to the role as of January 2024, was unaware of the annual EMR searches for these staff members and stated it was the HRD's responsibility to ensure these checks were completed annually. Interviews with the HRD and ADM revealed that the previous HRD had informed them that EMR searches were completed in 2023, but no evidence could be found to support this claim. The HRD acknowledged her role in ensuring staff were searched for employee misconduct but could not correct past mistakes. The ADM expressed her expectation that all staff be searched annually in the EMR, including existing staff before her tenure. The lack of evidence for the annual EMR searches for LVN A and CNA B raised concerns about the potential risk to residents, as they could be cared for by staff who had committed misconduct towards residents in long-term care.
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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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