Cascades At Galveston
Inspection history, citations, penalties and survey trends for this long-term care facility in Galveston, Texas.
- Location
- 3702 Cove View Blvd, Galveston, Texas 77554
- CMS Provider Number
- 675254
- Inspections on file
- 39
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 14 (2 serious)
Citation history
Health deficiencies cited at Cascades At Galveston during CMS and state inspections, most recent first.
A resident with a PEG tube, dysphagia, and anorexia was admitted on a pureed "pleasure" diet with orders for enteral feeds and oral Ensure, but staff did not administer tube feeding formula and documented repeated refusals of oral supplements and medications over multiple days without promptly notifying the NP/MD or the resident’s representative. The resident was observed alone with an uneaten pureed meal tray, reported only receiving water flushes through the PEG and difficulty swallowing, and described disliking the pureed food. Medication aides stated the resident had not taken oral meds or Ensure since admission due to swallowing problems and that they verbally informed charge nurses, while the RN and DON acknowledged they were unaware of the full extent of refusals and had not ensured timely provider notification. The NP and MD confirmed they had not been informed of the resident’s ongoing refusals or lack of a clear enteral feeding regimen, leading surveyors to cite the facility for failing to immediately inform and consult with the practitioner and representative when significant treatment changes were needed.
A resident with dysphagia, anorexia, and a newly placed PEG tube was admitted with hospital orders indicating that pureed oral intake was for comfort only and not sufficient for nutrition, and that she should otherwise remain NPO with tube feeding. The facility did not implement a specific enteral feeding formula order for the PEG, instead relying on a pureed diet and Ensure PO TID, which the resident frequently refused or did not receive as documented. Staff did not notify the NP or MD of the refusals, lack of tube feeding, or a documented 19% weight loss over 12 days, and weekly weights were not consistently obtained or accurately managed. The resident reported receiving only water through the PEG, and surveyors observed her seated alone with an uneaten pureed meal tray, stating she was hungry and needed help, while staff were unaware she had not eaten. The resident’s representative also reported multiple occasions where the resident was left with untouched trays and no feeding assistance, and an RN told the representative the resident needed to learn to feed herself with her non-dominant hand despite right-sided weakness.
A resident with dysphagia, anorexia, and a PEG tube placed in the hospital was admitted with orders for NPO status except for pureed food for comfort and active enteral tube flush orders. However, the admission MDS did not include an active diagnosis for gastrostomy status, and Section K reflected only a swallowing disorder with a mechanically altered diet. The resident’s EMR diagnosis list lacked a gastrostomy diagnosis at the time of the assessment, and the MDS nurse later acknowledged that the gastrostomy tube and related diagnosis should have been coded but were missed, despite relying on the RAI manual for MDS completion.
A resident admitted with dysphagia, anorexia, and a PEG tube placed in the hospital had orders for NPO status with pureed food for comfort and enteral feeding with scheduled water flushes, but the facility did not develop or implement a comprehensive, person-centered care plan addressing the G-tube, diet, or enteral feeding as required. The admission MDS documented a swallowing disorder and mechanically altered diet but omitted an active gastrostomy tube diagnosis, and care plan entries referencing the G-tube and mechanically altered diet were only added after surveyor inquiry. During observation, the resident sat with a pureed breakfast tray, reported needing help to eat, and later stated that staff only pushed water through the tube without providing medications or feeding formulas. The DON, Administrator, and MDS nurse acknowledged that care plans for the G-tube and diet should have been initiated on admission and that the lack of a comprehensive care plan could result in the resident not receiving appropriate care.
The facility failed to submit required follow-up investigation reports to the State Survey Agency within the mandated 5-day timeframe for two separate incidents involving two residents. Review of the state TULIP system showed no Provider Investigation Reports on file for these incidents, despite facility policy requiring the administrator to provide a follow-up report within five days. Interviews revealed that the former administrator had handled PIRs alone, current leadership and staff did not have TULIP access, and no one assumed responsibility for completing or locating the pending investigations during a change of ownership, resulting in noncompliance with state reporting requirements.
Nursing staff lacked adequate competency and training in controlled medication management, leading to multiple discrepancies and unsafe practices. For one resident with seizure disorder and severe cognitive impairment, an RN’s control count sheet for Lacosamide did not match the actual volume on the cart, and the RN reported no recent skill check‑off or training on medication administration or control counts. For another resident with dementia and pain management needs, a tramadol blister pack was found with a punched, half‑exposed tablet, and the same RN stated she did not know how to handle the situation and had not been trained on control counts. For a third resident receiving PRN acetaminophen‑codeine for pain, an LVN’s control sheet showed one more tablet than was present in the blister pack; the LVN admitted administering a dose without signing it out on the control sheet or MAR and indicated she had not received medication administration training beyond brief floor orientation, despite facility policy requiring nursing leadership to ensure staff competency.
Multiple failures in pharmacy services were identified, including inaccurate controlled drug counts, improper handling of damaged blister packs, and incomplete documentation. One resident receiving Lacosamide via G-tube had a control count sheet that did not match the actual volume in two bottles, and the RN who discovered the discrepancy reported no recent training on med administration or controlled counts. Another resident with PRN tramadol for pain had a blister pack with a punched-open seal and a half-exposed tablet, and the RN did not know the appropriate action. A third resident receiving PRN acetaminophen-codeine had a mismatch between the blister pack count and the control sheet because an LVN administered a dose but failed to sign it out on the control sheet or MAR. The DON reported limited time for comprehensive nurse training, the facility’s policy required MAR initials after each medication, and a requested drug diversion policy was not provided.
A resident with convulsions, hypertension, traumatic brain injury, severely impaired cognition (BIMS 3/15), and extensive to total ADL needs was found to have no active care plan after the existing plan was cancelled in the electronic record. The MDS Coordinator stated she did not cancel the plan and believed her supervisor did so, and she was unaware of the cancellation until the surveyor requested the care plan, despite having recently completed the quarterly MDS without reviewing it. The DON and Administrator reported they did not know why the plan was cancelled, confirmed that the care plan is used to guide care and communicate with providers and nursing staff, and acknowledged that every resident should have a current, quarterly-updated care plan, while also noting the facility had no specific care plan policy and followed the RAI manual instead.
A resident with multiple comorbidities, severe cognitive impairment, and on hospice care had PRN oral morphine ordered for pain. While counting the resident’s prefilled morphine syringes on the medication cart, an LVN dropped one syringe on the floor, then picked it up and placed it back with the other syringes instead of wasting it, thereby contaminating the entire group. In interviews, the LVN acknowledged the syringe was contaminated and should have been destroyed with another nurse, and the DON confirmed that the dropped syringe and the remaining syringes were considered contaminated, constituting a breach of the facility’s medication administration policy requiring adherence to infection control procedures. The requested infection control policy was not provided by administration at exit.
The facility did not include required staffing level information in its facility-wide assessment, and the assessment was not used to inform nursing staff schedules. Instead, staffing decisions were based on PPD, census, and national averages, without considering individual resident needs as outlined in facility policy.
