Brodie Ranch Nursing And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Austin, Texas.
- Location
- 2101 Frate Barker Rd, Austin, Texas 78748
- CMS Provider Number
- 676267
- Inspections on file
- 43
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 3 (1 serious)
Citation history
Health deficiencies cited at Brodie Ranch Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe dementia, mobility deficits, and dependence for transfers was provided bed rails without a documented entrapment risk assessment, physician order, or inclusion of bed rail use in the care plan, despite a facility policy requiring alternatives, IDT review, informed consent, and proper installation. Maintenance installed 1/3 bed rails on verbal request from nursing, believing the clinical steps had been completed, and the resident later was found partially out of bed with her head pinned between the rail and a low air loss mattress, unresponsive, and subsequently pronounced deceased. The medical examiner noted neck abrasions, bruising, and muscle hemorrhage consistent with entrapment between the mattress and bed rail and indicated the likely cause of death as strangulation on the rails or asphyxiation on the mattress, and the deficiency was cited as past Immediate Jeopardy.
A resident with severe dementia, a history of falls, and dependence for transfers had bed rails installed without a bed rail safety assessment, physician order, or inclusion of bed rail use and entrapment risk in the care plan, despite a signed consent outlining potential dangers. The care plan only addressed ADL assistance and bed mobility support, omitting any interventions related to bed rails. Maintenance installed 1/3 bed rails on a bed with a low air loss mattress based on a nurse’s request, without documented IDT involvement or verification that required clinical steps were completed. The resident was later found unresponsive, partially out of bed with her head and neck between the rail and mattress, and was pronounced deceased after CPR and EMS response; the medical examiner noted neck injuries consistent with entrapment between the mattress and bed rails and indicated a likely cause of death of strangulation or asphyxiation.
A resident with multiple comorbidities and a history of falls experienced an unwitnessed fall resulting in injury. The LPN assessed the resident and notified the NP and ADON, but did not inform the resident's emergency contact. The family member only learned of the incident from the resident the next day. Staff interviews and policy review confirmed that notification of the resident's representative was required, but this was not done.
Staff failed to consistently knock on resident doors before entering, as observed with three residents who had varying levels of cognitive impairment and complex medical conditions. Two residents reported irritation and a desire for staff to respect their privacy by knocking, while interviews with staff and management confirmed awareness of the policy but could not explain the lapse in practice.
Food was prepared hours in advance and held uncovered, resulting in meals being served at low temperatures and lacking flavor. Multiple residents consistently reported cold, bland, and repetitive food, with pureed meals containing lumps that required chewing. Staff interviews and facility records confirmed ongoing complaints about food quality and temperature, which were not effectively addressed.
A medication cart on one hall was left unattended and unlocked for about 10 minutes, allowing medications to be accessible to residents. Multiple staff passed by without securing the cart, despite facility policy requiring medication carts to be locked at all times when unattended. Interviews with the MA, RN, DON, and ADM confirmed the expectation and importance of keeping the cart locked to prevent unauthorized access.
A resident with severe cognitive impairment and a history of falls was found on the floor in the dining room and remained there for over an hour and a half without being assessed by nursing staff. Despite being at risk for falls, the resident was not evaluated, and no documentation or incident report was created. The resident's family eventually assisted him to bed without staff intervention, and he passed away approximately eight hours later. The facility's policies on fall management and incident reporting were not followed, leading to an Immediate Jeopardy situation.
A resident with multiple health issues, including schizophrenia and moderate cognitive impairment, eloped from a facility through an unsecured emergency exit door. The resident was later found at a gas station and tested positive for cocaine at the hospital. The facility failed to provide adequate supervision and secure the emergency exit, placing the resident at risk.
A facility failed to investigate a verbal abuse allegation between two residents, where one resident accused another of making sexual comments, leading to a physical altercation. Despite documentation by an LPN, the incident was not reported to the DON or ADM, preventing an investigation. The facility's policy requires immediate reporting of all ANE allegations, which was not followed, potentially placing residents at risk.
A resident with intact cognition and multiple medical conditions expressed a desire to transfer to another facility, but the LTC facility failed to develop and implement an effective discharge plan. The social worker did not document efforts in the EMR and was unsure about the resident's decision-making status, leading to a lack of progress in the discharge process. The facility's policy on involving residents in discharge planning was not followed, placing the resident at risk of unmet post-discharge needs.
The facility failed to post the most recent survey results in a place readily available to residents, family members, and legal representatives. A binder labeled 'Survey Results' was found to contain outdated information, missing the latest full recertification survey results. Residents expressed a desire to see these results to make informed decisions and understand issues within the facility.