The facility did not provide enough nursing staff to meet residents' needs, resulting in a resident remaining in a urine-soaked brief, another unable to get out of bed for an entire day, and a third experiencing long waits for incontinent care. Staffing assignments showed fewer CNAs present than scheduled, and staff interviews confirmed that care was delayed or missed due to inadequate staffing levels.
Multiple medication carts were found unattended and unlocked, with keys left accessible and a variety of prescription and OTC medications, including narcotics, stored inside. Nursing staff and the acting DON confirmed that facility policy requires all medication carts to be locked when not in use, but this was not followed, resulting in unsecured access to medications.
A resident with severe cognitive impairment and multiple medical conditions was not provided with a care plan that addressed her G-J tube feeding and pleasure feeding needs, despite clear physician orders and hospital discharge instructions. The care plan did not include protocols for pureed snacks with SLP or trained caregiver supervision, nor did it reflect the resident's tube feeding requirements.
Two residents were found to have roaches in their rooms, with one resident experiencing repeated infestations involving her bed, wheelchair, and personal items. Staff and maintenance confirmed ongoing pest issues despite regular pest control treatments, and food was often found left in the affected rooms, contributing to the problem. Housekeeping and maintenance staff acknowledged that pest control efforts had not been effective in eliminating the roaches.
Three residents were inaccurately assessed during the MDS process, including one whose bed grab bars were incorrectly coded as restraints, another who was documented as having a catheter that had already been removed, and a third who was assessed as having a catheter despite its prior discontinuation. Staff interviews, observations, and record reviews confirmed these inaccuracies, which resulted in incorrect documentation of the residents' actual conditions.
Two residents with complex medical needs did not have comprehensive care plans addressing their indwelling urinary catheter and oxygen therapy, despite clear documentation and physician orders indicating these interventions. Staff interviews and record reviews confirmed the absence of these care plans, which are required to guide care and ensure all needs are met.
A resident with multiple chronic conditions was sent to the hospital for altered mental status and tested positive for THC, but the physician was not notified of this significant change. Staff interviews revealed gaps in communication and review of hospital records, and the facility's policy requiring timely notification of clinical changes was not followed.
The facility did not update the care plans for two residents after they were hospitalized for altered mental status and tested positive for substances not prescribed to them, including benzodiazepines and THC. Despite these significant findings, care plans were not revised to address substance use, and staff interviews confirmed that this information was not incorporated into resident care planning.
Two residents experienced significant medication errors related to blood pressure management. One resident received Midodrine despite a high SBP, contrary to physician orders. Another resident was given Toprol X and Spironolactone when blood pressure readings indicated they should be held. The medication aide admitted to overlooking the orders, and the ADON acknowledged the incomplete documentation and potential health risks.
The facility failed to maintain accurate medication records for two residents, leading to improper administration of blood pressure medications. For one resident, the MAR did not consistently reflect whether Midodrine was given or held, and blood pressure logs were incomplete. Another resident received Spironolactone and Toprol X despite blood pressure readings indicating they should be held. Staff interviews revealed acknowledgment of these errors, highlighting the need for improved adherence to physician orders and documentation practices.
The facility failed to notify the physician and implement orders for a resident's G-tube care, leading to complications and hospital intervention. Staff were unaware of the physician's orders for an abdominal binder and did not properly manage the G-tube, resulting in pain and soiling at the site.
A facility failed to implement a physician's order for an abdominal binder and did not provide proper gastrostomy tube care for a resident, leading to hospitalization for G-Tube replacement. Additionally, medications were improperly administered via the G-Tube, placing the resident at risk for complications.
A facility failed to maintain a medication error rate below 5 percent, resulting in a 16 percent error rate. An LVN administered the wrong dose of Lactulose, used an incorrect volume of water for g-tube flushing, and did not elevate a resident's head during medication administration, contrary to physician orders and facility policy.
The facility, licensed for 150 beds, failed to employ a qualified full-time social worker for four months, despite job postings and interviews. An LVN was placed as acting social services, and residents expressed confusion over the delay in hiring a qualified social worker.
The facility failed to conduct a comprehensive and accurate assessment of a resident's functional capacity, missing critical information about hospice care and dental status. The resident, with multiple diagnoses including ovarian cancer and major depressive disorder, reported issues with her dentures that were not addressed in a timely manner. Staff interviews revealed gaps in MDS documentation and follow-up.
The facility failed to update a resident's MDS assessment within 14 days after the resident was discharged from hospice care. The resident, who had multiple diagnoses including diabetes and ovarian cancer, discharged herself from hospice due to restrictions on visiting her own physician. The facility did not reassess her condition following this significant change, as required by the RAI manual.
The facility failed to complete and transmit a Death in Facility MDS for a resident who passed away, due to the absence of a permanent MDS Coordinator and reliance on remote staff. The oversight led to the resident's assessment not being recorded in the EMR within the required timeframe.
The facility failed to ensure that a resident's Death in Facility assessment accurately reflected her date of death. The resident had severe cognitive impairments and multiple medical conditions. The Regional MDS RN acknowledged the need to review the resident's EMR to determine if a corrected or modified Death in Facility MDS was necessary.
A resident with COPD and other health issues was transported to a doctor's appointment without a portable oxygen tank, despite being on continuous oxygen therapy. Upon arrival, the resident's oxygen saturation was critically low, requiring immediate intervention. The facility's staff, including the ADON and the resident's nurse, acknowledged the oversight, which was due to a lack of communication and verification of the resident's needs before transport.
Failure to Notify Practitioner and Representative of Resident’s Refusals and Enteral Feeding Needs
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a resident’s practitioner and resident representative of significant changes in condition and treatment needs, including persistent refusals of medications, nutritional supplements, and meals, as well as issues related to swallowing and enteral feeding. A female resident with Wernicke’s encephalopathy, carotid aneurysm, dysphagia, and anorexia was admitted with a PEG tube placed in the hospital for long‑term nutrition, hydration, and medication administration. Her hospital discharge summary specified that pureed food was for comfort only and not sufficient for nutrition, and that she should otherwise remain NPO with PEG feeding. However, the facility’s admission documentation did not include an active diagnosis for a gastrostomy tube on the MDS, and an undated, unsigned note in the EMR referenced PEG use and Jevity via NG tube, even though the NG tube had been removed and replaced with a PEG. Physician orders in the facility record included a regular pureed diet “for pleasure food,” an enteral feed order every shift with water flushes, and an oral Ensure Plus supplement three times daily. The MAR showed that the resident refused all three scheduled Ensure doses on multiple days, had no documentation of administration on several days, and was noted as nauseated/vomiting or asleep on others. During surveyor observation, the resident was found seated alone in front of an uncovered, uneaten pureed breakfast tray, stating she was hungry and needed help to eat but no one had assisted her. In a later interview, she reported that staff only flushed her PEG tube with water and that she had not received medications or feeding formula through the tube since admission. She also described difficulty with food sometimes feeling like it got stuck, dislike of the pureed food’s appearance and taste, and selective eating based on her preferences. Interviews with staff revealed that the resident’s refusals and swallowing difficulties were not promptly or consistently communicated to the NP/MD or to facility leadership. RN A stated he had notified the NP at some point that there was no enteral feeding formula order but could not recall when or where it was documented, and he only learned on the survey date that the resident had been refusing Ensure. He acknowledged that refusals of medications and nutritional supplements would be considered a change in condition that should be reported immediately, but he had not reported them, assuming others had done so and indicating he had not been clearly trained on reporting expectations. Medication aides reported that the resident had not been taking medications or Ensure since admission due to inability to swallow, that they tried various methods (crushing meds in pudding, jelly, applesauce) without success, and that they verbally and via handwritten notes informed charge nurses of ongoing refusals, but were unsure whether this was documented in the EMR or escalated further. The DON stated she was unaware that the resident had no enteral feeding formula order, was refusing medications, supplements, and meals, and attributed missed order verification and change‑in‑condition follow‑up to workload and role strain. The resident’s representative reported finding the resident multiple times in front of untouched meal trays without staff assistance and stated they had not been informed of the resident’s medication and supplement refusals. The NP and MD both confirmed they had not been notified of the resident’s refusals or lack of enteral feeding orders and indicated these issues constituted changes in condition that should have been reported. These failures led surveyors to identify an Immediate Jeopardy related to the lack of timely notification and consultation when there was a need to alter treatment significantly.