Failure to Assess, Order, and Care Plan Bed Rail Use Resulting in Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and regulatory requirements for the assessment, ordering, care planning, and safe use of bed rails for a cognitively impaired resident. The resident was an elderly female with severe dementia, repeated falls, a fractured neck of the left femur, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan addressed ADL self-care performance deficits related to dementia and included interventions for bed mobility requiring one staff member to assist with repositioning, but it did not mention bed rails or any risk of entrapment. The facility obtained a bed rail consent form signed by the resident’s family member, which listed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment that could cause injury or death. However, from the time of admission through the date of the incident, there was no documented bed rail safety or entrapment risk assessment for this resident, no physician order for bed rails, and no inclusion of bed rail use in the resident’s care plan. Maintenance staff reported that a charge nurse verbally requested installation of bed rails on the resident’s bed, and he believed the usual clinical steps—assessment, IDT review, consent, and physician order—had already been completed, but he had no documentation of when the rails were installed. The DON later confirmed that, for this resident, the required risk of entrapment assessment, physician order, and care plan focus for bed rails were not completed, and alternatives to bed rails were not attempted prior to installation, contrary to facility policy. On the night of the incident, a CNA observed the resident resting calmly around 2:00 a.m. During a subsequent round close to 5:00 a.m., the CNA found the resident partially out of bed with her head pinned between the assist bar/bed rail and the mattress, and notified the LVN. The LVN’s written statement described finding the resident seated on the floor on the right side of the bed, off the mattress, with her head resting between the side rail and the mattress, unresponsive. CPR was initiated and EMS was called, but the resident was later pronounced deceased. The county medical examiner reported that the resident had bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, injuries consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress; while the rails were not loose and there was little space when the mattress was fully inflated, the air mattress could be compressed enough to create significant space between the mattress and rails. The facility’s failure to conduct a bed rail entrapment risk assessment, obtain a physician order, and incorporate bed rail use into the care plan prior to installation led to the resident’s entrapment and death, and constituted noncompliance identified as past Immediate Jeopardy. The facility’s written bed rail policy required that appropriate alternatives be attempted before installing bed rails, that the IDT assess each resident for entrapment risk, that risks and benefits be reviewed with the resident or representative, that informed consent be obtained prior to installation, and that manufacturer instructions and compatibility of bed, mattress, and rails be verified. It also required updating the care plan to reflect the need or choice for bed rails. In this case, staff interviews and record review showed that these steps were not followed for the resident involved. The DON acknowledged that the process did not occur as required, that the IDT did not meet to assess the resident for entrapment risk, and that the bed rails were installed based on the responsible party’s request without the mandated clinical review and documentation. This sequence of omissions and deviations from policy directly preceded the resident’s fatal entrapment between the bed rail and mattress.
Removal Plan
- Notify Medical Director
- Notify Ombudsman
- Conduct ad hoc QAPI
- DON to provide education to trainers regarding abuse and neglect
- Review admissions processes regarding bed rails and complete in-service with DON, ED, and IDT
- Provide in-service to all nurses involved with admissions process regarding bed rails
- Audit bed rails currently in use
- Inspect bed rails currently in use
- Verify consent on file for all bed rails in use
- Verify order and care plan for all bed rails
- Complete bed rail safety evaluation for all residents with bed rails
- Audit low air loss mattresses currently in use
- Verify order and care plan for all low air loss mattresses in use
- Complete fall risk assessment for all residents with low air loss mattress
- Provide staff education regarding use of enabler/bed rail
- Provide staff education regarding false safety
- Provide staff education regarding low air loss mattress
- Audit admissions for completion
- Audit low air loss mattresses and bedside rails
- Conduct ongoing monitoring for improvement to be reviewed at QAPI
Failure to Assess and Care Plan Bed Rail Use Leading to Fatal Entrapment
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing the use of bed rails and the risk of entrapment for a resident with severe cognitive impairment. The resident was an elderly female with diagnoses including a left femoral neck fracture, severe dementia, repeated falls, cognitive communication deficit, and a need for assistance with personal care. Her admission MDS showed a BIMS score of 03, indicating severe cognitive impairment, and documented that she required substantial staff assistance with bed mobility and was completely dependent on staff for transfers from bed to chair. Despite these needs, her care plan, focused on ADL self-care performance deficit related to unspecified dementia, only specified staff assistance for bed mobility and encouragement to participate, and did not mention bed rails or any risk of entrapment. The facility obtained a signed bed rail consent form from the resident’s family member, which detailed multiple potential dangers of bed rail use, including suffocation and various forms of entrapment between the rails and mattress or bed components. However, from the time of admission through the period reviewed, there was no documented assessment for bed rail safety, no physician order for bed rails, and no addition of bed rail use or entrapment risk to the resident’s care plan. Maintenance staff reported that bed rails were installed on the resident’s bed at the request of a charge nurse, without a documented work order date and under the assumption that all clinical steps had been completed. The facility’s policy required that alternatives be attempted first, that the IDT assess the resident for entrapment risk, obtain informed consent, verify equipment compatibility, and update the care plan, but these steps were not carried out for this resident prior to installation. The resident was later found unresponsive in the early morning hours, seated on the floor on the right side of the bed with her head and neck positioned between the side rail and the mattress. A CNA reported that the resident had been resting calmly during an earlier round and was later observed partially out of bed with her head pinned between the assist bar and the mattress. The LVN responding to the CNA’s report observed the resident in a sitting position off the mattress with her head resting between the side rail and mattress, and CPR was initiated before EMS arrived and pronounced her deceased. The county medical examiner reported bruising and abrasions around the neck and jawline and hemorrhaging in the neck muscles, consistent with being trapped between the mattress and bed rails, and indicated that the likely cause of death would be strangulation on the bed rails or asphyxiation on the mattress. Subsequent observation of the bed showed 1/3 bed rails of the same make and model as the bed frame and a low air loss mattress that, while initially leaving little space between the mattress and rails, could be compressed enough to create significant space between the mattress and rails.