Failure to Provide Ordered PEG Nutrition, Monitor Weight Loss, and Assist With Feeding
Penalty
Summary
The deficiency involves the facility’s failure to maintain acceptable nutritional status and follow physician and hospital discharge orders for a cognitively intact female resident with Wernicke’s encephalopathy, aneurysm, dysphagia, anorexia, and a newly placed PEG tube. On admission from the hospital, her discharge summary specified a regular diet with pureed texture for comfort only, explicitly stating that this oral intake was not sufficient for nutrition and that she had a PEG and should otherwise remain NPO. Despite this, the facility did not have an active, specific enteral feeding formula order in place for her PEG tube from admission through the date of the state survey entrance, and there was no active diagnosis for a gastrostomy tube documented on her admission MDS. An undated, unsigned handwritten note in the EMR referenced PEG use and Jevity 1.5 via NG tube, but this was not translated into a clear, implemented PEG feeding order. Instead of initiating PEG feedings, the facility obtained an order several days after admission for Ensure Plus PO TID and continued a regular pureed diet for “pleasure food.” Medication administration records showed that the resident refused all three daily Ensure doses on multiple days, had days with no documentation at all, and on some days was noted as nauseated, vomiting, or asleep at the time of administration. Nursing staff, including medication aides, reported that the resident had not really been taking her Ensure since admission because she could not swallow and that she regularly refused medications and supplements. The NP and MD both stated they were not notified of the resident’s refusals, lack of enteral feeding orders, or any significant weight loss, and believed she was tolerating a pureed diet based on information from facility staff. The resident herself reported that while in the hospital she had received a milk-like formula through a tube, that the tube was later placed directly into her stomach, and that since admission to the facility she only received water through the tube and no medications or feeding formulas. The facility also failed to obtain and monitor weekly weights as ordered and per policy. The only documented weight after admission was 120 lbs recorded seven days post-admission, which the DON later crossed out as inaccurate without knowing the resident’s true admission or current weight. A subsequent weight entry showed 96.5 lbs, reflecting a 23.5 lb loss and a 19% weight reduction in 12 days, but this significant change was not reported to the NP or MD. The DON acknowledged that weekly weights had not been done due to changes and inconsistency among CNAs and that she did not know who was responsible for obtaining weights. A CNA reported having no formal training on how to weigh residents and was unable to obtain an accurate weight for the resident due to lack of wheelchair tare weight and the resident’s refusal to transfer. Additionally, the resident’s risk of impaired nutrition related to her PEG tube and therapeutic diet orders was not addressed in a timely manner, and dietary recommendations were not in place from admission until the surveyor’s entrance. Direct observation by the surveyor further demonstrated failures in providing adequate assistance with meals. On the survey date, the resident was observed seated alone in a wheelchair with an uncovered, uneaten pureed breakfast tray in front of her; she stated she was hungry and needed help eating, but no staff had assisted her. The DON and RN assigned to her were initially unaware that she had not eaten. A receptionist, not clinical staff, ultimately reheated the tray and offered to assist before the RN took over. The resident’s representative reported having found her on at least two separate occasions in front of untouched meal trays without staff assistance and stated that when they raised concerns, an RN responded that the resident needed to learn to use her left hand to feed herself despite her right-sided weakness and prior right-hand dominance. These combined inactions and failures to follow orders, monitor intake and weight, and provide necessary feeding assistance led to the identified deficiency and were determined by surveyors to constitute Immediate Jeopardy until corrected.
Failure to Accurately Code Gastrostomy Tube Status on Admission MDS
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s admission MDS assessment accurately reflected her gastrostomy tube status. The resident, an adult female admitted with diagnoses including Wernicke’s encephalopathy, carotid artery aneurysm, dysphagia, and anorexia, had a PEG tube placed in the hospital and was ordered to remain NPO except for pureed food for comfort, which was not sufficient for nutrition. Despite this, her admission MDS dated 03/30/2026 did not include an active diagnosis for gastrostomy tube status in Section I, and Section K coded her as having a swallowing disorder with a mechanically altered diet, without reflecting her PEG-dependent nutritional status. Record review showed hospital discharge orders specifying a regular diet with pureed texture for comfort only and that the resident had a PEG and should remain NPO otherwise. The facility’s physician orders included a pureed diet for pleasure food and an enteral feed order with scheduled water flushes through the enteral tube every shift, indicating that the PEG tube was in use for hydration and enteral care. However, the resident’s diagnosis list in the EMR did not include gastrostomy status at the time of the admission MDS, and this omission carried through to the MDS coding, which failed to capture the presence of the gastrostomy tube. During observation, the resident was seen seated in a wheelchair with a breakfast tray containing pureed foods and liquids, stating she needed help eating and that no one had assisted her. In a subsequent interview in her room, she reported having had a tube placed in her stomach in the hospital and stated that staff pushed water through the tube daily but did not administer medications or feeding formulas through it. Interviews with the DON and the MDS nurse confirmed that the admitting nurse was responsible for entering diagnoses, that the MDS nurse was responsible for ensuring accurate diagnoses and coding, and that the resident should have had a diagnosis for gastrostomy status. The MDS nurse acknowledged that the omission of the gastrostomy diagnosis and failure to code the gastrostomy tube on the admission MDS was an oversight, despite using the RAI manual as guidance for accurate completion of the MDS.