Failure to Notify Resident Representative After Fall
Penalty
Summary
The facility failed to immediately notify a resident's representative after the resident experienced an unwitnessed fall that resulted in injury and had the potential for requiring physician intervention. The resident, an elderly male with diagnoses including unspecified dementia, hypertension, congestive heart failure, and metastatic prostate cancer, had a history of falls and was assessed as having moderately impaired cognition. On the day of the incident, the resident was found on the floor of his restroom after standing up from the toilet and experiencing weakness in his legs, leading to a fall. The nurse on duty assessed the resident, noted multiple skin tears, and initiated fall protocol and neurochecks. The nurse notified the on-call nurse practitioner and the assistant director of nursing but did not notify the resident's family member or representative. The resident's family member, who was listed as the emergency contact, was not informed of the fall by the facility. Instead, the family member learned of the incident directly from the resident the following morning, who described the fall and his pain. When the family member contacted the facility, the nurse confirmed the fall had occurred the previous day. Interviews with facility staff, including the LVN, RN, DON, ADON, and administrator, revealed that the expectation was for the family or emergency contact to be notified of any significant change, such as a fall, regardless of the resident's status as their own responsible party. The staff member involved stated she did not notify the family because she believed the resident was his own responsible party. Review of facility policies and in-service training materials confirmed that both the provider and the resident's representative should be notified of a fall, with documentation of the date and time of notification. The failure to notify the resident's representative was inconsistent with facility policy and staff training, as well as the expectations of facility leadership.
Failure to Knock on Resident Doors Before Entry
Penalty
Summary
The facility failed to ensure that staff consistently honored residents' rights to privacy and dignity by not knocking on residents' doors before entering their rooms. During observations, a CNA was seen entering the rooms of three residents without knocking. Interviews with two of these residents confirmed that staff did not always knock before entering, and both expressed irritation and a desire for staff to knock consistently, especially when their doors were closed or when they were changing. The residents involved had significant medical histories, including heart disease, cognitive communication deficits, dementia, muscle wasting, and other chronic conditions. Their cognitive abilities ranged from moderate to severe impairment, as indicated by their BIMS scores. Despite these challenges, the residents were aware of and affected by the lack of respect for their privacy. Interviews with the CNA, DON, and ADM revealed that all staff had been trained on the policy requiring staff to knock before entering residents' rooms, regardless of the residents' cognitive status, except in emergencies. The staff acknowledged the importance of this practice for maintaining residents' privacy and dignity, and management reported that compliance was monitored through rounds and in-service training. However, the deficiency occurred because the policy was not consistently followed, and staff could not explain why the required action was omitted.
Failure to Prepare and Serve Palatable, Safe, and Appetizing Food
Penalty
Summary
The facility failed to prepare and serve food in a manner that conserved nutritive value, flavor, and appearance for the majority of its residents. Observations revealed that food, including vegetables for various diets, was prepared as early as 2 hours and 45 minutes before meal service and held in shallow, uncovered pans on the stove for extended periods. Test trays for both regular and pureed diets were found to be at low temperatures and described as bland in flavor. Pureed foods were served with visible lumps, requiring chewing, which is inconsistent with prescribed dietary guidelines. Food temperatures recorded during meal service were often below recommended serving temperatures, with some items as low as 88 to 99 degrees Fahrenheit. Multiple residents reported dissatisfaction with the food, citing issues such as cold temperatures, lack of flavor, and insufficient variety. Interviews with residents and a confidential group interview indicated that complaints about cold and unappetizing food were consistent and ongoing. Staff interviews confirmed that food preparation often began several hours before service, and that food was sometimes left sitting in hallways before being served, contributing to the temperature issues. Despite repeated complaints documented in Resident Council meeting minutes and grievance logs, the facility did not address the concerns effectively, and the same issues persisted over several months. The facility's own Diet and Nutrition Care Manual specified that pureed foods should not contain visible lumps and should not require chewing, yet observations and test trays contradicted these standards. Staff interviews revealed a lack of clear communication and follow-through regarding resident complaints, with dietary management unaware of the extent of dissatisfaction. The ongoing failure to prepare and serve food at safe and appetizing temperatures, with appropriate flavor and texture, was directly observed and corroborated by resident and staff interviews, as well as facility documentation.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart located on the 200 hall, assigned to a medication aide (MA-A), was observed to be unattended and unlocked for approximately 10 minutes, making medications accessible to residents. Multiple staff members walked past the unlocked cart without securing it. The facility's policy requires medication carts to be locked at all times when unattended, and this was confirmed in interviews with the medication aide, a registered nurse (RN-C), the Director of Nursing (DON), and the administrator (ADM). Each staff member acknowledged the importance of keeping the cart locked to prevent unauthorized access to medications. The facility's policy, as reviewed, states that medications and biologicals must be stored safely, securely, and properly, with access limited to authorized personnel. The failure to lock the medication cart resulted in medications being accessible to residents and others, contrary to facility policy and accepted professional standards. No specific residents were identified as having accessed the medications during the incident.
Failure to Assess and Document Resident Fall
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The incident involved a male resident with a history of age-related physical debility, repeated falls, muscle wasting, and a history of stroke and heart attack. The resident was found on the ground in the dining room and remained there for over an hour and a half without being assessed by a nurse. There was no nursing documentation or incident report created by the responsible RN. The resident had a severely impaired cognition as indicated by a BIMS score of 00 and required substantial assistance with mobility. Despite being at risk for falls, the resident was not assessed after being found on the floor, and no vital signs or neuro checks were conducted. The resident's family members eventually arrived and assisted him to bed without any staff intervention or assessment. The RN claimed the resident was combative, which prevented an assessment, but this was contradicted by family members who stated the resident was not aggressive. The lack of assessment and documentation was a significant oversight, as the resident passed away approximately eight hours later. The facility's policies on fall management and incident reporting were not followed, as no physical assessment was completed, and no incident report was filed. This failure resulted in the identification of an Immediate Jeopardy situation, highlighting the risk of residents not receiving necessary medical care.
Resident Elopes Through Unsecured Emergency Exit
Penalty
Summary
The facility failed to ensure a safe environment for Resident #1, who was able to elope from the facility through an emergency exit door. This incident occurred after CNA C used the exit code to the emergency door, which was not supposed to be used except in emergencies. The door was not properly latched, allowing Resident #1 to leave the facility unnoticed. The resident was later found at a gas station by LVN B, who did not stay with him until assistance from the facility arrived. The resident was eventually taken to the hospital, where he tested positive for cocaine. Resident #1 was a male with multiple diagnoses, including type II diabetes, schizophrenia, and acute kidney failure. He had a moderate cognitive impairment and used a wheelchair. Despite being assessed as a low risk for elopement, he had expressed a desire to leave the facility on several occasions. His care plan included monitoring for behavior episodes, but there was no indication of exit-seeking behavior prior to the incident. The facility's failure to secure the emergency exit and provide adequate supervision placed Resident #1 at risk for unsafe elopement, dehydration, and hospitalization. The incident highlighted lapses in staff adherence to protocols regarding emergency exits and supervision of residents, particularly those with a history of leaving facilities against medical advice.
Failure to Investigate Verbal Abuse Allegation
Penalty
Summary
The facility failed to thoroughly investigate an alleged verbal abuse incident involving two residents. Resident #1 accused Resident #2 of making sexual comments, which led to Resident #1 throwing a cup of cold water on Resident #2. Despite the incident being documented by LVN A and reported as a resident-to-resident incident, the allegation of verbal abuse was not investigated as required by the facility's policy. Resident #1, who has a moderate cognitive impairment, reported the incident to LVN A, who documented it in the progress notes and completed an incident report. However, the Director of Nursing (DON) and the Administrator (ADM) were not informed of the nature of the incident, specifically the alleged verbal abuse. The DON was unaware of any aggressive behavior or sexual comments, and the ADM was not informed of the incident's details, which prevented the initiation of an investigation. The facility's policy mandates that all abuse, neglect, and exploitation (ANE) allegations be reported immediately to the Administrator. The failure to report and investigate the verbal abuse allegation could place residents at risk and prevent the facility from taking corrective actions to prevent further abuse, neglect, and exploitation. The incident was not discussed in the stand-up meeting, and the Psychologist noted that Resident #1 did not display signs of fear or recall the incident, attributing any paranoia to her dementia.
Failure in Discharge Planning Process
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for a resident, which focused on the resident's discharge goals and included regular re-evaluation to identify changes requiring modification of the discharge plan. The resident, a male with diagnoses including hemiplegia, hemiparesis, cognitive communication deficit, aphasia following cerebral infarction, and depressive episodes, expressed a desire to move to a specific local nursing facility. Despite having a BIMS score indicating intact cognition and being his own responsible party, the facility did not have a discharge plan in place for him. The social worker (SW) was aware of the resident's wish to transfer but had not documented any efforts in the electronic medical record (EMR). Instead, she kept a notebook with notes on her attempts to contact the desired facility. The SW was under the impression that the resident's family, who were only listed as emergency contacts, might be involved in decision-making, although the resident was his own responsible party. The SW had not reached out to the family or sent any clinical documents to the other facility, as she was waiting for a response from them. The SW's caseload was not considered large, yet she had not documented her efforts or progress in the EMR. The Director of Nursing (DON) and the Administrator (ADM) were aware of the resident's desire to move, but the ADM was unsure about the resident's Medicaid status, which he thought might be delaying the referral process. The facility's policy required the discharge planning process to focus on the resident's goals and involve them as active partners, but this was not adhered to in this case. The lack of documentation and communication regarding the resident's discharge planning placed him at risk of not having a plan to address his post-discharge needs.
Failure to Post Recent Survey Results
Penalty
Summary
The facility failed to have the results of the most recent survey posted in a place readily available to residents, family members, and legal representatives. During an observation, a binder labeled 'Survey Results' was found on a table at the entrance of the facility. This binder contained survey results dating back to 2021 but did not include the results from the most recent full recertification survey conducted from 02/06/24 to 02/08/24. The binder did contain a Notice of Accepted Plan of Correction Form referencing the full recertification survey dated 02/08/24. This omission was confirmed during an interview with the administrator, who had recently started working at the facility and was unsure of the exact date he had requested the survey results. Confidential interviews with four residents revealed that they were interested in knowing the results of State Agency investigations. One resident expressed a desire to see the results before entering the facility to determine if it was a safe place to live. Another resident felt that knowing the survey results was important to understand what was happening in their home and to see if others were experiencing similar issues. The administrator acknowledged that making the survey results available was his responsibility and recognized that residents might be more outspoken about their problems if they could see that others had similar issues documented in the survey results.