Failure to Develop and Implement Care Plan for G-Tube and Diet Needs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s gastrostomy tube status and diet, despite these needs being identified in admission and hospital records. The resident, an adult female admitted with diagnoses including Wernicke’s encephalopathy, aneurysm, dysphagia, and anorexia, had a PEG tube placed in the hospital and was ordered to remain NPO except for pureed food for comfort, which was not sufficient for nutrition. Her admission MDS showed intact cognition (BIMS 14), a swallowing disorder, and a mechanically altered diet, but did not list an active diagnosis for a gastrostomy tube. The physician orders included a regular pureed diet for pleasure and an enteral feed order with scheduled water flushes, yet there was no corresponding care plan for the gastrostomy tube, diet, or enteral feeding status upon admission. When the comprehensive care plan was reviewed, it contained an entry dated after admission stating that the resident had a G-tube related to oropharyngeal dysphagia and severe protein-calorie malnutrition, was receiving a puree diet for pleasure feeds with refusals to eat at times, and was NPO for her main source of nutrition. Another entry documented that she was receiving a mechanically altered diet due to oropharyngeal dysphagia. However, interviews and record review established that there had been no care plan specifically addressing the gastrostomy tube status, diet, or enteral feeding at the time they should have been initiated, and that these elements were only added after the state surveyor began asking questions. The facility’s own policy required a comprehensive, person-centered care plan with measurable objectives and timeframes to be developed and implemented for each resident within specified time limits after admission and MDS completion. During observation, the resident was seen seated in a wheelchair with a breakfast tray containing pureed foods and liquids; she stated that she needed help eating and that no one had come to assist her. Later, in her room, she reported having had no appetite for about a month, confirmed that she had a tube placed in her stomach in the hospital, and stated that staff pushed water through the tube daily but did not administer medications or feeding formulas through it. The DON, Administrator, and MDS nurse each acknowledged in interviews that the resident should have had care plans for her gastrostomy tube status and diet from admission, that the admitting nurse was responsible for initiating care plans, and that the MDS nurse was responsible for comprehensive care plans. They also acknowledged that the absence of a comprehensive person-centered care plan could result in a resident not receiving appropriate care, and that recent ownership and staff changes had disrupted IDT meetings and care plan reviews.
Failure to Submit Required Investigation Results to State Agency Within Required Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to report the results of abuse/neglect/theft-related investigations to the State Survey Agency within five working days as required by state law and facility policy for two separate incidents involving two residents. Record review of the TULIP system on 03/31/2026 showed that a Provider Investigation Report (PIR), Form 3613-A, was not filed in the system for two incidents that had been reported by the facility to Complaint and Incident Intake on 03/18/2026. The facility’s written policy, “Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating- F609,” revised in September 2022, states that within five calendar days of the incident, the administrator will provide a follow-up investigation report, but this did not occur for the two incidents. Interviews with multiple staff members revealed that no one currently in the building had submitted or could locate the required PIRs, and that responsibility for PIRs had been handled solely by the former administrator. The Director of Operations reported that his team was trying to locate the PIRs and that the former administrator may have shredded them. The new Administrator, whose first day was 04/01/2026 and who did not yet have access to TULIP, stated she was unaware of incomplete investigations pending a provider investigation and that there was no process in place to locate pending investigations during the facility’s recent change of ownership. The DON stated she did not have access to TULIP and was not responsible for PIRs, and other staff, including the Regional NHA, Social Worker, and RNs, each stated they were not responsible for submitting PIRs and did not have access or assistance from the former administrator. As a result of these actions and inactions, the required follow-up investigation reports for the two incidents were not submitted to the State Survey Agency within the mandated timeframe.
Inadequate Nursing Competency and Medication Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff had appropriate competencies and skills to manage controlled and other high‑risk medications for multiple residents. For one male resident with convulsions, hypertension, traumatic brain injury, severely impaired cognition, and extensive to total ADL needs, surveyors found a discrepancy between the control count sheet and the actual volume of Lacosamide oral solution on the medication cart. The control sheet documented 480 mL, while two bottles on the cart contained a total of 510 mL (one unopened 400 mL bottle and one 110 mL bottle). The RN responsible for the cart stated she did not know what to do about the discrepancy, suggested it might be a documentation or measurement error, reported she had not received any skill check‑off on medication administration or control counts since starting three weeks earlier, and did not respond when asked what could have happened if the resident did not receive the prescribed seizure medication dose. A second male resident with dementia, hypertension, diabetes, moderately impaired cognition, and supervision to partial assistance with ADLs had an active care plan for pain management and an order for PRN tramadol. During a controlled substance count on the same medication cart, surveyors observed that one tramadol blister in the resident’s card had a punched seal with the tablet half exposed. The RN stated the seal was punched and she did not know what to do, and also reported she had not received training on medication administration or control counts. The DON later stated that if a tramadol blister pack seal was broken, the nurse should waste the medication with another nurse and sign the control sheet, and that if the medication in the opened blister was not taken out and destroyed, it could have gone missing and would have been reportable for drug diversion. A third female resident with obesity, hypertension, diabetes, intact cognition, and independence to supervision with ADLs had a care plan for pain medication therapy and an order for PRN acetaminophen‑codeine. Review of the control count sheet showed 16 tablets documented, but surveyors found only 15 tablets in the blister pack on a different medication cart. The LVN assigned to that cart stated she had administered one tablet earlier that afternoon and forgot to sign it out on the control sheet or the MAR, and when asked when she should have signed the control book and MAR, she shrugged her shoulders. She reported having no medication administration training since starting three weeks earlier, aside from three days of floor orientation. The DON acknowledged that the LVN should have signed out the medication immediately when it was pulled and administered, and also stated that comprehensive nursing training had not been completed due to ongoing staffing needs, despite the facility’s written policy requiring nursing leadership to establish and monitor competency requirements and training for nursing staff.
Medication Control, Documentation, and Packaging Failures in Pharmacy Services
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, administering, and accounting of medications for multiple residents. For one resident with convulsions, hypertension, and traumatic brain injury, the control count sheet for Lacosamide oral solution (10 mg/mL, 20 mL via G-tube twice daily) documented 480 mL, while two bottles on the medication cart contained a total of 510 mL (one unopened 400 mL bottle and one 110 mL bottle). The RN conducting the count identified the discrepancy but stated she did not know what to do, suggested it might be a documentation or measurement error, and reported she had not received any skill check-off on medication administration or controlled drug counts since starting work three weeks earlier. The resident’s quarterly MDS showed severely impaired cognition and extensive to total assistance needs, and the resident had no current care plan after the prior plan was canceled. For a second resident with dementia, hypertension, and diabetes mellitus, who had a care plan identifying risk for pain and an order for tramadol 50 mg by mouth every six hours as needed for pain, surveyors observed that one tramadol blister pack on the medication cart had a punched-open seal with the tablet half exposed. The RN present stated she did not know what to do about the partially opened blister and reported she had not received training on medication administration or controlled drug counts. The DON later stated that if a tramadol blister pack seal was broken, the medication should be wasted with another nurse and documented on the control sheet, and also stated they were not sure if the medication in the opened blister was the original medication and that if not destroyed, the medication could come up missing and would be reportable for drug diversion. For a third resident with obesity, hypertension, and diabetes mellitus, who had intact cognition and a care plan for pain management with analgesic medications, the order summary showed acetaminophen-codeine 300-30 mg, one tablet by mouth every four hours as needed for pain. The control count sheet for this controlled medication showed 16 tablets, but the blister pack contained only 15 tablets. The LVN stated she had administered one tablet at 1:30 p.m. and forgot to sign it out on the control sheet or the MAR, and when asked when she should sign the control book and MAR, she shrugged her shoulders and reported she had not had any training on medication administration since starting at the facility, aside from three days of floor orientation. The facility’s written policy required the individual administering medication to initial the MAR after giving each medication and before administering the next one, and the surveyor’s request for a drug diversion policy was not fulfilled. The DON acknowledged that if controlled medications are not signed out when pulled, it would look like drug diversion and stated she had not had time for comprehensive nursing training while covering multiple roles.