Latest citations in Texas
Surveyors found that kitchen staff failed to follow facility policy and professional standards for food storage, leaving dry items such as spaghetti noodles, garlic powder, and salt unsealed, and refrigerated items such as a prepared drink, salad, and turkey lunch meat uncovered or undated. The DM and ADM both stated that all food should be sealed, labeled, and dated, that all staff are responsible for these tasks, and that staff had been trained, but observations showed food in both dry and refrigerated storage was not properly sealed or dated as required by the facility’s food receiving and storage policy.
The facility failed to enforce its smoking policy and safe smoking assessments for three residents who used tobacco. One resident with mild cognitive impairment and two residents without cognitive impairment were assessed as smokers who required the facility to store their cigarettes and lighters, yet they reported keeping these items in their rooms, and surveyors observed cigarettes and lighters in bedside furniture. An LVN and the housekeeping supervisor stated that all smoking was to be supervised and that supplies were to be kept at the nurse’s station, and the DON and ADM confirmed that residents were not supposed to keep smoking articles in their rooms. However, residents reported they had not been told they could not keep smoking supplies in their rooms, and the facility’s written policy stated residents may not have or keep smoking articles except under direct supervision.
A resident with dementia, severe cognitive impairment, limited lower extremity range of motion, and a need for assistance with ADLs was twice observed lying in bed without an accessible call light, which was either hanging under the head of the bed or tucked between the mattress and bedframe. An LVN confirmed the resident could use the call light if available, and a CNA, another LVN, the DON, and the ADM all stated that call lights should always be within reach, that all staff are responsible for ensuring access, and that they were unaware this resident’s call light was not in reach. This was inconsistent with the facility’s policy requiring each resident to have a means to call staff directly for assistance from the bed and other areas.
A resident reported that bedroom hand sinks did not provide warm water, requiring handwashing with cold water and causing discomfort. Surveyors observed that in two rooms, the hot water remained cold despite running for several minutes, and thermometer readings at shared hand sinks showed temperatures in the 70°F range on the hot side, below the facility’s stated 100–110°F expectation. Further observation with the MD revealed that in one room the hot and cold valves were transposed, with hot water only available from the cold side. The MD, ADM, and DON each stated the MD was responsible for monitoring and maintaining water temperatures, but none were aware of recent issues, and the DON did not know the required temperature range. The facility’s maintenance request policy was requested twice but was not provided.
A resident with documented Major Depressive Disorder (MDD), including recurrent severe and mild forms, was identified in multiple records such as the face sheet, MDS, care plan, physician orders, and diagnosis report, and was receiving Cymbalta for MDD. However, the resident’s PASRR Level I screening indicated no mental illness. The ADM stated the MDS nurse was responsible for PASRR accuracy and updates when mental illness diagnoses were made, and acknowledged the resident’s active MDD should have been reflected on the PASRR, but he was unaware of the inaccuracy. This resulted in an inaccurate and non-updated PASRR Level I for a resident with a mental illness diagnosis.
Two residents’ care plans were not accurately updated to reflect their assessed needs and physician orders. One resident with dementia, diabetes, and malnutrition had an active MD order and meal tickets for a large-portion, double-portion diet and was observed receiving double portions at meals, yet the care plan continued to list only a regular diet with thin liquids and did not specify the ordered double portions. Another resident with schizophrenia and schizoaffective disorder had a positive PASRR Level 1 for mental illness and a completed PASRR Level 2 evaluation, but the care plan, while listing the psychiatric diagnoses, contained no focus areas addressing the PASRR findings or related services. The ADM and DON acknowledged that care plans should have been updated to reflect these orders and PASRR results and were unaware that this had not occurred.
A resident with severe dementia, psychiatric comorbidities, and protein-calorie malnutrition had a physician order for weekly weights, but the facility failed to consistently obtain and document these weights over several months. Although the resident appeared adequately nourished and was observed eating most of a meal, multiple ordered weekly weights were missing from the treatment records. Facility leadership, including the DON and ADON, were unaware that the weekly weight order had not been followed, despite policies requiring adherence to physician orders and documentation of weights in the EHR.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
Surveyors found loose pills in drawers on two medication carts, indicating medications were not stored in their original packaging or assigned resident-specific areas as required by facility policy. On one cart, two loose tablets later identified as Carbidopa-Levodopa and Zofran were discovered with a medication aide who stated she was responsible for checking the cart at the start of her shift. On the second cart, four loose tablets identified as Allopurinol, Metoprolol, Lasix, and Amlodipine were found with another medication aide, who also reported routinely checking the cart for cleanliness and loose medications. The DON and ADM both reported they were unaware of the loose medications and stated that medication aides, nurses, and charge nurses were responsible for proper medication storage, monitored through administrative and pharmacy cart audits.
A resident with CHF, COPD, morbid obesity, chronic wounds, and total bowel/bladder incontinence was discharged home by stretcher despite being a mechanical-lift resident who could not walk or toilet independently. Home health was not in place, the family reported difficulty reaching SW, and the resident was discharged without an AMA notice or Ombudsman notice. She soiled herself at home, could not clean up, and was hospitalized shortly after for CHF exacerbation and fluid overload.