Cancelled Care Plan Leaves Resident Without Comprehensive Person-Centered Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with significant medical and cognitive needs. The resident was an adult male with diagnoses including convulsions, hypertension, and traumatic brain injury, and a Quarterly MDS showed a BIMS score of 3/15, indicating severely impaired cognition, with extensive to total assistance required for ADLs. Record review showed that this resident’s care plan was cancelled on 01/19/26, leaving him with no current care plan in place. The MDS Coordinator reported that she did not cancel the care plan and stated it had been cancelled by her supervisor, the MDS Supervisor, and that she was unaware it had been cancelled until the surveyor requested the care plan. The MDS Coordinator stated that care plans were reviewed quarterly in conjunction with MDS completion and acknowledged she had completed the quarterly MDS earlier in the month but had not reviewed the care plan. She did not provide an explanation of how care would be provided without a care plan. The surveyor was unable to reach the MDS Supervisor by telephone. In an interview, the DON stated that care plans were the responsibility of the MDS Coordinator and that she did not know why the care plan had been cancelled, while acknowledging that the care plan was used to provide care for residents and that its absence could have affected this resident’s care. The Administrator similarly stated that the resident should have had a current care plan and that it was used to communicate with providers and nursing staff. The DON also reported that the facility did not have a care plan policy and followed the RAI manual, and that every resident should have had a care plan updated quarterly.
Improper Handling of Prefilled Morphine Syringes Breaches Infection Control
Penalty
Summary
The deficiency involves a failure to maintain an infection prevention and control program when handling a resident’s prefilled morphine syringes. The resident was an elderly female with diabetes mellitus, hypertension, and a history of cerebral infarction, with a BIMS score of 8/15 indicating severely impaired cognition, requiring extensive to total assistance with ADLs, and on hospice care with a terminal prognosis related to CVA. Her care plan included close observation for pain and administration of pain medication as ordered, and her orders included PRN oral morphine sulfate concentrate. During observation of the medication cart, an LVN was counting the resident’s prefilled morphine syringes when one syringe fell to the floor. The LVN picked up the fallen syringe and placed it back with the other nine syringes instead of wiping or destroying it, thereby contaminating the remaining syringes. In interview, the LVN acknowledged the syringe that fell became contaminated and that she should have wasted it with another nurse. The DON stated the syringe that fell should have been wasted and that placing it back with the others contaminated all of them, identifying this as an infection control issue. The facility’s medication administration policy required staff to follow established infection control procedures, and when the infection control policy was requested from the administrator, it was not provided upon exit.
Facility Assessment Lacks Staffing Level Information
Penalty
Summary
The facility failed to ensure that its facility-wide assessment included information regarding the level of staff needed to meet the needs of each resident during both day-to-day operations and emergencies. Record review of the facility assessment dated 4/30/25 revealed that it did not contain details about staffing levels required to provide competent care for residents. The facility's policy states that the assessment should inform staffing decisions and consider staffing needs for each shift, but this was not reflected in the actual assessment document. During an interview, the Administrator acknowledged uncertainty about whether the facility assessment included staffing level information and confirmed that the assessment was not used when creating the nursing staff schedule. Instead, staffing decisions were based on the facility's PPD (per patient day) and census, with a CNA-to-resident ratio of 1:15. The Administrator also referenced the facility's star rating and national staffing averages but did not indicate that individual resident needs or the facility assessment were used to determine staffing levels.
Insufficient Nursing Staff Resulting in Unmet Resident Care Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple incidents involving three residents. One resident, who was legally blind, had dementia, and was dependent on staff for personal and toileting hygiene, was found by a family member in the evening with her hair, gown, and bed soaked in urine, and her room had a strong odor. Documentation showed that incontinent care was only provided once earlier in the day, and staff assignments indicated fewer CNAs present than scheduled. Interviews with staff could not clarify the care provided during the shift in question. Another resident, who had hemiplegia, hemiparesis, and required a two-person assist with a mechanical lift for transfers, reported that he was unable to get out of bed for 24 hours due to insufficient staff. Staffing records confirmed that fewer CNAs were present than scheduled, and a nurse was working as a CNA. The resident stated that delays in getting out of bed occurred when the facility was short-staffed, and a CNA confirmed that staffing ratios made it difficult to meet residents' preferences for getting up. A third resident, who was dependent on staff for transfers and toileting hygiene, reported waiting more than two hours for assistance with incontinent care during the evening shift, leading him to remove his own brief to prevent skin breakdown. Resident council records and staff interviews indicated ongoing concerns about insufficient staff, particularly at night, with residents reporting infrequent care and long wait times. The facility's assessment did not include information on the level of staff needed to meet each resident's needs, and scheduling was based primarily on census and PPD, without clear consideration of resident acuity.
Failure to Secure Medication Carts and Store Drugs in Locked Compartments
Penalty
Summary
The facility failed to store drugs and biologicals in locked compartments as required, as observed during medication storage inspections of four out of six medication carts. On multiple occasions, medication carts were found unattended and unlocked, with residents, visitors, and staff in close proximity. Specifically, Medication Cart #1 was left unlocked on hall 100 while the assigned nurse was on break, and the ADON confirmed that the cart should have been locked at all times when unattended. The nurse responsible for the cart acknowledged the oversight and stated that the cart contained various prescription and over-the-counter medications, including PRNs, insulin, blood pressure medications, pain and anxiety medications, antiepileptics, and OTC drugs. Although narcotics were said to be locked, the nurse admitted that they should have been secured under two locks, not one. Further observations revealed that Medication Carts #2, #3, and #4 were also left unlocked and unattended, with the keys placed on top of each cart and visible to anyone nearby. These carts contained a range of prescription medications, including heart, depression, diuretic, antinausea, diabetes, inhalation, anti-yeast, and OTC medications, as well as narcotics. At another time, Medication Cart #1 was again found unlocked, with several drawers open and no staff in sight. The cart contained a laptop, a cell phone, and keys hidden under the phone, along with a variety of prescription and OTC medications, insulin syringes, and lancets. Interviews with nursing staff and the acting DON confirmed that facility policy required medication carts to be locked at all times when unattended or out of direct sight of nurses. Staff acknowledged responsibility for ensuring the carts were secured and recognized that the failure to do so could result in medications being accessed by unauthorized individuals. The acting DON stated that the nurses had not followed the facility's medication storage policy, which mandates that all medications and biologicals be stored in locked compartments, with controlled substances separately locked.
Failure to Develop and Implement Person-Centered Care Plan for Tube Feeding
Penalty
Summary
The facility failed to develop and implement a person-centered care plan that addressed all identified needs for a resident with complex medical conditions. Specifically, the care plan did not include the resident's requirement for G-J tube feeding with small amounts of pureed textured snacks for pleasure, to be administered under the supervision of a Speech-Language Pathologist (SLP) or a trained caregiver. This omission was identified despite the resident's comprehensive assessment and physician orders clearly indicating the need for such interventions. The care plan also did not reflect the resident's G-J tube status or the specific feeding protocols outlined in the hospital discharge summary and physician orders. The resident in question was an elderly female with multiple diagnoses, including gastronomy status, dyskinesia of the esophagus, dysphagia (pharyngeal phase), metabolic encephalopathy, and acute pulmonary edema. Her admission Minimum Data Set (MDS) assessment indicated severe cognitive impairment and that eating was not attempted due to medical or safety concerns. Although the Care Area Assessment (CAA) triggered the need for care planning related to feeding tube care, the actual care plan failed to address the resident's specific nutritional and feeding needs as documented in her medical records and physician orders.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches in the rooms of two residents. One resident, a female with cerebral palsy, congenital ear malformation, and a mood disorder, was found by a nurse to have roaches crawling on her bedroom floor, bed, and wheelchair while she was sitting in her wheelchair. The nurse and a CNA observed roaches on the blanket the resident was sitting on and on her wheelchair, prompting them to remove her from the room for cleaning. The resident's care plan indicated she was dependent on staff for meeting her needs and had communication difficulties due to a hearing deficit and unclear speech. Progress notes and staff interviews confirmed repeated sightings of roaches in her room, with food crumbs frequently found on the floor and bed, and the resident often refusing to allow staff to remove her meal trays. Another resident was observed to have a small live roach on the floor near the doorway of his bedroom. During interviews, housekeeping staff confirmed the presence of roaches and stated that despite regular spraying, the pests continued to return. The Director of Maintenance reported treating the affected room on several occasions and consistently finding German roaches, especially when moving furniture and checking outlets. Pest control invoices and records showed that the facility had pest control services performed monthly and additional treatments were requested for the affected rooms, but the problem persisted, particularly in the room of the first resident. Staff interviews revealed that the pest control measures in place were not effective in eliminating the infestation, especially in rooms where food was present and not promptly removed. The ongoing presence of roaches was documented through observations, staff reports, and pest control invoices, indicating a failure to ensure the facility was free of pests and rodents as required.
Inaccurate MDS Assessments for Three Residents
Penalty
Summary
The facility failed to accurately assess the status of three residents during the Minimum Data Set (MDS) process, resulting in incorrect documentation of their conditions. For one resident with a history of hemiplegia, chronic kidney disease, and above-the-knee amputation, the MDS incorrectly coded the use of bed grab bars as restraints, despite observations and interviews confirming the bars were used to assist with bed mobility and did not restrict movement. The care plan also indicated the grab bars were for safe repositioning, and staff confirmed the coding was inaccurate. Another resident with schizoaffective disorder, hypertension, and a history of traumatic brain injury was incorrectly documented on the MDS as having an indwelling catheter. Progress notes and staff interviews revealed the resident had removed the catheter prior to the assessment and refused reinsertion, with no physician order for a catheter present at the time of the MDS. Observations confirmed the absence of a catheter or drainage bag, and staff familiar with the resident's care verified he did not have a catheter during the assessment period. A third resident, admitted with diagnoses including intracranial hemorrhage, chronic kidney disease, and urinary retention, was assessed on the admission MDS as having a catheter, although observations and staff interviews confirmed she did not have one upon return from the hospital. Documentation showed the catheter had been discontinued prior to readmission, and no evidence of a catheter was found during the assessment. The MDS coordinator relied on nurse documentation and resident observation but failed to accurately reflect the resident's current status.
Failure to Develop and Implement Comprehensive Care Plans for Indwelling Catheter and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, resulting in deficiencies related to the management of an indwelling urinary catheter and oxygen therapy. For one male resident with multiple diagnoses, including metabolic encephalopathy, peripheral vascular disease, osteoporosis, atrial fibrillation, and acute urinary retention, there was no care plan addressing his indwelling urinary catheter following a recent hospitalization and procedure. Despite clear documentation in hospital records, physician orders, and nursing notes regarding the presence and management of the catheter, the resident's care plan did not include this information at the time of review. Interviews with facility staff confirmed the absence of a care plan for the catheter, and staff acknowledged that such a plan was necessary to guide care. Another female resident with complex medical needs, including a tracheostomy, chronic kidney disease, pressure ulcer, hypertension, encephalopathy, urinary retention, gastrostomy, muscle weakness, dysphagia, diabetes, chronic pain, and chronic respiratory failure, was also found to have an incomplete care plan. Although physician orders and the Minimum Data Set (MDS) assessment indicated that she was receiving continuous oxygen therapy via tracheostomy, her care plan did not address this intervention. Observations confirmed the resident was on oxygen, and staff interviews revealed awareness of her oxygen use but also acknowledged the lack of a corresponding care plan. The facility's policy requires the interdisciplinary team to develop comprehensive, person-centered care plans based on resident assessments. In both cases, the care plans failed to include measurable objectives and time frames for the identified needs, specifically the indwelling urinary catheter and oxygen therapy. This omission was confirmed through record review, staff interviews, and direct observation, demonstrating a failure to ensure that care plans accurately reflected the residents' current conditions and required interventions.
Failure to Notify Physician of Positive THC Test After Hospitalization
Penalty
Summary
The facility failed to notify a resident's physician following a significant change in condition, specifically after the resident tested positive for THC at the hospital. The resident, an adult female with a history of lumbar fracture, paraplegia, asthma, and COPD, was sent to the hospital for altered mental status. Hospital records indicated a positive THC drug screen and a diagnosis of THC overdose, with additional documentation of a history of marijuana use. The resident did not have a physician order for THC, and her care plan did not address substance abuse. Interviews with facility staff revealed that while some staff were aware of the resident's altered mental status and suspected drug ingestion, there was no evidence that the physician was notified of the positive THC result. The DON at the time was not employed during the incident, and the Interim DON stated she was not verbally notified by the hospital nor did she review the hospital report. The admissions nurse was identified as responsible for reviewing hospital records, but there was no confirmation that this occurred. Nursing staff reported inconsistent access to hospital discharge paperwork, and the physician confirmed she was not made aware of the positive drug test. Facility policy required timely communication of significant changes in resident status to the medical staff, including pertinent information from recent hospitalizations. Despite this, the positive drug test and related hospital findings were not communicated to the resident's physician, resulting in a failure to ensure the physician was informed of a significant clinical change.