Improper Sealing, Dating, and Storage of Dry and Refrigerated Foods
Penalty
Summary
Surveyors identified a deficiency in the facility’s food storage and handling practices in the kitchen, based on observations, interviews, and record review. During a kitchen tour, they observed multiple instances of improperly stored food in dry storage and refrigerated areas. In dry storage, spaghetti noodles were kept in an unsealed zip lock bag, garlic powder was stored with its lid open, and salt was stored with its spout open. In refrigerated storage, a prepared drink was placed on a metal sheet pan without a cover, a plate of salad had no date, and a package of turkey breast lunch meat was undated and not sealed. In interviews, the Dietary Manager (DM) stated that all food in the refrigerator should be sealed and dated, and all dry storage food should be sealed and closed, explaining that sealing stored food keeps it fresh and prevents contaminants from entering. The DM also stated that all staff were responsible for dating and sealing stored food and that all staff had been trained in food storage. The Administrator (ADM) reported he was not aware that food was not properly stored, and stated that dating and sealing stored food was to maintain sanitary conditions, with everyone responsible for this task and all staff trained in food storage. Review of the facility’s “Food Receiving and Storage” policy, revised November 2022, showed that dry foods stored in bins must be removed from original packaging, labeled, and dated with a use-by date, and that all refrigerated and frozen foods must be covered, labeled, dated, and monitored so they are used, frozen, or discarded by their use-by date.
Failure to Enforce Smoking Policy and Control Resident Smoking Supplies
Penalty
Summary
The facility failed to follow its established smoking policy for three residents who used tobacco. Record review showed that one resident with hepatic encephalopathy, anxiety, depression, and hypertension had an annual MDS indicating tobacco use and a BIMS score of 09 (mild cognitive impairment), but there was no smoking care plan in her care plan report. Her safe smoking assessment indicated she required the facility to store her lighter and cigarettes and that she was safe to smoke without supervision. Two other residents, one with heart failure, diabetes, anxiety, and hypertension, and another with a history of cerebral infarction, depression, and hypertension, had MDS assessments indicating tobacco use and BIMS scores of 14 and 13 respectively (no cognitive impairment). Their care plans identified them as smokers, and their safe smoking assessments also indicated the facility should store their lighters and cigarettes and that they were safe to smoke without supervision. Staff interviews and observations revealed inconsistencies between the facility’s smoking policy and actual practice. An LVN stated that all resident smoking was to be supervised, that smoking supplies were kept in a box at the nurse’s station, and that staff supervised residents according to a smoking schedule, with the housekeeping supervisor assigned to supervise at a specific time. Observation confirmed the housekeeping supervisor was outside observing residents while they smoked. The housekeeping supervisor reported she was scheduled to supervise smoking, that all residents had their own cigarettes and lighters, and that she did not hand out smoking supplies, believing residents obtained them from the nurse’s station. Both the LVN and housekeeping supervisor stated they had been trained on the facility’s smoking policy. Resident interviews and room observations showed that residents were keeping smoking supplies in their rooms despite the policy and safe smoking assessments requiring facility storage. One resident reported keeping cigarettes in his nightstand and a lighter in his pants pocket and stated he had not been told he could not keep smoking supplies in his room. Another resident stated he kept cigarettes and a lighter in his nightstand, and the surveyor observed cigarettes and a lighter in the top drawer of the nightstand; he also stated he had not been told he could not keep supplies in his room. A third resident stated she kept her cigarettes and lighter in her room and that if you gave the nurses your cigarettes and lighter they would take them; she did not remember being told she could not have supplies in her room. The DON and ADM both stated that the policy required all residents to be supervised while smoking and that smoking supplies were to be kept at the nurse’s station, and they were not aware that residents had smoking supplies in their rooms. The written smoking policy stated that residents may not have or keep any smoking articles except when under direct supervision.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s call light was within reach, as required by facility policy and staff training. An elderly female resident with dementia, severe cognitive impairment (BIMS score of 03), limited range of motion in both lower extremities, and a need for partial/moderate assistance with ADLs was observed on two separate occasions without accessible call light access. On one observation, the resident was lying in bed with the call light hanging on the bed frame under the head of the bed; on another, the call light was tucked between the mattress and bedframe at the head of the bed, making it unavailable for use. Multiple staff interviews confirmed that the call light should always be within reach of residents and that there was no reason this resident should not have had access to it. An LVN stated the resident was able to use the call light if it was available and that it should always be in reach. A CNA, another LVN, the DON, and the ADM each stated that the purpose of the call light was for residents to call for assistance, that all staff had been trained on call light placement, and that all staff were responsible for ensuring residents had access to the call light. None of them were aware that this resident’s call light was not within reach. The facility’s written policy on the resident call system stated that each resident is to be provided with a means to call staff directly for assistance from the bed and toileting/bathing areas, which was not followed in this case.