Failure to Revise Care Plans After Positive Drug Screens
Penalty
Summary
The facility failed to revise the comprehensive care plans for two residents after significant changes in their condition were identified. Both residents were sent to the hospital for altered mental status and subsequently tested positive for substances not prescribed to them. Despite these findings, neither resident had their care plan updated to address substance abuse or the new information from their hospitalizations. One resident, a male with hepatic encephalopathy, alcohol cirrhosis, and other significant diagnoses, was admitted with moderate cognitive impairment. He was sent to the hospital for altered mental status, where a urine drug screen was positive for benzodiazepines and THC, neither of which were prescribed. The care plan did not reflect any interventions or monitoring related to substance abuse, and staff interviews confirmed that this information was not incorporated into his care planning. The second resident, a female with paraplegia and chronic respiratory conditions, was also sent to the hospital for altered mental status. Hospital records indicated a THC overdose, with a positive urine drug screen for THC. Like the first resident, her care plan did not address substance use, and staff interviews revealed that the hospital report was not reviewed or acted upon in terms of care planning. The lack of care plan revision was acknowledged by facility leadership and nursing staff.
Medication Errors in Blood Pressure Management
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. For one resident, the facility did not hold the medication Midodrine as ordered by the physician when the resident's systolic blood pressure (SBP) was above 100. Despite the blood pressure reading being 145/88, the medication was administered, contrary to the physician's instructions. This oversight was acknowledged by the medication aide, who admitted to overlooking the order and recognized the potential for adverse effects on the resident's health. Another resident was affected by the improper administration of blood pressure medications, Toprol X and Spironolactone. These medications were given even when the resident's blood pressure readings were within the parameters that required the medications to be held. Specifically, the medications were administered when the diastolic blood pressure (DBP) was 58 and the SBP was 105, both of which were below the threshold for administration. The medication aide admitted to possibly overlooking the parameters and acknowledged the potential consequences of such errors. The facility's policy on pharmacy services emphasizes the accurate and safe administration of medications, yet these incidents highlight a failure to adhere to physician orders and established protocols. The Assistant Director of Nursing (ADON) confirmed the expectations for staff to follow physician orders and acknowledged the incomplete documentation in the blood pressure log. The ADON also recognized the potential risks associated with these medication errors, including the possibility of adverse health effects for the residents involved.
Deficient Medication Documentation and Administration
Penalty
Summary
The facility failed to maintain clinical records in accordance with accepted professional standards and practices, specifically in the documentation of medication administration for two residents. For Resident #1, the Medication Administration Record (MAR) for May 2024 did not consistently reflect whether the medication Midodrine was given or held, despite specific physician orders to hold the medication if systolic blood pressure (SBP) was above 100. Additionally, there was a lack of documentation in the blood pressure log for several dates, and no explanation was provided in the nurse's notes for why blood pressure readings were not recorded or why the medication was not held when required. Resident #2's MAR also showed discrepancies in medication administration. The medications Spironolactone and Toprol X were administered on specific dates when the blood pressure readings indicated they should have been held according to physician orders. The nurse's notes lacked documentation explaining why these medications were given despite the blood pressure parameters indicating they should be held. This oversight in documentation and adherence to physician orders could potentially lead to adverse effects on the residents' health. Interviews with staff, including a medication aide and the Assistant Director of Nursing (ADON), revealed acknowledgment of the errors in medication administration and documentation. The medication aide admitted to possibly overlooking orders, which could result in incorrect medication administration, potentially causing residents' blood pressure to drop or rise inappropriately. The ADON confirmed that medications should not be given when blood pressure readings are within the parameters to hold them and emphasized the importance of documenting reasons for holding medications in the progress notes or MAR.
Failure to Notify Physician and Implement Orders for G-Tube Care
Penalty
Summary
The facility failed to immediately consult with the resident's physician regarding the dysfunction or malfunction of a gastrostomy tube (G-tube) for a resident. The resident had a diagnosis of Gastrostomy Status and Gastro-Esophageal Reflux Disease (GERD). The facility did not implement the physician's order for an abdominal binder to protect the G-tube and its site due to an inadequate supply. This failure resulted in the resident requiring discharge to the hospital for G-tube replacement. The facility also failed to notify the physician of complications related to the resident's G-tube site pain and the administration of medications via the G-tube. An LVN administered medications by forcefully pushing them into the G-tube instead of allowing them to flow by gravity, placing the resident at immediate risk for potential harms such as G-tube blockage and aspiration. The resident was observed not wearing the prescribed abdominal binder, and the G-tube site was found to be soiled and painful. Interviews with facility staff revealed a lack of awareness and communication regarding the physician's orders for the abdominal binder and the proper care of the G-tube. The staff did not routinely check the resident's orders each shift, and there was a failure to notify the physician of the complications and the inability to implement the prescribed abdominal binder. The facility's failure to follow physician orders and properly manage the resident's G-tube care led to significant complications and the need for hospital intervention.
Failure to Implement Physician's Orders and Proper G-Tube Care
Penalty
Summary
The facility failed to ensure that a resident who was fed by enteral means received the appropriate treatment and services to prevent complications. Specifically, the facility did not implement the physician's order for an abdominal binder, which was indicated to prevent complications of the gastrostomy tube. This failure resulted in the resident requiring discharge to the hospital for G-Tube replacement. Additionally, the facility did not provide proper gastrostomy tube site care, leading to the resident experiencing pain and a visibly soiled dressing with dark red substance at the gastrostomy tube site. The resident was often seen pulling on the gastrostomy tube, and the staff was unaware of the abdominal binder order, which was not implemented due to the facility not having the proper size available. The facility also failed to use the proper technique and safety precautions for administering medications via the G-Tube. An LVN administered medications by plunger pushing them into the gastrostomy tube instead of administering to gravity, placing the resident at immediate risk for potential harms such as G-Tube blockage and aspiration. The LVN did not check the tube placement by auscultating for bowel sounds or visualizing the site to ensure the tube had not become dislodged or infected. The LVN also did not follow the physician's order to flush the feeding tube with water before and after administering medications. Furthermore, the facility did not notify the physician of the complications related to the G-Tube and the failure to implement the abdominal binder. The staff, including the DON and Administrator, were aware of the physician's order but did not take appropriate actions to ensure the resident received the necessary care. The facility's failure to implement the physician's orders and provide proper care placed the resident at immediate risk for complications, including infection and hospitalization. The facility's deficiencies were identified during a survey, and an Immediate Jeopardy was declared, indicating the severity of the situation.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate below 5 percent, resulting in a 16 percent error rate. This was observed during a medication administration pass involving one resident and one LVN. The LVN administered the wrong dose of Lactulose and flushed the resident's g-tube with an incorrect volume of water. Additionally, the LVN did not elevate the resident's head during medication administration, increasing the risk of aspiration. These actions were not in accordance with the physician's orders and the facility's policy for administering medications through an enteral tube. The resident involved had a diagnosis of Gastrostomy Status and Gastro-Esophageal Reflux Disease (GERD) and required an abdominal feeding tube. The resident's care plan specified the need for proper g-tube care, including checking tube placement and flushing with the correct volume of water. However, the LVN failed to follow these protocols, leading to the resident experiencing pain and discomfort during the medication administration process. Interviews with the LVN and the DON revealed that the LVN had been trained but did not follow the correct procedures for g-tube medication administration. The LVN admitted to pushing medications with force instead of using gravity flow and did not report complications related to the g-tube. The DON confirmed that the head of the bed should have been elevated and that pushing medications with force could cause harm to the resident. The facility's policy and training records were reviewed, and it was noted that additional training would be provided to address these deficiencies.