Failure to Maintain Adequate Hot Water Temperatures at Resident Hand Sinks
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents had access to safe, functional, sanitary, and comfortable handwashing facilities in their rooms. A resident reported that there was no warm water in the hand sinks in residents’ bedrooms and that they often had to wash their hands with cold water, which made their hands feel cold. The resident also stated they felt the facility did not take the cold water issues seriously and expressed a desire to have warm water available to wash their hands and face. Surveyor observations confirmed that the hot water in two resident rooms remained cold even after running the water for several minutes. Subsequent temperature checks with a thermometer at the shared hand sinks in these rooms showed water temperatures of 73.6°F and 70.5°F on the hot water side, which were below the facility’s stated expected range of 100–110°F for resident room sinks. During a later observation with the Maintenance Director (MD), the hot water at one shared hand sink again measured 70°F on the hot side, and when the cold side was turned on, the water became warm, with a measured temperature of 100°F, indicating the hot and cold valves had been transposed after a plumbing repair. In interviews, the MD stated he was responsible for ensuring adequate water temperatures and that he conducted weekly spot checks of shared hand sinks, maintaining temperature logs, but he was not aware of any recent issues or reports regarding water temperatures. The Administrator (ADM) confirmed that the MD was responsible for water temperatures and that the expected range was 100–110°F, and acknowledged that a recent toilet repair in one of the rooms could have resulted in the hot and cold valves being transposed. The DON stated the MD was responsible for regular water temperature checks and repairs, was not aware of any concerns about hot water temperatures, and was unsure of the required temperature range. When the facility’s maintenance request policy was requested from the ADM on two occasions, it was not provided.
Failure to Maintain Accurate PASRR Level I for Resident With Mental Illness
Penalty
Summary
The facility failed to ensure an accurate and updated PASRR Level I assessment for a resident with a diagnosed mental illness. The resident, a female with hemiplegia following a cerebral infarction, had documented diagnoses of Major Depressive Disorder (MDD), recurrent, severe without psychotic features, and MDD, recurrent, mild, as reflected on her electronic face sheet, MDS, care plan, physician orders, and diagnosis report. Her Annual MDS identified active psychotic/mood disorders of anxiety and depression, and her care plan and physician orders both documented active MDD diagnoses and treatment with Cymbalta (duloxetine) for MDD. The diagnosis report showed onset dates for MDD recurrent severe without psychotic features and MDD recurrent mild well before the survey. Despite these documented mental health diagnoses, the resident’s PASRR Level I screening dated 07/28/2024 indicated "NO" for both primary diagnosis of dementia and mental illness. During an interview, the Administrator stated that the MDS nurse was responsible for ensuring PASRR Level I screenings were accurate upon admission and for requesting updates when new mental illness diagnoses were made, and acknowledged that the resident did have an active MDD diagnosis that should have been reflected as a mental illness on the PASRR. The Administrator reported he was unaware that the PASRR Level I was inaccurate and noted that PASRR screenings were supposed to be reviewed during the admission process and updated with any changes. The report states that this failure could place residents with inaccurate PASRR Level I screenings and no PASRR Level II evaluation at risk for not receiving needed care and services.
Failure to Maintain Accurate Care Plans for Dietary and PASRR-Related Needs
Penalty
Summary
Surveyors identified a deficiency in the facility’s development and implementation of comprehensive, person-centered care plans with measurable objectives and timeframes for residents’ identified needs. For one male resident with dementia, type 2 diabetes, malnutrition, and vitamin deficiency, the admission MDS showed moderate cognitive impairment and independence in eating, with no diet restrictions or weight loss documented in Section K. His care plan included focus areas for diabetes management and potential nutritional problems, with goals to avoid complications related to diabetes and malnutrition and to maintain weight. Interventions listed included dietary consults, monitoring meal intake percentages, providing a regular diet with thin liquids, monitoring for signs and symptoms of malnutrition, and having the RD evaluate and recommend diet changes as needed. Record review showed that this resident had an active physician order for a “Large Portions diet Regular texture, Regular consistency, Double Portions” starting in early February, and his weights increased from 132 lbs to 158 lbs over several months. His lunch meal ticket reflected a regular diet with double portions, and observations confirmed he was receiving double portions at meals, sometimes requesting additional items such as a salad when still hungry. However, the resident’s care plan did not reflect the physician’s order for large/double portions; it continued to reference a regular diet and thin liquids without specifying the ordered double portions. During interviews, the resident reported he sometimes asked for more food because he was hungry but was able to get second portions and felt full after meals. The ADM and DON both stated that the MDS nurse was responsible for updating care plans when diet orders changed, acknowledged that the care plan should have reflected the double-portion order, and were unaware that it had not been updated. For a female resident with hypertensive emergency, schizophrenia, and schizoaffective disorder, bipolar type, the annual MDS documented moderate cognitive impairment and active diagnoses of anxiety disorder, schizophrenia, and schizoaffective disorder, bipolar type. Her active physician orders also listed schizophrenia and schizoaffective disorder, bipolar type. PASRR Level 1 screening indicated no primary diagnosis of dementia and a positive finding for mental illness, and a PASRR Level 2 evaluation had been completed, documenting that she was not interested in enrollment in a community-based program. Despite these PASRR findings and active mental health diagnoses, the resident’s current care plan, while listing schizophrenia and schizoaffective disorder as active diagnoses, contained no focus areas addressing the PASRR Level 1 screening or the PASRR Level 2 evaluation. In interviews, the ADM and DON both stated that the resident’s positive PASRR findings should have been reflected in the care plan and did not know why they were not. The facility’s policy on interdisciplinary care planning stated that resident care plans are to be developed according to the timeframes and criteria established by §483.21, but the care plans for these two residents were not accurate, consistent, or complete with respect to their dietary and PASRR-related needs.
Failure to Follow Physician Orders for Weekly Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document weekly weights as ordered by the physician for one resident with significant nutritional risk factors. The resident was an elderly female with severe dementia with agitation, depression, schizoaffective disorder–bipolar type, and protein-calorie malnutrition. Her Quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment, and documented a weight of 120 pounds. A physician order dated 05/14/26 directed that weekly weights be obtained every Wednesday starting 01/21/26. Record review showed that, despite this standing order, multiple weekly weights were not obtained or recorded over several months. The Treatment Administration Records from 01/01/26 through 05/13/26 reflected missing weekly weight assessments on at least six ordered dates: 01/28/26, 02/11/26, 03/11/26, 03/25/26, 04/08/26, and 04/22/26. Progress notes documented weights on some dates (01/19/26, 01/21/26, 02/23/26, and 03/18/26), but these did not fulfill the requirement for consistent weekly weights as ordered. The facility’s own policy on Physician Orders stated that such orders are essential for comprehensive care, and the Weight Assessment and Intervention policy required that weights be recorded in the electronic health record. During observations, the resident appeared well-groomed, did not appear underweight or emaciated, and was seen consuming approximately 75% of a meal with staff assistance. However, interviews with the DON, ADON, and Administrator confirmed that they were not aware that the weekly weight orders had not been consistently followed for this resident. The ADON reported that the resident had significant cognitive impairment and often refused to be weighed, but there was no documentation in the report that these refusals were linked to the missed ordered weight dates or that alternative measures were taken to comply with the physician’s order. The deficiency centers on the facility’s failure to follow the physician’s weekly weight order and to ensure weights were consistently obtained and recorded in accordance with professional standards, the care plan, and facility policy.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Loose Medications Found on Two Medication Carts
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored properly on two medication carts. During an observation of the Station 1 medication cart with a medication aide, surveyors found two loose pills in a drawer. The medication aide acknowledged that the cart should not contain loose pills and stated she was responsible for the cart once she received the keys, usually checking it at the beginning of her shift for loose or expired medications and cleaning it prior to medication pass. The Director of Nursing (DON) later identified the loose pills as Carbidopa-Levodopa 25-100 and Zofran 4 mg. The facility’s policy on Medication Labeling and Storage, revised February 2023, states that medications and biologicals are to be stored in the packaging or dispensing systems in which they are received, and that medications are to be stored in an orderly manner with each resident’s medications assigned to an individual cubicle or drawer to prevent mixing. A similar issue was identified on the Station 2 medication cart, where four loose pills were found in the drawers during an observation with another medication aide. The DON identified these pills as Allopurinol 100 mg, Metoprolol 25 mg, Lasix 20 mg, and Amlodipine 5 mg. The second medication aide also stated that the cart should not contain loose pills and that she was responsible for checking the cart for cleanliness and loose medications at the beginning of each shift. In interviews, the DON and the Administrator both stated they were not aware that there were loose medications on the carts, and each indicated that medication aides and nurses or the charge nurse were responsible for proper storage of medications on the carts. Both referenced that nursing administration and the pharmacy consultant conducted periodic or monthly cart audits, and the DON and Administrator described potential negative outcomes such as residents missing medications or inventory control issues. These findings demonstrate that medications were not consistently stored in accordance with the facility’s policy and accepted professional principles.
Unsafe discharge without needed supports
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the discharge of a resident with significant functional and medical needs. The resident had diagnoses including acute on chronic diastolic CHF, acute pulmonary edema, obesity, COPD, chronic lower-leg ulcer, and bowel and bladder incontinence. Her admission assessment showed a BIMS score of 15, but her functional status was highly limited: bed mobility required dependent to maximal assistance, transfers were not attempted due to medical/safety concerns, walking 10 feet was not attempted, and she was always incontinent of bowel and bladder. Therapy documentation identified her as a mechanical lift resident, and progress notes described persistent debility, high fall risk, and ongoing counseling about unsafe home discharge. Despite these limitations, the resident was discharged home by stretcher with no home health services in place. The discharge summary listed home care and durable medical equipment, including a wheelchair, hospital bed, and 3-in-1 commode, but the home health agency later reported that the referral was declined because of insurance denial. Facility staff and the resident’s family reported that the resident could not walk and could not get to the bathroom by herself. The resident’s family also reported difficulty reaching social services and stated they did not know who would care for her at home. The resident was discharged without an AMA discharge notice and without notice to the Ombudsman, despite facility policy describing requirements for facility-initiated discharge and resident notification. After discharge, the resident arrived home by EMS on a stretcher and was unable to ambulate. Within less than 24 hours, she urinated and defecated on herself and was unable to change her clothing or clean her body. She was then hospitalized for CHF exacerbation and fluid overload. Interviews with facility staff showed conflicting accounts about the discharge process, the availability of home health, and whether the discharge was safe. The attending MD stated she did not recommend the resident go home and recommended long-term care, while other staff stated the resident wanted to go home and that the discharge was insurance driven.
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