Failure to Employ a Full-Time Social Worker
Penalty
Summary
The facility, licensed for 150 beds, failed to employ a qualified full-time social worker despite having a capacity of more than 120 beds. The facility had been without a social worker for four months since the last social worker's employment ended on 11/23/23. The job description for the social worker position required a high school diploma or a bachelor's degree in social work along with an LCSW or LMSW. Despite job postings from 1/18/24 to 3/28/24 and a reposting from 3/11/24 to 4/10/24, the position remained vacant. The HR representative confirmed that an LVN was placed as acting social services in the interim. The Administrator, who joined on 1/16/24, acknowledged the vacancy and stated that several interviews had been conducted, but the candidates were not licensed. The Administrator also mentioned that they were waiting for corporate approval to have a social worker from a sister facility assist for 2-3 days. During a resident council meeting, four residents confirmed that the facility had not had a social worker for the last five months and that a nurse was acting in that capacity. The residents expressed confusion over the delay in hiring a qualified social worker.
Failure to Conduct Comprehensive Assessments
Penalty
Summary
The facility failed to conduct a comprehensive, accurate, and standardized assessment of Resident #27's functional capacity upon admission and periodically thereafter. Specifically, the facility did not assess the resident for hospice care and the lack of natural teeth in her oral cavity. Resident #27, a female with multiple diagnoses including diabetes, ovarian cancer, and major depressive disorder, was admitted on hospice with a DNR status. However, her Admission MDS did not reflect her hospice status, and her oral/dental status was marked as unable to examine. The resident later discharged herself from hospice services and reported issues with her dentures, which were not addressed by the facility in a timely manner. Interviews with staff revealed that the facility had been without a full-time MDS coordinator for some time, and the newly hired MDS coordinator was still in training. The Regional MDS Coordinator and a remote MDS coordinator had been assisting with assessments, but there were gaps in the documentation and follow-up. The resident's care plan did not reflect her current needs, and there was no significant change MDS assessment completed. The facility's policy on MDS accuracy was not specific, and the staff relied on the RAI manual. This lack of comprehensive assessment and follow-up could lead to unmet medical needs for the residents.
Failure to Update MDS Assessment After Significant Change in Condition
Penalty
Summary
The facility failed to conduct a comprehensive, accurate, standardized, and reproducible assessment of Resident #27's functional capacity within 14 days after a significant change in the resident's condition. Specifically, the facility did not update Resident #27's MDS assessment within 14 days of the resident being discharged from hospice care. This oversight was identified through observation, interview, and record review. Resident #27, a female with multiple diagnoses including diabetes, ovarian cancer, major depressive disorder, and mobility issues, had a care plan indicating she was on hospice for a terminal prognosis. However, she discharged herself from hospice because the hospice company restricted her from visiting her own physician, and the facility did not reassess her condition following this significant change. Interviews with the MDS Coordinator and the Regional MDS Coordinator revealed that the resident should have been assessed for a significant change in status after being discharged from hospice. The Regional MDS Coordinator acknowledged the oversight and indicated that a modification would be made. The facility's policy on the accuracy of MDS assessments was requested but not provided, with the Administrator and Regional MDS Coordinator stating that the facility followed the RAI manual. According to the Long-Term Care Facility RAI Manual, a Significant Change in Status Assessment (SCSA) must be completed within 14 days from the determination date of the significant change in status, which was not done in this case.
Failure to Complete and Transmit Death in Facility MDS
Penalty
Summary
The facility failed to ensure resident assessments were completed within the required 7 to 14 days and transmitted to the CMS system for a resident who had passed away. Specifically, the facility did not complete a Death in Facility MDS for the resident, who had been admitted with diagnoses including dementia, drug-induced systemic lupus, hypertension, hyperlipidemia, and chronic hepatitis C. The resident expired at the facility, but no death in facility or discharge MDS was recorded in the electronic medical record (EMR) within the required timeframe. Interviews with the Regional MDS RN and MDS Coordinator B revealed that the facility had been without a permanent MDS Coordinator, and the assessments were being completed remotely. The Regional MDS RN, who was responsible for oversight, admitted that they did not know why the death in facility MDS had not been completed or initiated. MDS Coordinator B, who worked remotely, also did not know why the death in facility MDS was missed and depended on the information in the facility's EMR, which was found to be incorrect. The review of the resident's records confirmed that the Death in Facility MDS was not completed or transmitted within the required timeframe. The Regional MDS RN acknowledged that the assessment should have been completed within 14 days of the resident's death. The lack of a permanent MDS Coordinator and reliance on remote staff contributed to the oversight and failure to meet regulatory requirements for timely and accurate resident assessments.
Inaccurate Death in Facility Assessment
Penalty
Summary
The facility failed to ensure that a resident's Death in Facility assessment accurately reflected her date of death. The resident, an elderly female with severe cognitive impairments and multiple medical conditions including hyperlipidemia, dementia, dysphagia, peripheral vascular disease, and combined systolic and diastolic heart failure, was readmitted to the facility and later expired. The nursing clinical progress notes documented her death and the pronouncement by a hospice RN, but the Death in Facility MDS did not accurately reflect the date of death. The Regional MDS RN acknowledged that the MDS assessments were completed based on the census line provided by the facility and that there had not been an in-house, in-person MDS person at the facility. The Regional MDS RN indicated that they would need to review the resident's electronic medical record (EMR) to determine if a corrected or modified Death in Facility MDS was necessary. The facility's failure to ensure the accuracy of the resident's assessment could place residents at risk for inadequate care, services, and dignity in death.
Failure to Provide Continuous Oxygen During Resident Transport
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required continuous oxygen therapy. The resident, who had a history of Chronic Obstructive Pulmonary Disease (COPD) and other serious health conditions, was transported to a doctor's appointment without a portable oxygen tank. Upon arrival at the appointment, the resident's oxygen saturation level was critically low at 73%, and he experienced difficulty breathing. The clinic nurse had to administer oxygen to stabilize the resident's condition. Interviews and record reviews revealed that the resident was on continuous oxygen therapy as per physician orders, which required oxygen to be administered at 5L/min via nasal cannula. Despite this, the resident was transported without the necessary oxygen support. The Assistant Director of Nursing (ADON) and the resident's nurse, LVN A, acknowledged that the resident should have been transported with a portable oxygen tank, as he was oxygen-dependent. However, due to a lack of communication and oversight, the resident left the facility without the required oxygen support. The transporter, who was responsible for taking the resident to the appointment, assumed the resident was ready for transport and did not verify the need for a portable oxygen tank. The transporter stated that it was the nurse's responsibility to ensure all necessary items were provided before transport. The facility's administrator was unaware of the resident's continuous oxygen requirement and the oversight that led to the resident being transported without oxygen. This incident highlighted a significant lapse in the facility's procedures for ensuring residents receive necessary medical support during transport.
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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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